The deficient practice remained for actual harm that is not immediate jeopardy and is evidenced by the following: Complaint #NJ156357. Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to investigate a fracture of unknown origin that occurred in a severely cognitively impaired resident, who required two staff for assistance for completion of activities of daily living. This deficient practice occurred for 1 of 6 residents reviewed for abuse (Resident #65), who sustained a medial malleolar fracture (a fracture where the bones meet the joint and normally accompanies injuries to the ankle) to the right foot on 07/04/22. This deficient practice was evidenced by the following: On 09/21/22 at 10:37 AM, during the initial tour of the second floor, surveyor #3 observed Resident #65 in bed. Surveyor # 3 attempted to interview Resident #65, who responded to the surveyor's questions with a smile and a thumbs up. The surveyor reviewed the medical record for Resident #65 which revealed the following: The admission Record revealed Resident #65 was admitted to the facility with diagnoses, which included but were not limited to; Type 2 Diabetes (a chronic condition that effects the way the body process blood sugar) and transient cerebral ischemic attack (a brief stroke-like attack). The Quarterly Minimum Data Set (MDS), an assessment tool dated 07/15/22, Resident #65 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #65 had a severely impaired cognition. The MDS documentation indicated that Resident #65 required extensive staff assistance for Activities of Daily Living (ADLS). Review of the Care Plan Activity Report revealed Focus: Communication Goals: We will ensure hearing device is in place before attempting to communicate, active effective date 6/22/22. Focus: Osteopenia (bone loss) Goals: will be pain free from pain related to Right Malleolus Fracture (bony prominence on each side of the ankle), active effective date 7/06/22. Review of Licensed Practical Nurse (LPN) #5 Nursing Progress, dated 07/02/22 at 1:29 PM, revealed: CNA (Certified Nursing Assistant) brought to my attention that patient was complaining of pain to right foot during am [morning] care and donning [putting on] socks. Examination reveals slight swelling to right ankle as compared to the left ankle skin warm to touch skin color normal for patient no redness or bruising noted no open areas noted MD made aware orders for X-ray of foot and knee obtained and Ibuprofen 800 mg given STAT. patient appears to only be uncomfortable during movement. patient is not fully able to describe type of pain or pain level. Nursing Progress note (unidentified nurse), dated 07/02/22 at 10:45 PM, revealed: Resident c/o right lower leg and right foot pain, PRN Tylenol 650 mg was given with + (positive) effect. Awaiting X-Ray to be performed. A follow up call was placed to [redacted]. Confirmation was received of the orders and a staff member from [redacted] stated they will be out to perform the x-ray with the next available mobile unit. Slight edema, non- pitting was noted to the right foot with no discoloration or warmth noted. Normal petal pulse noted 3+. Right leg elevated while sitting and in bed. Review of subsequent Nursing Progress note documented by LPN #5, dated 07/04/22 at 11:36 am, revealed: Called to follow up on X-ray ordered Saturday and was told that the technician will be here sometime this afternoon 7/4/22. Review of an additional Nursing Progress note documented by LPN #5, dated 07/04/22 at 3:08 PM, revealed: X-ray of right leg/foot complete awaiting results. A Nursing Progress note (unidentified nurse), dated 07/04/22 at 8:38 PM, revealed x-ray of the right ankle was done, result was relayed to the nurse on call, that the pt. (patient) has an acute appearing malleolar fracture recommend; Ankle Series, dr (doctor) made aware of the fracture and the recommendation with new order to apply ace bandage, and an orthopedic and podiatry consult ASAP (as soon as possible), ace wrap bandage applied pt in bed, no actual swelling or warmness noted, no facial grimaces noted at this time, awaiting for the hard copy of the x-ray. A Radiology Report of the Foot-Right (3 Views) dated 07/04/22, revealed Impression: Acute appearing medial malleolar fracture. The Physician's Orders revealed an order dated 07/04/22 at 8:19 PM, Treatment: apply ace wrap to right ankle daily only remove for care and an order dated 7/4/22 at 8:22 PM, for Consultation: pt to have an orthopedic appt for the fracture of right ankle ASAP. Nursing Progress note (unidentified nurse), dated 07/08/22 at 4:05 PM, revealed: Appointment made for Wednesday July 20 2022 at 930 am .Family has been made aware of appointment .Transportation needs to be made. Family may be able to accompany patient. Review of Nursing Progress (unidentified nurse) note dated 7/11/22 at 10:41 am, revealed: Resident Transportation has been scheduled for apt on 07/20/22. On 09/27/22 at 10:04 AM, Surveyor #3 interviewed CNA #4, who stated that Resident # 65 required total care from staff, and that you have to make sure the resident's hearing aides were in to communicate. She stated Resident #65 required two-person assistance with the use of a mechanical lift (mobility device used to help people with mobility challenges to get out of bed). When surveyor asked CNA #4 about the resident's right malleolar fracture, she stated the resident has never fallen but the resident had a cast recently from arthritis. CNA #4 stated that if there was a bruise or an injury of unknown origin, she would tell the nurse right away and would have to give a statement as to what was found and where it was. On 09/27/22 at 10:15 AM, Surveyor #3 interviewed LPN #6, who stated that an injury of unknown origin wound would have to be assessed by the nurse, the physician would be called, and the family notified. There would be an incident report completed, a three day look back for nurses aids and she would obtain statements from the nurse aides that had taken care of the resident. She stated that the findings would be listed on the 24-hour report. LPN #6 stated that Resident #65 required use of a mechanical lift with two persons to get out of bed. She stated she did not know how the right malleolar fracture had occurred but she knew the cast was taken off a few weeks ago. She stated there should have been an investigation started by the nurse caring for the resident when the injury was found. On 09/27/22 at 12:09 PM, in the presence of the survey team, Surveyor #4 requested the grievance policy, incident policy, any investigation policy from the LNHA. He then confirmed that the surveyors had all the investigations, incidents, and grievances from the past three months. This did not include an investigation regarding the alleged incident with Resident #65, On 9/28/22 at 11:20 AM, any soft files, incident reports, investigations, or reportable events from the DON for Resident #65 were requested) at that time the Regional Administrator (RA) confirmed that there was nothing further for Resident # 65. On 9/29/22 at 10:19 AM, Surveyor #3 interviewed LPN# 7, who stated that if there was an injury of unknown origin, there should be an investigation which included going back 72 hours and getting statements from all staff that had come into contact with the resident. If possible, try to get information from the resident. Notify the supervisor, the family and the physician. There should be an incident report, a progress note and an investigation. The nurse should complete a full body check to make sure there were no other injuries underneath the clothing. LPN #7, who was assigned to Resident # 65 at the time of the interview, stated she did not know about the resident's recent right malleolar fracture. She further stated that Resident #65 was total dependence with ADLs and that there absolutely should be an incident report and investigation from all staff that had contact with that resident for past 72 hours. Surveyor #3 asked LPN #7 the process for when a resident went to a physician visit. She stated the report of consultation form was sent with the patient, the nurse filled out the reason why the facility was sending the resident and the consulting physician should fill out findings and recommendations and send the form back with the resident. She further stated that the form should be in paper chart. At this time, Surveyor #3 requested LPN #7 to show the surveyor the consult from the orthopedic physician for 07/20/22. She was unable to locate the consult form or the physician's consult in the chart. She stated she would have to check to see if the chart was thinned. On 09/29/22 at 10:30 AM, Surveyor #3 interviewed CNA #4 in regards to Resident #65, she stated she was assigned to the resident at the time of the interview. She stated she knew the resident well. She stated the resident had a recent ankle fracture, but she didn't know how it happened. CNA#4 took the surveyor to Resident #65's room and showed the surveyor Resident #65's right ankle which was propped up on a pillow. A review of the orthopedic consults provided by the facility on 09/29/22, revealed a consult dated 07/20/22, Treatment: Non-displaced fracture of lateral malleolus of right fibula, initial closed fracture; Procedure: Orthotics, Cast BK NWB (below the knee, non-weight bearing) right. On 09/30/22 at 10:15 AM, Surveyor #3 interviewed Registered Nurse/Unit Manager (RN/UM) #1, who stated that if there was an injury of an unknown origin it would be initially investigated, an incident report would be done, interview who identified the injury, inspect the surroundings, written statements would be taken from all staff shifts going back 72 hours, the family and the physician would be notified. The incident would be discussed in morning meeting and depending on what the interdisciplinary team found, it would be reported to the New Jersey Department of Health (NJDOH). The family and the physician would be notified of the investigation results. Review of the Daily CNA Assignments sheet for the 7A-3P shift on 07/01/22 revealed CNA #5 was assigned to Resident #65 and CNA #6 was working on the unit; On 07/02/22, CNA#4 was assigned to Resident #65 and CNA#5 and CNA#6 were working on the unit. On 09/30/22 at 10:46 AM, Surveyor #3 interviewed CNA #5, who stated that if there was an injury of unknown origin, tell the nurse immediately. The nurse would start an investigation and the CNA would write a statement about what they found and what they saw. CNA#5 stated she was aware of Resident #65's fracture but does not know how it occurred. She stated she remembers the residents entire leg was puffy from knee down but was not asked to write a statement. She further stated that Resident #65 doesn't walk and when transferring, the resident was unable to bear weight and pivot. On 09/30/22 at 11:06 AM, Surveyor #3 interviewed CNA#6, who stated if she found a new bruise or any changes to a resident, she would get the nurse. Then the unit manager, the DON, or the Administrator would get written statements. They would ask the resident and ask for a statement from everyone on that shift. She stated she knew about Resident #65's fracture but was not asked to give a statement. On 09/30/22 at 11:18 AM, Surveyor #3 observed 2 CNAs in Resident #65's room with a mechanical lift. At 11:30 AM, Resident #65 was observed dressed sitting in a high back wheelchair in the room. On 10/04/22 at 10:41 AM, Surveyor #3 conducted a phone interviewed with LPN #5, who was taking care of resident #65 at that time of the incident. She stated with an injury of unknown origin, it would be reported to nurse, who would immediately assess the injury. An incident report would be initiated. There would be a look back 24 to 72 hours of staff that cared for the resident. It would be reported to administration. The family and the physician would be called. LPN#5 recalled the incident the CNA reported to her that Resident #65's ankle was swollen. LPN#5 stated she assessed the foot with minimal range of motion, she interviewed the resident but the resident was unable to tell her what happen. She called the physician who ordered an X-ray and that the ankle be wrapped. She further stated, she started an incident report and gave it to the current LNHA. LPN #5 stated that she did not do a statement because I thought since I did the incident report and a progress note that was my statement. She stated she definitely called the family, cousin or niece, not sure which one. She stated I took care of the resident I think 2 days later and the X-ray was not done yet, so I called the mobile X-ray and they came that day. She further stated that she was unaware of the results of the investigation. On 10/04/22 at 10:49 AM, Surveyor #3 requested any investigation for resident # 65 since January from the Regional Administrator (RA). On 10/05/22 at 8:45 AM, Surveyor #4 requested from the Interim Infection Preventionist Licensed Practical Nurse (IIPLPN) for any incidents/investigations for Resident #65. The IIPLPN stated she will look again. On at 10/05/22 at 9:24 AM, during a meeting with the survey team and the RA, LNHA, DON and the Regional Nurse (RN), Surveyor #4 asked for documents that have been repeatedly requested by the survey team(On 09/27/22 at 10:46 AM from DON, On 09/27/22 at 11:09 AM from LNHA). On 10/05/22 at 9:44 AM, Surveyor #3 interviewed the DON, who stated if there was an injury of unknown origin, i.e skin tear or bruises, they would go back 72 hours and question all staff that took care of the resident. She stated she would talk to the resident and look at their habits. She stated that if a CNA discovered it, they should report it to the nurse, the nurse would start the incident report and report it to the DON. She stated she would start investigation by looking back at the last 72 hours and contacting everyone the resident had been in contact with. The DON stated she would obtain written statements, but if the employee was unable to come to the facility I write it. She stated a completed investigation report should have been done within 3 to 5 days. She stated a summary should be done once all information was obtained. The DON stated that the family would be notified of the results of the investigation. Surveyor #3 asked the DON about the incident involving Resident#65. She stated she was unaware of the ankle fracture, it was prior to coming here. She further stated she was later told it happened during transfer when the resident's foot dropped to the floor. She stated that it wasn't reported because it wasn't something from an unknown origin. At that time, the DON confirmed that she was unable to locate an incident report. On 10/05/22 at 11:13 AM, Surveyor #3 interviewed the LNHA, who stated that if there was an injury of unknown origin, staff tells the nurse, who tells the DON or the supervisor. They look to see what caused the injury, i.e. bruise. He stated written statements would be taken from all staff that took care of resident for the last 72 hours and from all the unit aides to find out what happened because they help each other out. The LNHA stated an incident report was for the base line facts and it should be completed by the nurse assigned the resident. He stated an investigation would be done to see if it was from a mechanical lift, during care, if new equipment used to see if education is needed. He stated they would ask the resident what happened. He stated they would try to recreate the environment, i.e.: therapy new way to transfer. They would, try to make an educated decision of how something happened, if unable to find a cause, it would be reported to the NJDOH within 2 hours especially with a new bruise. He stated an investigation must be completed as soon as possible while it was fresh in everyone's mind, usually within 3 days. He further stated that the family and physician would be notified at the time of discovery by the nurse, but the DON would usually notify the family with the investigation results. The LNHA stated that the purpose of doing an investigation was to find root cause. He stated that there cannot be an assumption, there must still be a complete investigation and administration must be made aware. Surveyor #3 reviewed the incident for Resident #65 with the LNHA. The LNHA stated I remember being told it happened while putting a sock on the resident, the foot fell and hit floor. He further stated that an incident report was done but does not recall if family was notified of conclusion and that it was not reported because the cause was identified. Surveyor #3 made the LNHA aware that LPN#5 stated she did incident report and it was given to him. The LNHA acknowledged that the facility was unable to provide an incident report/investigation for the incident. Surveyor #3 asked the LNHA If there is not a report, or an investigation how can you show it was investigated? The LNHA stated I can't. On 10/06/22 at 9:19 AM, Surveyor #3 interviewed the Social Worker (DSS) in regard to the incident involving Resident # 65, who stated she did not know about the incident, and did not have soft file regarding the incident. On 10/06/22 at 10:25 AM, in the presence of the survey team, Surveyor #3 interviewed the Regional Administrator (RA), who stated that if there was an injury of unknown origin, an incident report would be generated to determine how the incident happened. She stated that statements would be taken from every staff including activities and therapy for the past 48 to 72 hours to determine if they knew how it happened. The RA stated she would ensure the incident/accident was completed in its entirety. She stated a complete head to toe assessment would be done and the injuries would be documented to include the size and location. The family and physician should be notified at the time the incident was discovered and then circle back when the investigation was completed and review any interventions being implemented with them. She stated staff would be in services if the incident occurred during care; equipment would be assessed like the wheelchair or the bedside tables to determine the cause and to prevent further injuries. The RA stated an investigation summary would be completed and kept for future purpose. She stated that if unable to determine the cause, it would be reported to the NJDOH. At that time, Surveyor #3 made the RA aware of the incident Resident #65. She stated that the incident should absolutely have been an investigated and yes 100% it should have been reported to the NJDOH. She further stated, If it is not documented it was not done, that is a nursing standard of practice. On 10/06/22 at 2:45 PM, in the presence of the survey team and the IIPLPN, LNHA, DON, and RA, Surveyor #3 presented the concern of not being provided with an incident report/investigation for Resident #65. On 10/07/22 at 9:08 AM, in the presence of the survey team, the IIPLPN stated that an Incident/Accident report for Resident #65 was found in the DON's office. Review of the undated Incident/Accident report revealed Incident Occurred: 07/02/22 at 9:30 AM, Incident description: Injury of unknown origin was checked; Incident Type: unwitnessed was checked; Mobility Status: dependent was checked; investigation initiated by: was blank and undated, Contributing Factors and Possible causes of incident was blank; Signatures lines for the Administrator, Director of Nursing, Medical Director, and Nurse were blank. Review of the Investigative Statements revealed three statements; one from CNA #4 dated 07/02/22 revealed: .am care on Resident #65, I noticed a bruise on right foot and I told the nurse and one from an unidentified staff (who was later identified as the assigned 3:00 PM to 11:00 PM CNA on 07/02/22) dated 07/02/22 was in the bed. I call the nurse come see it; and a undated statement from a CNA (who was later identified as the assigned 11:00 PM to 7:00 AM CNA on 07/01/22) I took care of the resident in room .did not complained of pain. The resident was fine when I left him/her. There was no assignment sheet attached and no indication that an investigation was completed. On 10/07/22 at 10:04 AM, in the presence of the survey team, the DON stated she could not find the incident report for Resident #65. The DON stated the LNHA handed it to her after he found it in a pile in her office. She stated she does not know who completed it, she didn't sign it and it should have been signed, LPN #5 no longer works here. She stated I am saying investigation sheet was here, not that it was complete. When asked by the survey team if the document was complete with causative factors, the DON stated no. When asked, what would you have expect to see, she stated since it was found in am care, I would have went back a few days, if it was found by the CNA which was documented as such, you don't know if it happened then or prior, there is nothing from a nurse regarding a statement. The DON stated the incident/accident report was absolutely incomplete, there are no times. The DON read the summary and conclusion and stated it doesn't tell you what happened or an attempt to find out what happened. The DON again confirmed that she did not find it, the LNHA handed it to her. On 10/07/22 at 11:34 AM, Surveyor #4 conducted a telephone interview with the Medical Director (MD), who confirmed she takes care of Resident #65. She stated they did not tell her that the X-ray wasn't completed the same day, and not until 07/04/22. She stated she may have sent her to the Emergency room. She stated she was not aware that there was no appointment available until the 20th for the orthopedic physician, and that it did not appear that the facility called until 07/08/22. The MD stated I 100 % expect them to call her if they cannot get an appointment, I can send them out. On 10/12/22 at 12:40 PM, in the presence of the survey team, the RN and the RA confirmed that there was no additional information, or evidence to provide regarding any of the requested information including investigations, besides what had already been provided to the surveyors throughout the survey process. A review of a package titled, Sensitivity, Individuality and Resident Rights provided by the facility as part of the sensitivity training for the TNA, the following were documented: Key Facts to Remember: A resident is not dependent on us. we are dependent upon him. A resident is not an interruption of our work, he is the purpose of it We are not doing him a favor by serving him. He is doing us a favor by giving us an opportunity to do so. A resident is not someone to argue with. Nobody ever won an argument. A resident is someone who brings us his wants. It is our job to fill them. Under Resident Rights the following were noted: Rights are both human privileges and legal protections. Frailty,dependency factors and advanced age cause nursing home residents to be highly vulnerable to violations of their individuality and autonomy. Residents have the same rights as you: To be treated with respect and dignity. To pursue a meaningful life. To be free from fear. The facility and staff are legally responsible for protecting and promoting each resident's rights. Violating a resident's right is breaking the law, and punishment could include being fired or sent to jail by a court of law. A review of facility policy, Charting and Documentation reviewed 5/26/22, Policy Interpretation and Implementation: 2. The following information is to be documented in the resident medical record: d. changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. A review of facility policy, Abuse Prevention & Reporting revised 5/20/22, Policy: 1. Residents of Atrium Center for Rehabilitation and Nursing will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations. 2. All alleged or suspected incidents of abuse, neglect, mistreatment, or misappropriation of residents' property will be thoroughly investigated, and findings documented in report format. 3. Any case in which abuse, neglect, mistreatment, or misappropriation of resident's property has been identified via the investigation, or a conclusion cannot be drawn will be reported promptly to the State Department of Health. 4. Allegations of abuse will be investigated in accordance with abuse and reporting guidelines. Identification: 2. The facility will investigate all unusual incidents and all injuries of unknown origin. Clues to help Identify Abuse: A. Physical Abuse Clues: Resident denies physical abuse however physical exam reveals .fractures. Responsibility: All non-licensed employees, Actions: 1. reports complaints and/or evidence of suspicion of abuse neglect injury of unknown origin or mistreatment to their supervisor immediately, 2. will complete written statements to aid in investigation. All licensed employees, Actions: 1. Notifies their supervisor immediately, 2. Notifies Administration of same. 3. Will complete written statement to aid in investigation. Nursing Supervisor/Social worker, Actions: 1. Obtains a statement from the resident in question, 2. Takes immediate necessary precautions/management pending complete investigation, 3. Interim case conference is held to develop interventions to ensure resident physical harm, pan, and/or anguish is minimized. Administrator/DNA/Designee, Actions: 1. Will ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source . are reported immediately to the administrator and/or representative and to other officials in accordance with State law through established procedures (including to the State survey and certification agency), 2. Will ensure that the results of all investigations are reported to the administrator .within 24 hours of the incident. Allegation of Abuse, neglect, exploitation or mistreatment and injuries of unknown source, Action: 1. All alleged violations of abuse are to be reported immediately but no later that 2 hours if the alleged violation involve abuse or results in serious bodily injuries. A review of the facility provided, Rehabilitation and Care Center Abuse Prevention & Reporting policy dated revised 5/20/22, included all residents of [name of another facility] will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations; all alleged suspected incidents of abuse, neglect .will be thoroughly investigated and findings documented in a report format; any case of abuse, neglect .has been identified via the investigation, or a conclusion cannot be drawn will be reported to the State Department of Health; allegations of abuse will be investigated in accordance with abuse and reporting guideline . sexual abuse: includes but is not limited to sexual harassment, sexual coercion, or sexual assault by family, visitor, staff or another resident .prevention: the facility will continue to provide individualized care plans that identify risk factors of residents at risk to implement plans for protecting their rights .identification: the facility will investigate any complaint, observation, or suspicion of resident abuse, mistreatment, or neglect .a report is to be filed if any individual has reasonable cause to believe the resident has been physically abused, mistreated, or neglected by the staff of this facility and/or by a family member or visitor .sexual abuse cues: difficulty walking or sitting; torn, stained, or bloody under clothes; pain or itching in genital area; bruising or bleeding in external genitalia, vaginal, and/or anal area; unexplained sexually transmitted disease .actions: all non-licensed employees should report complaints and/or evidence or suspicion of abuse, neglect .to their supervisors immediately; will complete a written statement to aid in investigation; all licensed employees: should notify supervisor immediately and administration at same time; will complete written statement to aid in investigation; Administrator/DON will ensure all alleged violations of mistreatment, neglect, or abuse .are reported immediately to the administrator and/or representative and to other officials in accordance with State law through established procedures .law enforcement to be notified no later than twenty-four hours. A review of the facility's Charting and Documentation policy dated effective 1/5/22 and reviewed 5/26/22, included .any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .the following information is to be documented in the resident medical record: objective observations .events, incidents or involving the resident; and progress toward or changes in the care plan and objective goals . A review of the facility provided, Rehabilitation and Care Center Abuse Prevention & Reporting policy dated revised 5/20/22, included all residents of [name of another facility] will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations; all alleged suspected incidents of abuse, neglect .will be thoroughly investigated and findings documented in a report format; any case of abuse, neglect .has been identified via the investigation, or a conclusion cannot be drawn will be reported to the State Department of Health; allegations of abuse will be investigated in accordance with abuse and reporting guideline . sexual abuse: includes but is not limited to sexual harassment, sexual coercion, or sexual assault by family, visitor, staff or another resident .prevention: the facility will continue to provide individualized care plans that identify risk factors of residents at risk to implement plans for protecting their rights .identification: the facility will investigate any complaint, observation, or suspicion of resident abuse, mistreatment, or neglect .a report is to be filed if any individual has reasonable cause to believe the resident has been physically abused, mistreated, or neglected by the staff of this facility and/or by a family member or visitor .sexual abuse cues: difficulty walking or sitting; torn, stained, or bloody under clothes; pain or itching in genital area; bruising or bleeding in external genitalia, vaginal, and/or anal area; unexplained sexually transmitted disease .actions: all non-licensed employees should report complaints and/or evidence or suspicion of abuse, neglect .to their supervisors immediately; will complete a written statement to aid in investigation; all licensed employees: should notify supervisor immediately and administration at same time; will complete written statement to aid in investigation; Administrator/DON will ensure all alleged violations of mistreatment, neglect, or abuse .are reported immediately to the administrator and/or representative and to other officials in accordance with State law through established procedures .law enforcement to be notified no later than twenty-four hours. A review of the facility's Charting and Docume[TRUNCATED]

Based on interview, record review and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure policies, procedures and systems were developed and implemented to ensure immediate action was taken to make certain that the facility operated in a manner to ensure residents' attained or maintained the highest practicable physical, mental and psychosocial well-being of each resident by ensuring that a resident was free of sexual abuse, and the facility maintained an effective infection control program that limited the spread of COVID-19 an infectious deadly virus as was identified during an on-site survey that began on 09/21/22 and was evidenced by the following: Refer to 600L, 880L, 886L This IJ situation began on 9/28/22 and the facility administration was notified of the IJ on 9/28/22 at 2:55 PM. The facility submitted an acceptable removal plan on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/04/22 at 12:02 PM. Two Immediate Jeopardy (IJ) situations were identified on 09/23/22 at 1:04 PM for 880L and 886L, which began on 09/21/22 at 1:09 PM, when the Licensed Nursing Home Administrator (LNHA) was unable to provide the survey team with requested policies, procedures and documentation required to conduct the survey, and on 10/11/22 at 2:03 PM, the 880L and 886L were revised to incorporate additional IJ findings of deficient practice. A subsequent IJ situation was identified on 09/28/22 at 2:55 PM for 600K, and on 09/30/22 at 1:31 PM was revised to incorporate additional findings which elevated the deficient practice to widespread finding of abuse at 600L. An additional finding of IJ was identified on 10/11/22 at 2:03 PM for 888L. Refer to 880L Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of COVID-19, infectious disease by failing to ensure: 1.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units, and 2.) a process was in place to ensure all required staff were appropriately fit tested for an N-95 respirator for 3 of 3 resident care units which placed all residents and staff at risk for contracting a contagious infectious and potentially deadly virus. Refer to 886L Based on interview, record review and document review it was determined that the facility failed to: 1.) conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result, and 2.) ensure a system was in place, and the facility Infection Preventionist followed the facility policy to ensure that all staff who required weekly or bi-weekly COVID-19 testing was completed and documented during a COVID-19 outbreak. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC) and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious potentially deadly virus. Refer to 600L Based on observation, interview, record review, and other pertinent facility documentation, it was determined the facility failed to ensure a.) residents were free from sexual abuse after an allegation of sexual abuse involving (Resident #10), and b.) protect vulnerable residents from being verbally abused by staff (Resident #56). Refer to 888L Based on interview, record review and document review it was determined that the facility failed to: 1.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22 and 2.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC) and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious potentially deadly virus. The non-compliance remained on 10/12/22 for no actual harm with the potential for more than minimal harm that is not IJ based on the following: 1. Based on interview and document review during the on-site survey conducted on 10/12/22, multiple Immediate Jeopardy situations were identified, in addition to a subsequent IJ identified on 10/11/22 at 2:03 PM for 888L, multiple deficient practices that were identified that had the potential to affect the health, safety and welfare of all residents who resided at the facility on 3 of 3 resident units. Refer to 609F, 610F, 689H, 865F, 725F, 812F, 843F, 865F, 867F, 882F On 09/21/22 at 9:05 AM, the LNHA informed the survey team that the facility was presently experiencing a COVID-19 outbreak and he would provide the facility line listing. The surveyor requested all of the infection control information, including staff vaccination policies and matrix, information on residents who smoked and times, and Quality Assurance and Performance Improvement (QAPI) information. On 09/21/22 at 1:09 PM, the surveyor conducted a follow-up interview with the LNHA who stated the Infection Preventionist, who had not completed an infection control certification, was responsible for all of the vaccination effort and would be able to provide all the information. On 09/22/22 at 10:06 AM, the Director of Nursing (DON) provided the survey team with a list of smokers, without the corresponding policy. On 09/22/22 at 2:14 PM, the DON and LNHA were unable to provide the survey team with all of the requested entrance conference documents including all infection control policies and procedures, vaccination matrix (document with the vaccination status of all staff) and a current facility line listing. On 09/22/22 at 2:26 PM, the LNHA confirmed that the facility infection control policies and procedures were not available. On 09/23/22 at 10:00 AM, the facility uncertified Infection Preventionist provided the survey team with a copy of the facility line listing two days after the initial request. On 09/23/22 at 11:32 AM, the LNHA informed the survey team that he was unable to provide the QAPI policies and procedures. On 09/23/22 at 11:34 AM, the survey team conducted an interview with the LNHA and DON regarding the National Health and Safety Network information that is required to be submitted regarding the staff vaccination status. The LNHA confirmed he inputted the information and confirmed there was no current employee vaccination list since not all employees were on it. The DON stated I am not making up what I don't have. On 10/06/22 at 2:43 PM, the survey team presented findings to the LNHA, DON, Regional Interim Infection Preventionist Licensed Practical Nurse (RIIPLPN), Regional Administrator and Regional Nurse. On 10/12/22 at 12:41 PM, the survey team met with the Regional Administrator and Regional Nurse who confirmed there was no rebuttal for the findings presented by the survey team and the facility had not additional information to provide. A review of the Administrator Job Description, signed by the LNHA on 06/22/2022, revealed the Purpose of Your Job Position; The primary purpose of your position is to direct the day-to day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times., Delegation of Authority; As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties., Administrative Functions; Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issues by management, Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility, Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice, Review the Facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations, Interpret the Facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary, Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures, Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice, Inform the Medical Director of all suspected or known incidents of resident abuse ., Resident Rights; .Review resident complaints and grievances and make written reports of action taken. Discuss such actions with resident and family as appropriate, Ensure that all policies governing the timely notice for resident discharges and/or room or roommate changes are strictly followed by all personnel .; Administrator; .Report all allegations of resident abuse and/or misappropriation of resident property, The Acknowledgement section of the jog description, dated 06/22/2022 and signed by the LNHA revealed I have read this job description and fully understand that the requirements set forth therein have be determined to be essential to this position. I hereby accept the position of Administrator and agree to perform the tasks outlined in this job description in a safe manner and in accordance with the Facility's established procedures. N.J.A.C. 8:39-9.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c.) On 09/22/22 at 12:52 PM, the surveyor #5 observed Resident #86 seated up in bed eating lunch. Surveyor #5 observed that a resident had a catheter (a tube used to drain urine from the bladder) and the catheter drainage bag (device to collect the urine) was in a blue privacy bag. Resident #86 stated that he/she was recently in the hospital for a procedure. The surveyor did not observe any signs on the door to indicate Resident #86 was on TBP. On 09/22/22 at 1:02 PM, surveyor #5 reviewed Resident #86's electronic medical record which revealed: A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to; congestive heart failure, benign prostatic hyperplasia (enlarged prostate) without lower urinary tract symptoms, and chronic bladder pain. The individualized, comprehensive care plan (CP), which included a care concern of infections with an active effective date of 8/10/22. The CP did not include an intervention of TBP. The August and September, 2022 Medication and Treatment Administration Records. The Administration Records reviewed did not include an order for TBP. The laboratory results which indicated that the resident had a urine culture on 8/5/22, and that the result was abnormal (deviation from normal). Surveyor #5 was unable to view the results and the organism identified in the abnormal culture result. On 10/04/22 at 12:20 PM, after Surveyor #5 requested the facility to correct the inability of surveyor #5 view the complete urine culture result, surveyor #5 viewed Resident #86's 08/05/22 urine culture result which included the following: RESULT Enterobacter cloacae (Isolate 1) RESULT Proteus mirabilis ESBL (Isolate 2) (ESBL-extended spectrum beta-lactamase is an enzyme or chemical produced by enzymes that is resistant to many antibiotics). A review of the progress notes failed to include an entry that indicated Resident #86 was placed on TBP. On 10/04/22 at 12:29 PM, surveyr #5 interviewed LPN #2 who stated that she had not observed any resident culture results that were ESBL. She added that the physician would inform them if a resident required to be placed on TBP and LPN #2 then confirmed that Resident #86 was not on TBP. On 10/04/22 at 12:46 PM, during surveyor interview, the IIPLPN stated that some residents would need to be placed on TBP for certain infections. She added that for ESBL, TBP would include face shield, gown and gloves. The IILPN stated that the physician, Infection Preventionist or Director of Nursing would review culture results and would decide if TBP were required. On 10/05/22 at 10:32 AM, surveyor #5 interviewed a Registered Nurse (RN) who stated that the process for the result of the urine culture would be that the result is transmitted through the computer system and that the nurse would call the physician with an abnormal result. The surveyor then asked the RN what would be required if a result was ESBL. The RN stated if a result was ESBL then the nurse would contact the physician and the resident would be placed on TBP which would include full contact precautions, with a gown and gloves prior to entry into the room. The surveyor had the RN view Resident #86's 08/05/22 urine culture result. The RN confirmed that Resident #86's urine culture result was proteus mirabilis ESBL. On 10/05/22 at 10:48 AM, surveyor #5 interviewed the DON regarding the process for results of a resident urine culture. The DON stated that the nurse would view the result and notify the physician. She added that the physician would order accordingly, and the nurse would document in the medical record. The surveyor then asked the DON what the process was if a urine culture result was ESBL. The DON stated that the resident would be isolated (placed on TBP) but was not sure for how long. The surveyor then asked the DON if she would expect a physician order for TBP, or a progress note that the resident was placed on TBP. The DON stated that she would expect both. The surveyor then asked the DON to view Resident #86's 08/05/22 urine culture in the electronic medical record. The DON confirmed that the urine culture result was ESBL and that she did not see a physician's order for TBP or a progress note that Resident #86 was placed on TBP. The surveyor then asked the DON if she reviewed urine culture results. The DON stated that she did not review urine culture results unless someone would bring the result to her attention. She added that now she would need to. She then stated that she would expect the URNIP to have viewed the result and placed the resident on TBP. She added that the URNIP at the time of the result was no longer here. The surveyor then asked the DON if Resident #86 should have been placed on TBP. The DON stated that Resident #86 should have been placed on TBP and that she would find out if the resident needed to be placed on TBP. On 10/05/22 at 12:09 PM, surveyor #5 interviewed the IIPLPN. The IIPLPN stated that she had previously been the Regional Educator and on 09/25/22 her role was transitioned to IIPLPN. The surveyor then asked the IIPLPN what the process was if a resident had ESBL. The IIPLPN stated that for ESBL, staff would need to wear goggles, gloves and gowns when staff had high contact care with the resident. The surveyor then asked the IIPLPN if ESBL was a MDRO (multi-drug resistant organsim) and the IIPLPN confirmed that it was. The surveyor then asked the IIPLPN how long the resident would need to be on TBP and if there was a recent change in guidance for MDRO isolation. The IIPLPN stated that TBP length depended on the antibiotic therapy. She then added that if there was new guidance on MDRO's that she had not been aware. On 10/05/22 at 1:06 PM, the DON stated that Resident #86 was now placed on TBP. On 10/6/22 at 8:40 AM, surveyor #5 reviewed the facility provided Physician's Order set which included an order, dated 10/5/22, Maintain Contact Precautions (ESBL in urine). On 10/07/22 at 11:04 AM, the surveyor asked the LNHA if a resident with ESBL needed to be placed on TBP. The LNHA stated that a resident that had ESBL should be placed on TBP. He added that he did not have a clinical background but that it should be a combined effort with nurses, the physician, DON and Infection Preventionist and that they should have a discussion. On 10/07/22 at 11:34 AM, during surveyor interview, RLNHA stated that a resident with ESBL should be placed on TBP. On 10/07/22 at 01:35 PM, in the presence of the survey team and the LNHA, the RLNHA confirmed that the facility did not have a policy specifically for ESBL. A review of the facility provided policy titled, Multidrug-Resistant Organisms, with a reviewed date of 1/5/22, included the following: Under Policy Statement Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism. Under Policy Interpretation and Implementation General guidelines 1. Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs . Under Enhanced Infection Control Precautions Use of Contact Precautions 1. Implement Contact Precautions routinely for all resident colonized or infected with a target MDRO. 2. Because environmental surfaces and medical equipment, especially those in close proximity to the resident, may be contaminated, don gowns and gloves before or upon entry to the resident's room or cubicle. A review of the facility provided policy titled, Urinary Tract Infections/Bacteriura-Clinical Protocol, with a reviewed date of 1/5/22 did not include any information on TBP for MDRO's. Reference: Centers for Disease Control and Prevention's (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), with an updated date of July 12, 2022, included the following: Key Points [1]: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: -Wounds or indwelling medical devices, regardless of MDRO colonization status -Infection or colonization with an MDRO . Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) [10] which contributes to the silent spread of MDROs . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Reference: CDC's Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, with a last reviewed date of 7/27/22, included the following: These FAQs were created to address questions about Enhanced Barrier Precautions as defined in the CDC guidance Implementation of Personal Protective Equipment (PPE) in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) Definition and scope of Enhanced Barrier Precautions What are Enhanced Barrier Precautions? Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of Multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). a.) On 09/21/22 at 11:07 AM, Surveyor #4 observed the COVID-19 PUI unit on the first floor. Surveyor #4 observed room [ROOM NUMBER] with a Stop sign affixed to the door and a plastic bin located next to the door. The plastic bin contained PPE gowns, surgical masks, N95 masks, gloves, hand sanitizer, and eye protection. Surveyor #4 observed another sign on the door Stop Observation-Quarantine Precautions, in addition to standard precautions; only essential personnel should enter this room; everyone MUST: hand hygiene before gloving and after glove removal, wear Mask N95 if fit tested and available or surgical mask if not fit tested or failed fit test, and eye protection; gown and gloves required prior to entering if you anticipate contact with resident or potentially contaminated surfaces in close proximity to resident. Quarantine Precautions: for use during COVID-19 pandemic - newly admitted residents during observation period (14 days); unvaccinated residents with frequent visits outside the facility .personal protective equipment with illustration how to don (put on) and doff (take off). Surveyor #4 then observed a staff member inside of the room without wearing eye protection, or a PPE gown, and the staff was wearing a cloth mask, and gloves. The staff member was handing Resident #245 a bar to exercise with. The staff member was identified as an Occupational Therapy Aide (OTA), and the OTA proceeded to exit the room wearing the same cloth mask and gloves. The OTA stated that PPE was not part of her training when she began at the facility about two weeks prior, and stated she had not been fit tested for the N95 mask. She stated she did see the signage on the door but did not wear any PPE because she had seen the resident before and she did not think it was a problem. The OTA then stated to Surveyor #4 that by not wearing her PPE, she could become contaminated, and possibly spread the COVID-19 infection. The OTA stated she had been trained about a year ago on PPE, but that was with a different company. Surveyor #4 asked the OTA if she was aware why the resident was on isolation. The OTA stated she believed something for COVID-19, but the resident did not have any symptoms that she was aware of. The OTA acknowledged the Stop sign affixed to the door and stated that she had not checked with the nurse prior to entering the room. A review of Resident #245's medical records revealed the resident had been recently admitted with diagnoses which included, but was not limited to; Multiple Sclerosis and pain. A review of the admission Minimum Data Set (MDS), an assessment tool dated 09/16/22, revealed a Brief Interview of Mental Status (BIMS) of 15/15 indicating the resident was cognitively intact. A review of the Physician's Orders (PO) revealed an order dated 09/13/22, for Occupational Therapy Screen, Evaluate and Treat. A review of the facility provided immunizations for the resident revealed Resident #245 had not been vaccinated for COVID-19. During an interview with Surveyor #4 on 09/21/22 at 11:19 AM, and in the presence of the OTA, the DON stated the therapy department was not new to the facility. The DON stated there would be signs on the doors of isolation rooms to alert the staff of what PPE should be worn inside the rooms, and the DON confirmed there was a sufficient supply of PPE in the bins next to the doors. The DON then informed the OTA that she should not be wearing a cloth mask, and could not wear gloves in the hallway. The OTA at that time placed her gloved hands into her scrub top pockets. The DON stated if staff did not wear the appropriate PPE, they could spread infection (COVID-19). The DON further stated she was not sure who would be responsible for training new therapy staff on PPE. The DON then acknowledged the OTA had not been fit tested and stated the OTA should not be in the COVID-19 isolation room without first being fit tested. At that time, the DON again instructed the OTA to remove her gloves and wash her hands. On 09/23/22 at 9:06 AM, during an interview with Surveyor #4, the acting URNIP stated she had not fit tested everyone working on the PUI/COVID-19 unit with the residents. The RN #1 stated the staff should be wearing N95 masks and that she had not gotten around to check, or work with staffing to see who should be working with the PUI/COVID-19 positive residents. On 09/28/22 at 8:39 AM, Surveyor #4 observed a staff member on the first floor PUI/COVID-19 unit. The staff member was wearing an N95 mask that was not secured around her head and both straps of the N95 mask were sticking out of the sides of a surgical mask she was wearing. The staff member was stepping into the COVID-19 isolation room of Resident #249 with signage on the door. The signage, Stop Observation-Quarantine Precautions, in addition to standard precautions, only essential personnel should enter this room, everyone MUST: hand hygiene before gloving and after glove removal, wear Mask N95 if fit tested and available or surgical mask if not fit tested or failed fit test, and eye protection; gown and gloves required prior to entering if you anticipate contact with resident or potentially contaminated surfaces in close proximity to resident. Quarantine Precautions: for use during COVID-19 pandemic .personal protective equipment with illustration how to don (put on) and doff (take off). At that time Surveyor #4 interviewed the staff member who identified herself as an LPN who worked with a contracted wound care company. The wound care LPN stated she had been in-serviced on PPE before, but not at the facility. She further stated she was not sure if the resident was positive for COVID-19. The wound care LPN stated she had been fit tested for the N95 mask and knew that the straps should be around her head, but my nose is sore, so I anchored the N95 with a surgical mask. Surveyor #4 asked how the N95 should fit. The wound care LPN stated the N95 should be a tight fit and acknowledged that hers was not really a tight seal. She further stated that by wearing the N95 incorrectly, she could become exposed to COVID-19. A review of Resident #249's medical records revealed the resident had been admitted diagnoses, the included but were not limited to; Dementia, Type 2 Diabetes Mellitus, cardiovascular disease, and pain. A review of the PO revealed the following orders: dated 07/21/22, wound consult and treat as needed, and dated 09/29/22, for contact and droplet precautions related to positive COVID-19 test on 09/24/22. A review of the Treatment Administration Record (TAR) dated September 2022, revealed an order start date of 09/17/22, to cleanse post calf of left leg with normal saline solution (NSS) apply calcium alginate, cover with dry dressing, and wrap daily. A second TAR order start date of 08/27/22, to cleanse posterior right calf with NSS apply calcium alginate, cover with dry dressing, and wrap daily. A review of the COVID-19 vaccination record card revealed the resident had the initial two COVID-19 vaccinations on 10/8/21 and 03/18/22, but no booster. During an interview with Surveyor #4 on 09/28/22 at 11:35 AM, the OT Director stated newly hired staff would be oriented on their case load, the computer system, be given a tour of the facility, educated on how to enter notes into the computer, and orders, and also stated would be educated on COVID-19 signs and symptoms. He stated the protocol for what staff should wear into an isolation room would be to follow the signs on door. The OT Director stated the OTA was educated on PPE, however, the OT Director was not sure who conducted the education. He further stated newly hired staff orientation education would not have an orientation check list that he was aware of. On 09/28/22 at 11:43 AM, during an interview with Surveyor #4, the IIPLPN stated the facility would inform any vendors of any positive COVID-19 cases in the building. The IIPLPN stated there would be signs on the doors to let everyone know what (PPE) to wear, the type of isolation, and there was available PPE. She further stated the N95 mask needed to be snug, or whoever was wearing it could be exposed (to COVID-19). The IIPLPN stated anyone going into a COVID-19 positive resident room must wear the N95 mask, eye protection, PPE gown, and gloves. On 09/28/22 at 12:21 PM, the IIPLPN, who had previously been the facility nurse educator until 09/23/22, provided new hire information dated 08/25/22 for the OTA. The information provided did not contain any education on PPE or TBP. On 09/30/22 at 9:26 AM, during an interview with Surveyor #4, the Human Resources (HR) staff member stated that during on-boarding a new employee, the facility would obtain their license and vaccination cards. The new hire would next attend orientation about policies and facility dress code. When asked about PPE training, HR stated that the Infection Preventionist would be responsible for that. HR further stated that staff should not work without PPE training. When asked about new hire information regarding PPE for the OTA, HR acknowledged she was unable to locate anything. On 10/03/22 at 11:49 AM, Surveyor #5 observed a Behavioral Aide (BA) #1 working on the first floor COVID-19 positive unit. BA #1 was wearing an N95 mask with both straps not properly secured. Upon interview, she stated she did not know why the N95 mask was not secured properly. BA #1 was not aware of what PPE she was supposed to wear, or what was supposed to be done before entering into a COVID-19 positive room. BA #1 stated her job was to watch behavioral residents on the third floor locked unit. She further stated she had been in-serviced recently on PPE, donning/doffing. Surveyor #5 next observed LPN #5 trying to stop BA #1, but BA #1 had already entered into the COVID-19 positive room [ROOM NUMBER] wearing her N95 mask with both straps unsecured and a surgical mask. LPN #5 informed BA #1 she needed to don/doff and secure her N95 mask properly. The surveyor observed BA #1 exit the COVID-19 positive room wearing the PPE. LPN #5 in-serviced BA #1 on proper PPE usage while Surveyor #5 was still present on the unit. The LNHA was made aware. On 10/05/22 at 12:58 PM, the facility provided the wound care company's sign in sheet with the topic, Proper use of PPE, COVID protocol, infection control dated 07/20/22, with the signature of the wound care LPN with her title listed as Quality Assurance Nurse. There was a PPE true or false Quiz included in the documentation. The facility further provided the wound care company, Infection Prevention policy updated September 2021; which included, but was not limited to, Policy: all personnel shall follow the infection control policy and procedure of each affiliated facilities to prevent the spread of infection; Interpretation and Implementation: 6. Any signage outside patient's door, personnel shall inquire to the staff in the unit the type of infection, and follow the appropriate PPE. The facility provided the undated wound care company, Sequence for Putting On PPE, which included 2. Mask or respirator, secure ties or elastic bands at middle of head and neck, fit flexible band to nose bridge, fit snug to face and below chin, and fit check respirator. A review of the facility provided, Outbreak Plan COVID-19 Response revised 03/10/22, included but was not limited to: Suspected Case in the Facility: c. if the suspected infectious person requires care .follow .policies for isolation procedures, including all recommended PPE for staff at risk for exposure. g. implement the isolation protocol in the facility .as described in infection prevention and control plan and/or recommended by local, state or federal public authorities. A review of the NJ DOH, Recommendations for Long-Term Care Facilities during COVID-19 Pandemic, dated 03/20/20, included but was not limited to: for suspect or confirmed COVID-19 case(s), standard and TBP including use of N95 respirator, gown, gloves, and eye protection. A review of the CMS, COVID-19 Long-Term Care Facility Guidance dated 04/02/20, included but was not limited to: 4. Longer-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents .full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19. b.) On 09/21/22, during the facility entrance conference, the facility informed Surveyor #1 that they currently were in an outbreak of COVID-19 but were unsure of the date the outbreak began. On 09/22/22 at 3:45 PM, during an interview with four surveyors, Registered Nurse (RN #1) stated she had administered a COVID-19 rapid test to Resident #44 on 09/21/22, who had symptoms and the result was positive. RN #1 stated that COVID-19 testing should be completed for someone if they were symptomatic. RN #1 confirmed that Resident #44 had a cough and could not state when the cough began. A review of Resident #44's medical records revealed that the resident had been admitted with diagnoses which included, but were not limited to, sepsis, Diabetes Mellitus, and diabetic nephropathy. A review of the COVID-19 Vaccination Record Card revealed that Resident #44 had two initial doses of COVID-19 vaccination and two booster doses. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated September 2022, revealed an order to monitor for symptoms of COVID-19 with a start date of 09/24/22. On 09/23/22 at 8:53 AM, during an interview with Surveyor #1, LPN #1 (working on the 2nd floor) stated she knew symptoms of COVID-19 would consist of a cough and runny nose. She stated that a rapid COVID-19 swab should be done. Surveyor #1 inquired to LPN #1 if she was responsible for completing any COVID-19 symptom monitoring for her assigned residents. She stated, vitals are taken on everyone usually, if there were new symptoms then she would check vital signs (clinical measurements, specifically pulse rate, temperature respiration rate and blood pressure that indicate essential body functions), and that she would do vital signs if she had to and stated she has not seen any formal monitoring for vital signs. On 09/23/22 at 8:53 AM, during an interview with Surveyor #4, RN #2 (working on the 1st floor) stated she would monitor residents for temperature, sneezing and coughing. She stated she would document any symptoms in the progress notes because there was no place to document in the electronic medical record (EMR). RN #2 stated that if a resident needed to have a rapid COVID-19 test, the IIP RN would have to administer it. RN #2 further stated if she had to do the rapid COVID-19 test, she would have to call to get the test. On 09/23/22 at 9:42 AM, the URNIP stated she was not made aware that Resident #44 had symptoms of COVID-19 on 09/20/22, because the staff had not informed her. On 09/23/22 at 11:45 AM, during an interview with surveyors, the DON stated that anyone should be tested as soon as symptoms of COVID-19 develop. The DON further stated that as of right now I don't have a form that they (staff) are testing for symptoms and that there was no symptom monitoring system for residents who had symptoms of COVID-19 in the currently used EMR. A review of the facility provided, Outbreak Response Plan revised 03/10/22, included but was not limited to Goal; to protect our residents, families, and staff from harm resulting from exposure to an emergent infectious disease while they are in our facility .The local state and federal health authorities will be the source of the latest information and most up to date guidance on prevention, case definition, surveillance, treatment .response related to a specific disease threat. Local Threat: a .specific surveillance and screening as instructed by Centers for Disease Control and Prevention (CDC). A review of CMS, QSO-20-26-NH, dated 04/19/20, included but was not limited to Guidance; Nursing homes are currently required to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This includes a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. A review of the NJ DOH, Recommendations for Long-Term Care Facilities during COVID-19 Pandemic, dated 03/20/20, included but was not limited to: Surveillance and Tracking: maintain and/or implement protocols for daily monitoring of residents and HCP for fever and other symptoms of COVID-19 (ie: gastrointestinal upset, fatigue, sore throat, dry cough, shortness of breath); enhance active surveillance: when a confirmed COVID-19 case is identified monitor residents twice daily at minimum (ie: gastrointestinal upset, fatigue, sore throat, dry cough, shortness of breath) vital signs should include heart rate, blood pressure, temperature, pain and pulse oximetry. The facility administration was unable to provide documentation of consistent monitoring of fever, respiratory illness, or other signs/symptoms of COVID-19 at least daily, in order to immediately isolate and test anyone who was symptomatic. Surveyor: [NAME], [NAME] Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of infectious disease by failing to ensure: 1.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units, and 2.) a process was in place to ensure all required staff were appropriately fit tested for an N-95 respirator and documentation was completed for 3 of 3 resident care units. This deficient practice placed all residents and staff at risk for contracting a contagious infectious and potentially deadly virus and was evidenced by the following: Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022 Part 1 The facility's failure to ensure a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units resulted in an Immediate Jeopardy (IJ) situation that began on 09/20/22, when two symptomatic residents (Resident #44 and Resident #52) were not immediately tested for COVID-19 and tested on e day later, on 9/21/22, and both residents were positive for COVID-19. The facility uncertified Registered Nurse Infection Preventionist (URNIP) confirmed contact tracing was not completed to identify any close contacts for Resident #44 and Resident #52, and the URNIP was unable to provide documented evidence of contact tracing that was completed to identify close contacts for both residents. The facility administration was notified of the IJ on 9/23/22 at 1:04 PM. The facility submitted an acceptable removal plan via electronic mail (email) on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an on-site visit on 10/03/22 at 1:49 PM. The evidence was as follows: On 09/21/22 at 9:18 AM, upon entrance to the building, Surveyor #1 requested information from the Corporate Nurse (CN) regarding any COVID-19 positive residents currently residing in the building. The CN stated there were no COVID-19 positive residents in the building, and there were two persons under investigation (PUI- a person who had been in contact with a person [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The non-compliance remained on 10/12/22, for no actual harm with the potential for more than minimal harm that was not IJ evidenced by the following: 1. Based on interview and review of facility documentation, it was determined that the facility failed to test unvaccinated staff for Coronavirus Disease 2019 (COVID-19) at a frequency based on the facility's policy, COVID 19 Management (All Policies). This deficient practice was identified for 3 of 3 staff members reviewed for COVID-19 testing and was evidenced by the following: On 09/26/22 at 12:02 PM, the DON provided the Staff Vaccination Matrix (SVM) to the survey team, she confirmed it was completed over the weekend because they did not have staff vaccination cards prior to that time. On 09/26/22 at 2:18 PM, the IIPLPN provided an updated SVM to the survey team. On 10/05/22 at 9:37 AM, after a review of the SVM in the presence of the survey team, the RLNHA, the LNHA, the Regional Nurse (RN) and the DON, Surveyor #3 requested 9 weeks of testing from August 1, 2022 for the two staff members identified by the facility as having COVID-19 vaccination exemptions, and one partially vaccinated staff member as listed on the SVM. A review of the testing from August 1,2022 provided by the Regional Administrator (RA) on 10/5/22 at 10:53 AM, revealed the following: A. The Staffing Coordinator tested negative on 9/28/22 and 10/4/22. B. LPN # 3 tested negative 8/17/22. C. Temporary Nurses Aide (TNA) #1 tested negative on 8/17/22 and 9/28/22. On 10/05/22 at 1:18 PM, in the presence of the survey team, the RLNHA confirmed that the above provided testing was the only COVID-19 testing that could be located for the prior nine weeks beginning August 1, 2022 and confirmed that the facility's Outbreak started 06/24/22. On 10/06/22 at 1:50 PM, in the presence of the survey team, Surveyor #3 interviewed the IIPLPN. The IIPLPN reviewed the facility's policy COVID 19 Management (All Policies), and confirmed that all staff who are exempt or not up to date with the COVID-19 vaccine should be tested for COVID-19 at least once a week but they are not. Surveyor #3 reviewed the testing for the above listed staff members with the IIPLPN. She then stated that staff with an exemption or partially vaccinated should be tested twice a week during an outbreak. She stated LPN #3 works per diem (as needed). Surveyor #1 confirmed LPN #3 worked on 9/16/22, the IIPLPN confirmed that there was not testing provided for 9/16/22, but she should have been tested that day. She further stated, if staff with an exemption work per diem they should test when they come to work. She stated that the Staffing Coordinator was here every day so she should have been tested twice a week and TNA #1 is not fully vaccinated and should have been tested twice a week. The IIPLPN acknowledged that staff that are exempt and/or not up to date were not being tested the way that they should be during an outbreak, which was twice a week and according to the facility's policy, which was once a week. On 10/06/22 at 02:45 PM, in the presence of the survey team, Surveyor #3 made the IIPLPN, the LNHA, the DON, and the RA aware of the above concerns with testing of employees that were not up to date with their vaccination. A review of the facility's policy, COVID 19 Management (All Policies) revised on 5/31/2022, revealed; Staff COVID 19 Vaccination and Testing Requirements, Procedure: 3. All employees of this facility must be fully vaccinated including booster vaccinations as they are mandated or have an approved medical exemption. 4. For Staff whom are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): at minimum perform weekly testing, 12. All employees, contract staff and medical staff will be tested for COVID-19 as per the most current guidelines. N.J.A.C. 8:39-5.1(a) Based on interview, record review and document review it was determined that the facility failed to: 1.) conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result, and 2.) ensure a system was in place, and the facility Infection Preventionist followed the facility policy to ensure that all staff who required weekly or bi-weekly COVID-19 testing was completed and documented during a COVID-19 outbreak. The facility's failure to take immediate action, follow Centers for Disease Control and Prevention (CDC) , Centers for Medicare and Medicaid Services (CMS) guidance, and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious deadly virus. Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 03/10/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022 Refer to 880L, 888L Part 1 The failure to conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result. This resulted in an Immediate Jeopardy (IJ) situation which began on 09/20/22 and was identified on 09/23/22 at 1:04 PM. The facility's COVID-19 outbreak began on 06/24/22. Two residents (Resident #44 & #52) were symptomatic, coughing and sneezing on 09/20/22, and the facility's uncertified Infection Preventionist Registered Nurse (UIPRN) confirmed testing was not immediately performed on 09/20/22. The facility administration was notified of the IJ on 9/23/22 at 1:04 PM. The facility submitted an acceptable removal plan on 09/27/22 at 3:46 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/03/22 at 1:49 PM. The evidence was as follows: On 09/21/22 at 9:18 AM, upon entrance to the building, Surveyor #1 requested information from the Corporate Nurse regarding if there were any COVID-19 positive residents in the building. The Corporate Nurse stated there was no COVID-19 positive resident in the building, and there were two persons under investigation (PUI- a person who had been in contact with a person with an infection or awaiting testing for a suspected infection) who resided on the first floor. At 9:05 AM, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility was currently in an outbreak of COVID-19 and would provide the survey team with a copy of the current line listing. On 09/21/22 at 1:09 PM, Surveyor #1 held an entrance conference with the LNHA and Director of Nursing (DON). The LNHA stated the UIPRN was not certified since she had not yet completed the infection control training. The LNHA stated that the UIPRN was responsible for all of the facility vaccination effort. Surveyor #1 inquired to the number of COVID-19 positive residents and symptomatic residents who were currently residing in the facility and the LNHA stated there were currently no COVID-19 positive residents who resided at the facility, and there were two residents who were considered persons under investigation. Surveyor #1 requested all the information related to the current COVID-19 vaccination status of all residents and staff and all related testing for COVID-19. The LNHA and DON stated that residents and staff were tested twice per week, however, they were unable to provide the documentation and stated that the UIPRN would be able to provide the testing information. On 09/22/22 at 9:43 AM, the DON and LNHA informed the survey team that two residents (Resident #44 & Resident #52) had tested positive for COVID-19 and now resided on the first floor after being transferred from the third floor due to testing COVID-19 positive. The LNHA stated the positive results were identified during routine COVID-19 testing. On 09/22/22 at 9:55 AM, the DON and LNHA failed to provide the survey team with the requested documents related to infection control, which included staff vaccination and staff and resident testing documentation. The LNHA stated the documents were with the corporate people and he was unable to produce the documents. On 09/22/22 at 3:42 PM, the UIPRN was interviewed by Surveyor #1, #2, and #3, regarding the facility testing process. The URNIP stated that not all staff and residents were tested twice weekly. She stated if the resident had not yet received a COVID-19 booster vaccine, they would be tested twice weekly. Surveyor #1 inquired as to what was the criteria that was used to determine what staff were tested for COVID-19. The UIPRN reviewed her COVID-19 testing log with the surveyors and stated if some staff felt like they had a cold, they could be tested. The URNIP then stated there is no staff members that need to be tested at present. The UIPRN presented a log with handwritten COVID retesting employees, [brand name rapid COVID-19 test] Test Sign Off dated 09/20/22, and contained three staff names, dated 09/20/22, with a negative result documented for a Licence Practical Nurse (LPN #1), Maintenance Director (MD) and Staff #1. The UIPRN stated only residents were on her list to receive COVID-19 testing twice per week. A second document provided by the UIPRN, revealed a handwritten COVID testing, 09/20/22, pt's The handwritten document contained eleven names, dated 09/20/22, with a negative result and seven names were listed and dated 09/21/22. The UIPRN stated the eleven names that were listed did not receive a COVID-19 test due to the COVID-19 Positive residents identified on 09/21/22. Resident #52 and Resident #44 were also listed on the document, with a positive result, and the remaining five names were listed with a negative result. Surveyor #1 inquired to the UIPRN regarding why the other names listed had received a COVID-19 test. The UIPRN stated three staff requested a test, one resident requested a test, one resident was the Unsampled Resident roommate of Resident #44 who also requested to be tested. At 3:45 PM, the UIPRN confirmed the two pages that were provided to the surveyors, and reviewed with the surveyors, was the only COVID-19 testing log for employees or staff on 09/20/22 and 09/21/22, with no other testing dates provided. A review of the Electronic Nursing Progress Notes (EPN) for Resident #44 revealed on 09/21/22 at 10:51 PM a nurse documented that Resident has been coughing and sneezing since yesterday. MD [doctor] made aware and ordered COVID test. Resident tested positive for COVID 19 .Resident Transferred to the 1st floor room . The Care Plan Activity Report for Resident #44 revealed, The COVID-19 Actual or suspected Care Plan, As Evidenced By: Confirmed positive for COVID 19 09/21/22, Effective: 09/21/22, Goals revealed, I will recover from COVID 19, Effective 09/21/22, Interventions included; We will place you in isolation form droplet and contact precautions until the virus is resolved. Effective:09/21/22, We will confine you to your room during your illness to prevent the spread of the virus, Effective:09/21/22, We will monitor your temp [temperature], vital signs, pulse ox [blood oxygen level] and symptoms to see if you are responding to treatment, Effective 09/21/22. A review of the EPN for Resident #52 revealed on 09/21/22 at 3:50 PM, Licence Practical Nurse #1 (LPN #1) documented covid swab requested., and at 10:50 PM, another nurse documented Resident has been coughing since yesterday. MD made aware and ordered COVID test. Resident tested positive for COVID 19 .Resident Transferred to the 1st floor . (This represented a seven hour delay from the documented request for the Covid swab at 3:50 PM) On 09/23/22 from 9:42 AM to 10:00 AM, Surveyor #1 again interviewed the UIPRN in the presence of Surveyor #2, #3, and #4. The URNIP stated Resident #44 was tested on [DATE], and confirmed the resident was symptomatic on 09/20/22. The UIPRN stated that Resident #52 was tested due to also having symptoms on 09/20/22, and the resident tested positive on 09/21/22. The UIPRN stated she was not made aware until 09/21/22, that Resident #44 and #52 were symptomatic on 09/20/22. When asked if she should have been informed of the symptomatic residents she stated yes, I would think so. When asked who is responsible for completing any contact tracing related to the COVID-19 positive cases, the UIPRN stated that is a good question and stated it would be under her jurisdiction. The surveyor inquired to the UIPRN if she was aware that Resident #52 had attended a funeral on 09/16/22, as documented in Resident #52's progress notes. The URNIP stated no, she was not aware. The UIPRN stated that she had just found out from the survey team that Resident #52 had left the facility out on pass, otherwise, she stated she would have tested the resident for COVID-19 before and after having left the facility out on pass. The UIPRN stated that she tried to get information from staff and made rounds daily. When inquired to the URNIP when the current outbreak started and what the status was, the UIPRN stated she did not know when the outbreak started, not the specific date, and as far as she knew they were always in an outbreak. The Regional Licensed Nursing Home Administrator (RLNA) provided the survey team with a copy of the facility Outbreak Plan/Covid-19 Response, revised 03/10/22, which was reviewed in the presence of the UIPRN . The document revealed a Higher -risk exposure- refers to exposure of an individual's eyes, nose, or mouth to material potentially containing SARS-CoV-2, particularly if present in the room for an aerosol-generating procedure. This can occur when staff does not wear adequate personal protective equipment during care or interaction with an individual. The document also revealed Upon identification of a single new case of COVID-19 in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing though two approaches, contact tracing or broad-based (e.g., facility-wide) testing. Surveyor #1 inquired to the UIPRN regarding what staff were considered exposed to Resident #44 and Resident #52 and were any of the staff tested for COVID-19 in response to the exposure. The UIPRN stated everyone could be going into the room, anyone can answer a light, and stated, I will be honest with you, I didn't test anyone and stated I tested the two [Resident #44 and #52] that were positive and the immediate roommate. The UIPRN then confirmed, in the presence of the survey team, that she did not complete any contact tracing and the book of testing that she had provided to the survey team was in it;s entirety, no other COVID-19 testing documentation was available and confirmed there was no facility wide testing completed in response to the Residents #44 and #52 positive COVID-19 status. The UIPRN stated any other staff member could complete a COVID-19 test if they were trained. When inquired if any other staff had been trained to do COVID-19 testing she stated, not off the top of my head. Surveyor #3 inquired to the UIPRN regarding what should be done when a resident was experiencing symptoms of COVID-19. The UIPRN stated that the facility had a DON and testing supplies can be obtained as needed and the residents should be tested if they are symptomatic and unvaccinated, the resident should be transferred to a COVID-19 isolation room with isolation signs placed. The UIPRN stated if residents were symptomatic and then tested negative for COVID-19, they should be moved to an isolation room for PUI in the event they became COVID-19 positive. The UIPRN stated if there was a room mate to the COVID-19 positive resident, that person would be tested, and Resident #52 did not have a roommate. The UIPRN stated that the roommate of Resident #44 was tested for COVID-19 on 09/21/22, and tested negative, but was not restricted to the PUI section at this point. The URNIP stated both Resident #44 and #52 were both coughing on 09/20/21, and were very alert. The URNIP was asked if she completed the facility line listing (the spreadsheet of all COVID-19 infections that is transmitted to the Department of Health) and communicated with the local Department of Health (DOH) regarding new COVID-19 cases. The URNIP stated the LNHA was responsible for the line listing and contacting the DOH. The UIPRN provided the survey team with a copy of the facility line listing which revealed that the symptoms for Residents #44 and #52 had an onset date of 09/21/22, and the survey team inquired if that date was correct, and the UIPRN stated that date should be changed to 09/20/22. On 09/24/22 at 9:30 AM, Surveyor #1 toured the third floor unit and observed a Certified Nursing Aide (CNA #1), who was wearing a black surgical mask and was making the bed in Resident #44's room. The surveyor inquired to CNA #1 where Resident #44 was at present and CNA #1 stated that the Resident #44 was in physical therapy. Surveyor #1 interviewed Licensed Practical Nurse #1 regarding where Resident #44 was at present. The nurse stated that Resident #44 had tested COVID-19 positive and had been transferred to the 1st floor COVID-19 unit and CNA #1 was not made aware. CNA #1 was not tested for COVID-19 on 09/21/22, when she had been assigned to provide care for Resident #44 while the resident was symptomatic for COVID-19 on 09/20/22, and had tested COVID-19 positive on 09/21/22. Part 2 The facility infection preventionist failed to ensure a system was in place, and was followed to ensure the all staff who required weekly, or bi-weekly COVID-19 testing was implemented and documented during a COVID-19 outbreak. This resulted in an IJ situation that was identified on 10/11/22 at 2:03 PM, when the facility failed to complete required COVID-19 testing which placed all residents and staff at risk for contracting a contagious and potentially deadly virus. The facility submitted an acceptable removal plan on 10/12/22 at 1:42 PM. The survey team verified the removal plan as implemented during an onsite survey on 10/12/22 at 2:35 PM. The deficient practice was evidenced by the following: On 09/23/22 at 9:42 AM, Surveyor #2 conducted an interview with LPN #1 who stated she was not vaccinated, had a medical exemption, and was not fit tested. On 09/26/22 at 12:02 PM and 2:18 PM, the Director of Nursing (DON) and Interim Infection Preventionist Licence Practical Nurse (IIPLPN), respectively provided the staff vaccination matrix and both did not include LPN #1. The DON confirmed at 12:05 PM, that the facility vaccination matrix had not been completed until the past weekend. On 10/04/22 at 11:19 AM, Surveyor #1 conducted an interview with the IIPLPN, in the presence of the survey team regarding what the frequency was for testing staff that were not up to date with COVID-19 vaccines. She stated it depended on the county rate and the staff should be tested on ce or twice per week, and we are low, so we are testing everyone every three to five days because of the outbreak. The IIPLPN stated that staff that was not up to date with COVID vaccinations should also have been wearing N-95 respirator masks when they provided care. At that time, Surveyor #1 requested that the IIPLPN review the facility Outbreak Response Plan regarding any guidance for facility testing for information regarding testing. The IIPLPN stated testing was once or twice per week, she did not write the facility policy, and she had reviewed it. On 10/06/22 at 1:46 PM, Surveyor #1 interviewed the IIPLPN in the presence of the team regarding the staff COVID-19 vaccination requirements. The facility had been informing staff that they must receive a COVID-19 booster. The surveyor inquired regarding if the staff that are not fully vaccinated are being tested for COVID-19. The IIPLPN stated I am going to say no, and stated the facility was in an outbreak and they were tested for that. Surveyor #3 inquired to what testing frequency should have been completed. The IIPLPN stated that everyone should have been tested twice per week due to the current COVID-19 outbreak, and confirmed the facility testing lists were not consistent and were not updated. On 10/06/22 at 2:09 PM, Surveyor #3 conducted an interview with the IIPLPN in the presence of the survey team. The IIPLPN acknowledged that all staff were currently not up to date with their COVID-19 vaccinations, and the vaccination staff tracking was not current. The IIPLPN stated this was not known until she assumed the role of IIPLPN. The IIPLPN was unable to provide any documentation and confirmed staff that were currently not up to date or exempted from receiving the COVID-19 vaccination, were not being tested for COVID-19 the way they should be tested, which was twice per week during an outbreak which began on 06/24/22. On 10/07/22 at 11:52 AM, Surveyor #2 observed LPN #1 providing care on 09/21/22, 09/22/22, 09/24/22, 09/26/22, 09/28/22, 09/29/22, 09/30/22, 10/03/22, 10/04/22 and 10/06/22. During all observations, LPN #1 was observed wearing a black surgical mask. The LPN #1 stated she had cared for the Unsampled third floor Resident who was symptomatic, and then tested COVID-19 positive on 10/06/22. LPN #1 stated she had been working at the facility for four months, and confirmed to the survey team that she had not been fit tested for an N95 respirator mask. On 10/11/22 10:51 AM, the IIPLPN, in the presence of the LNHA, provided an updated vaccination list to the survey team. Surveyor #1 inquired to the LNHA and IIPLPN why the list was provided today and the IIPLPN stated I did it yesterday and I don't have an answer why it was not done earlier. The IILPN stated there are a lot of components to this program and I cannot fix it in a week or two. The LNHA stated I was aware, when asked if he knew the vaccination list was incomplete, and the IILPN stated she was not aware that the vaccination list was incomplete. A review of the facility's policy, Update to COVID Vaccination and Testing dated 04/06/22 and facility reviewed on 9/2/2022, revealed Policy: It is the policy of [redacted] Rehabilitation and Care Center to offer COVID-19 vaccination and testing as per CDC and DOH guidance as a preventative health measure to reduce the risk of infection from COVID 19. Based on the above definitions, CMS has set the requirement that if staff have not received a COVID booster they are not considered up to date and will require routine testing in accordance with CDC community transmission rates. A review of the facility's policy, COVID 19 Management (All Policies), revised on 5/31/2022, revealed; Staff COVID 19 Vaccination and Testing Requirements, Procedure: Employee Vaccinations for COVID 19 (per DOH order summary action). This facility will track and securely document the COVID 19 vaccination and/or testing status of all staff including vaccination booster doses. 3. All employees of this facility must be fully vaccinated including booster vaccinations as they are mandated or have an approved medical exemption. 4. For Staff whom are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): at minimum perform weekly testing and use of NIOSH N95 or equivalent for source control, 12. All employees, contract staff and medical staff will be tested for COVID-19 as per the most current guidelines. A review of the facility's policy, Outbreak Plan/COVID-19 Response, revised 3/10/22, revealed Guidelines: Testing of Nursing Home Staff and Residents to enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set for the the HHS Secretary.

The non-compliance remained on 10/12/22 for no actual harm with the potential for more than minimal harm that is not IJ based on the following: Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to: a.) develop and implement a policy to track and document facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates; and, b.) follow the facility policy for contingency plans by failing to ensure unvaccinated staff wore an N95 respirator mask (a tight-fitting mask that protected the wearer from air particles) to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 09/26/22 at 12:02 PM, five days after the survey began on 09/21/22, the DON provided the Staff Vaccination Matrix (SVM) to the survey team. She confirmed it was completed over the weekend because they did not have staff vaccination cards. On 09/26/22 at 2:18 PM, the ILPNIP provided an updated SVM to the survey team. A review of the SVM revealed that there were 94 total staff, 85 completely vaccinated staff, four partially vaccinated staff, two staff granted an exemption, and three staff temporary delay/new hires. Of the 94 total staff, 29 staff did not receive the booster dose. The SVM revealed that 62 staff of the 94 were up to date (received all recommended COVID-19 vaccines, including any booster dose (s) when eligible) with the vaccination requirement. A review was completed of the National Healthcare Safety Network (NHSN) data regarding the facility's reported percentage of fully vaccinated staff for the week ending 09/04/22. The facility reported the ratio of staff fully vaccinated was 100%. A review of the facility-provided SVM revealed that 95.7% of staff were vaccinated. On 10/04/22 at 2:10 PM, Surveyor #3 interviewed the Staffing Coordinator (SC), who stated she had a medical exemption. When asked what PPE she had to wear in the building, she said she wore a surgical mask, but she was told she had to wear an N95 if she had to go into a COVID-positive room. On 10/05/22 at 11:26 AM, Surveyor #3 observed the SC, wearing a surgical mask, on the 3rd floor at the nurses' station, conversing with one resident and one staff member. On 10/05/22 at 1:00 PM, Surveyor #3 requested testing for LPN#3, who was listed as a temporary delay per CDC/new hire on SVM from the Regional Administrator (RA). The RA gave the surveyor a copy of LPN #3's vaccination card, which showed she was fully vaccinated and boosted. Therefore, no testing was required. On 10/06/22 at 8:40 AM, the ILPNIP provided an updated SVM to the survey team. On 10/06/22 at 9:34 AM, Surveyor #3 observed the Maintenance Director (MD) (listed on the SVM as completely vaccinated but had not received the booster dose) touring the facility on the 2nd floor with the Life safety surveyor. The Maintenance Director wore a surgical mask. On 10/06/22 at 12:15 PM, Surveyor #4 interviewed CNA #1 while working on the 2nd floor. CNA #1 stated she received two doses of the COVID-19 vaccination. She wore a surgical mask and stated that this was what she had to wear in the building unless she cared for residents with COVID, then she would wear goggles, an N95, and a gown. A review of the SVM revealed CNA#1 was listed on the SVM as completely vaccinated but had not received the booster dose. On 10/06/22 at 12:42 PM, Surveyor #4 interviewed TNA #1, who stated she had two vaccinations but needed a booster that was due in July and was going to get the booster soon. She wore a surgical mask, and she stated that she could wear a surgical mask. She said she would need to wear an N95, a gown, gloves, and a face shield with Covid residents. TNA# 1 stated that right now, on the third floor, it was okay for her to wear a surgical mask. A review of the SVM revealed TNA#1 was listed on the SVM and was listed as partially vaccinated. On 10/06/22 at 1:50 PM, in the presence of the survey team, Surveyor #3 interviewed the ILPNIP. The ILPNIP reviewed the facility's policy, COVID-19 Management (A Policies), and confirmed that all staff who are exempt or not up to date should be wearing an N95, but they are not. She stated that staff is being told that they must be up to date and that it is mandated. The ILPNIP noted that staff would be removed from the schedule if they refused and did not have an approved exemption. At that time, the ILPNIP stated that they should have a list of all employees, copies of their vaccination cards, and a spreadsheet to track how many doses staff had received. She stated that new hires should have had to show their vaccination card. Surveyor #3 asked if employees could decline the COVID vaccine without an approved exemption. The ILPNIP stated that if that was the case, they should not be employed in healthcare .She said employees could not sign a declination form for the COVID-19 vaccine. She further stated that the Centers for Disease Control mandated at the Federal and State levels that everybody in healthcare must be up to date. Surveyor #3 reviewed the SVM and the vaccination cards with the ILPNIP, who acknowledged that there were inconsistencies. On 10/06/22 at 2:09 PM, in the presence of the survey team, the ILPNIP stated, I totally acknowledge staff are not up to date, tracking employees was not current, but we weren't aware until I took over the Infection Preventionist role. She then acknowledged that staff that was exempt or were not up to date were not being tested the way they should be during a COVID-19 outbreak, which was twice weekly. On 10/06/22 at 02:45 PM, in the presence of the survey team, Surveyor #3 made the ILPNIP, the LNHA, the DON, and the RA aware of the above concerns with employees not being boosted, employee vaccination not being tracked, and with employees that are exempt or not up to date wearing proper personal protection equipment according to the facility policy. A review of the SVM received on 10/06/22 from the ILPNIP which revealed the vaccination list, who is not up to date (IP List) received 10/10/22, staff vaccination cards and interviews revealed the following: 1. The LNHA was listed on the SVM as up to date, on the ILPNIP list as needing booster, vaccination card #1 (name redacted) lot #EN5318 02/03/21 hamilton; (name redacted) lot # EN5318 02/03/21 [another facility name] post-acute vaccination card # 2 1st (name redacted) [pharmacy name] and 2nd dose (name redacted) [pharmacy name], no date, boosted (name redacted) 03/31/22 generation pharmacy. On 10/11/22 at 10:52 AM, in the presence of the survey team, the LNHA stated he was up to date on his vaccines and provided proof. 2. Unit Secretary (US) #1 was listed on the SVM as up to date, on the ILPNIP list as needing a booster, vaccination card: (name redacted), 4/22/21, 5/20/21, 11/15/21. On 10/12/22 at 9:46 AM, Surveyor #3 interviewed US#1, stating she was up to date on her vaccines. 3. Housekeeper (HSK) #1 was listed on the SVM as completely vaccinated and needs a booster dose. On the IP list, nothing was recorded. Vaccination card: (name redacted) 06/28/22, 07/18/22, on 10/12/22 at 9:51 AM. Surveyor #3 interviewed HSK #1, who stated he was up to date on his vaccines. 4. LPN #4 was listed on the SVM as up to date, on the ILPNIP list as needing booster, vaccination card: (name redacted) 07/16/21, 08/06/2. On 10/12/22 at 9:53 AM, Surveyor #3 interviewed LPN #4, who stated she was up to date on her vaccines. 5. Behavior Aide (BA) #1 was listed on the SVM as partially vaccinated, on the ILPNIP list as needing a booster, vaccination card: (name redacted), 06/31/22. On 10/05/22 at 11:28 AM, Surveyor #3 interviewed BA #1, who stated she was up to date on her vaccines and gave the facility a copy of her vaccination card. On 10/12/22 at 9:56 AM, Surveyor #3 observed CNA#1 on the 2nd floor wearing a surgical mask. During an interview at that time, CNA#1 stated, I was told yesterday I need to get the booster today. On 10/12/22 at 1:46 PM, Surveyor #3 observed the SC on the 2nd floor wearing a surgical mask. On 10/12/22 at 2:00 PM, in the presence of the survey team, Surveyor #3 made the RA and Regional Nurse aware that CNA#1 and the SC were observed wearing only surgical masks, as mentioned above. They both acknowledged that the facility's policy was if not up to date or exemptions, staff should have been wearing an N95. A review of the facility's policy, COVID-19 Management (All Policies), revised on 5/31/2022, revealed it is the policy of this facility to follow CDC and DOH [Department of Health] guidelines for the management of the COVID-19 (Sars-COV-2). The policy addressed Staff COVID-19 Vaccination and Testing Requirements, Procedure: Employee Vaccinations for COVID-19 (per DOH order summary action). This facility will track and securely document the COVID-19 vaccination and/or testing status of all staff, including vaccination booster doses. Staff who need an exemption form can request it from Human Resources or their Department Head. Procedure: 3. All employees of this facility must be fully vaccinated, including booster vaccinations, as they are mandated or have an approved medical exemption. 4. For Staff who are partially vaccinated (one dose for multi-dose vaccine schedule or those who are eligible for the booster vaccines as it is mandated): Use of NIOSH-approved N95 or equivalent for source control. 5. Providing all personnel who decline to be vaccinated a written affirmation for their signature, which signifies that they were offered the opportunity for a COVID-19 vaccination but declined. For employees, the reason for declination must fall into a medical reason or religious reason. 7. Upon request from the DOH, the following must be presented: a. number and percentage of personnel that have been vaccinated for COVID-19, b. Number and percentage of personnel for which medical exemptions have been granted, c. The total number of covered personnel. 8. For staff who are not vaccinated do not fall into the exemption or are temporarily delayed in obtaining the vaccine as it is mandated and staffing is in crisis levels. a. This facility will communicate the staffing crisis to the appropriate government agency and will attempt to place identified staff members who aren't fully vaccinated in non-resident areas and to duties that can be performed remotely (i.e., telework), or to duties which limit exposure to those most at risk (e.g. assigning to residents who are not immunocompromised, unvaccinated). 9. This facility will require staff who have not completed their primary vaccination series (including .been granted an exemption or who have a temporary delay) to follow addition CDC-recommended precautions, such as adhering to universal source control and physical distancing measures in areas that are restricted from resident access, even if the facility or service site is located in a county with low to moderate community transmission. 10. Any employee who refuses testing and is not fully vaccinated per the current guidelines will not be permitted to work in this facility. N.J.A.C. 8:39-9.3(c);19.1(b); 19.4(a) Based on interview, record review and document review, it was determined that the facility failed to: a.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22; and, b.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. The facility's failure to take immediate action, follow Centers for Medicare and Medicaid Services (CMS) guidance, Centers for Disease Control and Prevention (CDC), and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a deadly contagious virus. Reference: Centers for Disease Control and Prevention, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated September 23, 2022 Refer to F880 and F886 The failure to ensure all staff were up to date with COVID-19 vaccinations or granted a qualifying exemption during a COVID-19 outbreak were not permitted to work in the facility placed all residents and staff at risk for contracting a contagious, potentially deadly virus. This situation resulted in an Immediate Jeopardy (IJ), which began on 06/24/22 when a Licensed Practical Nurse (LPN #1), who was unvaccinated for COVID-19, without having a qualifying exemption, proceeded to work forty-seven shifts from the start of the facility outbreak on 06/24/22 until 10/10/22. The IJ was identified on 10/11/22 at 2:03 PM. The facility administration was notified of the IJ on 10/11/22 at 2:03 PM. The facility submitted an acceptable removal plan on 10/12/22 at 01:42 PM. The IJ removal plan was verified as implemented during an onsite visit on 10/12/22 at 02:35 PM. The evidence was as follows: On 09/21/22 at 9:09 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that the facility was currently in outbreak status for COVID-19, and the outbreak was three days from ending. On 09/21/22 at 1:09 PM, Surveyor #1 conducted an entrance conference with the LNHA and the Director of Nursing (DON). During the entrance conference, Surveyor #1 requested the facility infection control policies related to COVID-19 and the COVID-19 Staff Vaccination Matrix. The LNHA and DON confirmed the Uncertified Registered Nurse Infection Preventist (URNIP) did not have an infection control certification and that she was responsible for all of the COVID-19 vaccination efforts. The LNHA stated that the URNIP has all of the documents and noted that there was currently no symptomatic resident in the facility. On 09/22/22 at 3:42 PM, in the presence of the survey team, the URNIP stated that not everyone was tested twice weekly. When the survey team asked the criteria for the staff to be tested, she said, if some people feel like they have a cold, they would be tested and that currently, there were no staff members that needed to be tested. The URNIP confirmed that her log was the only facility testing document at that time. The survey team inquired to the URNIP regarding the staff vaccination list, and the URNIP stated that she did not have a completed list for the staff's COVID-19 vaccination status. On 09/23/22 at 11:34 AM, the survey team interviewed the LNHA and DON regarding the National Health and Safety Network information that is required to be submitted. The LNHA confirmed that he inputted the data and that there was no current employee vaccination list since not all employees were on it. The DON stated, I am not making up what I don't have. On 09/22/22 at 9:43 AM, the DON and LNHA informed the survey team that two residents (Resident #44 & Resident #52) had tested COVID-19 positive and had been moved to the first floor for isolation. The LNHA stated the positive results were identified during routine COVID-19 testing. On 09/22/22 at 9:55 AM, the DON and LNHA failed to provide the survey team with the requested infection control documents, which included the staff vaccination and staff and resident testing documentation. The LNHA stated the documents were now with the corporate people, and he could not produce the documents. On 09/23/22 at 8:53 AM, Surveyor #1 observed LPN #2 on the second-floor medication cart wearing a surgical mask. Surveyor #1 then interviewed LPN #2, who stated she was a new hire. The surveyor asked LPN #2 if she was vaccinated for COVID-19 and if she had been fit tested for an N-95 mask. LPN #2 replied, not fit tested, not boosted (a test to determine if a respirator mask appropriately fits to protect the wearer). She stated she was vaccinated for COVID-19 and confirmed that the facility was aware that she was not boosted. LPN #2 said that she signed a waiver form that the facility provided since she did not want a COVID-19 booster. Surveyor #1 inquired to LPN #2 if she had received COVID-19 testing, and she stated that the facility would let her know if she needed to take a test and that she could also let the URNIP know if she needed to take a COVID-19 test. Surveyor #1 asked LPN #2 if she was assigned to a particular unit. LPN #2 replied that she floated to different units. On 10/06/22 at 12:30 PM, Surveyor #1 observed LPN #2 on the 1st floor COVID-19 unit at the nursing station wearing a National Institute of Occupational Safety and Health (NIOSH) N-95 mask. Surveyor #1 further inquired about what N-95 mask she was required to wear. LPN #2 removed two different masks from the bins outside a resident room and told the surveyor that she could wear either one. LPN #2 stated the mask Surveyor #1 was wearing (N95 #8210) was very tight, and she said that she was fit tested for both masks by the Interim Licensed Practical Nurse Infection Preventist (ILPNIP). Surveyor #1 inquired if LPN #2 had a medical or religious exemption for the COVID-19 booster. LPN #2 reiterated that she had signed a paper waiver provided by the facility, which indicated she did not want the booster and stated no; it was not a medical or a religious exemption, only that it was a document that offered risks and benefits. On 10/06/22 at 1:46 PM, surveyor #3 interviewed the ILPNIP in the presence of the survey team. The ILPNIP stated that the facility had been telling staff they must get boosted for COVID-19. The ILPNIP said the facility should have a list of all the employees, a copy of the vaccination cards, and a spreadsheet to track when everyone was due. When asked about the new hire process, the ILPNIP stated the new hires should have received a booster or provided proof of COVID-19 Vaccination status. She then said, I mean, anyone can decline, and they shouldn't be employed in healthcare [if the COVID-19 vaccines are declined]. The ILPNIP stated it was mandated to be up to date with COVID-19 vaccines, per the federal government, Centers for Disease Service (CDC), and the state government. At that time, the ILPNIP confirmed that all staff were not up to date with COVID-19 vaccines and stated, I am acknowledging now since she had not been aware of all staff not being up to date with COVID-19 vaccines and she also confirmed that the staff were not being tested twice per week. On 10/07/22 at 11:01 AM, Surveyor #1 interviewed the Regional Licensed Nursing Home Administrator (RLNHA) regarding agency staff's vaccination status before working at the facility. The RLNHA confirmed there was no system in place to ensure that the staffing agencies were sending fully vaccinated staff who had been fit tested for N-95 masks. On 10/07/22 at 11:52 AM, surveyor #2 had observed LPN #1 providing care on 09/21/22, 09/22/22, 09/24/22, 09/26/22, 09/28/22, 09/29/22, 09/30/22, 10/03/22, 10/04/22 and 10/06/22. LPN #1 was wearing a black surgical mask during all observations. LPN #1 stated she had cared for the unsampled third-floor resident, who was symptomatic and tested COVID-19 positive on 10/06/22. LPN #1 stated she had worked at the facility for four months and confirmed she had not been fit tested for an N95 mask. On 10/07/22 at 12:58 PM, the ILPNIP provided the facility line listing, which revealed a symptomatic unsampled COVID-19-positive resident was identified on the third floor on 10/06/22. On 10/07/22 at 1:01 PM, the ILPNIP confirmed that LPN #2 was not up to date with her COVID-19 vaccines, and the ILPNIP confirmed she had been unaware. The ILPNIP stated, I will be honest with you she did not know why LPN #2 got through the system. The ILPNIP said there was no form she was aware of that the facility provided to staff for declining a COVID-19 vaccination. The ILPNIP stated, from my understanding, everyone needs to be up to date on their vaccines. The ILPNIP noted that once she had a complete list of the unvaccinated staff, the staff would have to find another place to work if the staff refused to vaccinate. On 10/11/22 at 8:49 AM, the ILPNIP provided a copy of the Resident/Employee Contact Tracing Record dated 10/11/22. The document revealed that LPN #1 was identified as the nurse who cared for eight residents who tested COVID-19 positive, including Residents # 44 and #52, who tested COVID-19 positive on 09/21/22 and the unsampled resident on 10/6/22; All eight residents resided on the third floor. LPN #2 was identified as a close contact for two residents, Resident #10 and an unsampled resident, on 10/03/22, who resided on the third floor. On 10/11/22 at 12:53 PM, the facility Human Resources Manager (HRM) provided the survey team with Time Card detail for LPN #1 and LPN #2. LPN # 1 worked forty-seven shifts since the facility outbreak began on 06/24/22, which was revealed in the Time Card detail from 06/21/22 through 10/11/22. LPN #2 worked twenty shifts from 09/19/22 through 10/11/22.