**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ161922, NJ169428 Based on interviews, medical record review, and review of other pertinent facility documentation on 12/5/2023 and 12/6/2023, it was determined that the facility failed to ensure that the process of receiving medications from an outside pharmacy vendor was followed by staff. It was determined on 3/4/2023 that a Security Guard (SG) working at the main lobby of the facility received a mailed package addressed to Resident #2 with his/her name and room number on the unopened package. The SG delivered the unopened package to Resident #2 . Resident #2 is cognitively impaired and SG failed to give this package to nursing staff , so the package could be opened by resident with staff present. After SG left package with Resident #2, a Certified Nursing Assistant (CNA) observed the resident with an opened bottle of Risperdal 2 milligrams (mg) (a medication used to treat to treat schizophrenia) which contained 30 tables was empty. The Registered Nurse/Supervisor (RN/Supervisor) was made aware, the empty bottle with the label Risperdal 2mg was retrieved along with other unopened bottles of medications that were in the delivered package to Resident #2's room. The Physician was made aware and emergency response number 911 was called by facility staff. Resident #2 was sent to the emergency room (ER) for evaluation and treated for overdose with no adverse effects noted. This deficient practice of failure to follow facility policy and proceedures for the delivery of packages of medications posed a safety hazard for residents with cognitive impairment to be accessible to encounter hazardous items that could cause injury, harm or death. The Immediate Jeopardy Past Non -Compliance began on 3/4/2023 and ended on 3/6/2023 after the facility educated all staff, residents and family members on the new mail delivery process and revised the delivery policy. The facility- initiated monitoring of all incoming mail with the resident's knowledge to ensure that this does not reoccur. The facility submitted the following document at the time of the survey that indicated the following: 1.Security will not be delivering packages to any residents. 2. Any items coming in from the outside that may cause any risk to the resident and the facility will be monitored, with the resident's knowledge, upon delivery to the resident. 3. On 3/6/2023 the facility in-serviced security, Nursing and all staff about the new mail delivery process. The Mail deliver policy was revised. 4. No other incident has occurred since the new system has been implemented. There is sufficient evidence that the facility corrected the non-compliance and is in substantial compliance at the time of this Complaint Survey for the specific F689 regulatory requirements. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for incidents and accidents. During a tour of the unit on 12/5/2023 at 9:00 A.M., the Surveyor did not observe any unopened packages in resident's rooms that could be a risk to the resident or facility. On 12/5/2023, a review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the admission Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Post -traumatic stress disorder, and Unspecified Mood Disorder. According to the Minimum Data Set (MDS), an assessment tool dated 3/6/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7/15, which indicated the Resident was severely cognitively impaired. Review of the facility's form titled Incident/Accident report dated 3/4/23 and timed 4:00 p.m., under possible cause of incident Resident was confused and was given a bag of drugs and ingested 30 pills of 2mg of risperidone. Review of the facility's transfer form titled New Jersey Universal Transfer Form dated 03/04/2023 under reason for transfer reveal: Consumption of unknown amount of unknown substance. Review of Resident #2's Progress Notes (PN)dated 3/4/2023 and timed 6:01p.m., by the Social Worker Director (SWD) revealed the following: SWD working on nursing unit when CNA reported to LPN (Licensed Practical Nurse) that she had found the pt (Resident #2) with an opened package of medications and the pt (Resident #2) taking pill and having the pill bottle up to his/her mouth. Nursing immediately came to the pt's (Resident #2) room and asked him/her if they took the medication. The pt (resident #2) allegedly stated to nursing, 'I don't know. Nursing searched room for pills in sheets, pt (resident #2) clothing, on floor, in trash can, but no pills were found. Nursing alerted the doctor, the DON (Director of Nursing) and SWD alerted the LNHA and daughter of Resident #2. Vitals were taken and the pt (Resident #2) was given a 1:1 CNA (Certified Nursing Assistant) observer to report any unusual signs and symptoms of the drugs overdose which were researched from the medication alert paperwork that came with the drug. All other medications that had been delivered from the VA (Veterans Association) to the pt (Resident #2) were accounted for and the VA pharmacy was called, and verification given by VA pharmacist that signed dispense of the medication (quantity of 30) in the empty bottle was recorded. The doctor ordered the pt (Resident #2) sent to the ER (Emergency Room) via 911 and the nursing Supervisor called in Nurse-to-Nurse report later and was informed that pt (resident #2) was stable and alert and aware and responsive with flat affect. The poison control center was contacted and recommended the pt (Resident #2) be sent 911 to the hospital ER. The pt (Resident #2) is presently at Virtua ER for continued evaluation. The administrator will complete the investigation. During an interview on 12/5/2023 at 11:32 a.m., the SG informed the Surveyor that he received packages from the mail on 3/4/2023 that were addressed to residents on the units. I took the packages that had the names and room numbers of residents on it and delivered to the residents. When asked by the Surveyor if he delivered a package to Resident #2's room, he stated yes, I did. During the same interview, the SG acknowledged that he didn't ask Resident #2 to open his/her package in his presence to ensure the package was safe for Resident #2 and the facility. The SG further stated that he was aware of Resident's Right to received unopened mails/packages but was not aware he could ask the residents permission to open his/her package in his presence. During a telephone interview on 12/5/2023 at 1:20 p.m., the CNA stated she saw a guy on the unit with a package and he asked for Resident #2's room, and she pointed him in the direction and went to provide care to another resident. She further stated, I didn't know who the guy was at the time. The CNA revealed that on her way back he observed Resident #2 sitting on his/her bed with an empty bottle pill bottle in his/her hand. I asked the resident (Resident #2) what he/she was doing, and they stated, I was going to drink my medicine. When asked by the Surveyor if there were any other opened bottles of pills or pills on the floor or bed, the CNA responded, No. The CNA stated she immediately went out to the nurse's station and notified the nurse of what she has seen. During a telephone phone interview on 12/5/2023 at 12:06 p.m., the RN/Supervisor stated she was notified by staff that probably Resident #2 had taken Risperdal, but they were not a 100% sure. I immediately told one of the nurses to call 911 and get the crash cart. Resident #2 was observed sitting on his/her bed, alert, awake, responsive and in no acute distress with no respiratory distress noted. Resident #2 was assessed, vitals were stable, poison control/doctor was notified, and an order obtained to transfer Resident #2 to the ER for further evaluation. The Risperdal 2mg bottle was empty, I don't remember a 100%, there was no pills on Resident #2's bed, room floor, pillow or anywhere. The RN/Supervisor acknowledged that the bottle of Risperdal was empty when she got it from Resident #2's room. I asked the staff how Resident #2 got a whole of the pills and was told, the SG delivered the package directly to Resident #2, instead of giving the package to the nursing. The RN/Supervisor revealed the rest of the unopened bottles of medications were retrieved from Resident #2's room and placed in the package and taken to the DON's office. During the same interview, when asked by the Surveyor what the process is for residents receiving mails/packages, she revealed normally all packages should be delivered to the nurse's station and we (Nurses) will take the package to the resident and ask their permission to open the package to ensure the resident is allowed to have what is in the package. When asked if the process was followed on 3/4/2023, the RN/Supervisor said, No. During an interview on 12/5/2023 at 10:07 a.m., the SWD stated the process for receiving medications from the VA pharmacy included the following steps: the medical doctor came into the facility and wrote the scripts, give them to the DON who in turn will give them to her. She would than fax the scripts over to the VA pharmacy and follow-up with a phone call for delivery time. She stated the medications were delivered in a white bag with the resident's name and room number on the bag. The bag also had the VA pharmacy address on it, and you can fill the bottles in the bag. The SWD stated on 3/4/2023, she was on the unit when the CNA notified nursing of what she observed with Resident #2. We all ran to the Resident's room. Once I got to the room, I saw the package opened with several other bottles of pills that were still intact and unopened. The Nurse had the opened bottle of Risperdal 2mg in her hand. Resident #2's daughter had ordered their medications through the VA pharmacy prior to their admission to the facility. The VA pharmacy was called to confirm all the numeric quantity of pills in each bottle that was dispensed. After the count, it was confirmed that all other medications were correct, and it was only the Risperdal 2mg bottle that was empty. When asked by the Surveyor if there was any Risperdal 2mg in the opened bottle, the SWD said, I don't remember if there was any Risperdal left in the bottle. During the same interview, the SDW said the expectation was if a package is delivered to the main lobby, the SG is expected to bring the package to the nurse's station and deliver to the nurse and advice he didn't know what was in the package. The receiving Nurse would then take the package to the resident and ask their permission to open the package in their presence to ensure it was safe for the resident to have the package. When asked if the process was followed on 3/4/2023, the SWD said, No. During an interview on 12/5/2023 at 2:06 p.m., with the DON in the presence of the Administrator, the Administrator informed the Surveyor that all packages go to the main lobby and is distributed to the various buildings. Packages of concerns go to Nursing who will than deliver to the residents, and with their permission open the package to ensure the resident's and facility's safety. He further stated, any package of possible danger or risk to the residents has to be opened in the presence of the nurse with the resident's permission. When asked if the process was followed on 3/4/2023, the Administrator said No, the package should not have been delivered directly to Resident #2. During the same interview, the DON stated, there was no policy in place on how resident's packages were delivered prior to the incident. After the incident on 3/4/2023, the facility implemented the following for the SG on monitoring packages: All mail for skilled unit must go to management to ensure it goes to the right person. Please do not deliver anything directly to the patient's room until inspected. N.J.A.C.: 8.39- 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) implement appropriate infection control practices related to hand hygiene and the use of Personal Protective Equipment (PPE); b.) post appropriate transmission-based precaution signage; and, c.) provide the appropriate bins for PPE storage and disposal in a manner to prevent the transmission of COVID-19 in accordance with the Center for Disease Control and Prevention (CDC) and New Jersey Department of Health (NJ DOH) guidelines. This deficient practice was identified for 1 of 3 units (200 Unit) during the Recertification survey conducted 05/03/21. The 200 Unit was the designated unit for Persons Under Investigations (PUI) for COVID-19. A review of the resident roster of the PUI unit revealed 2 of 10 residents (Residents #243 and #244) were not fully vaccinated. The facility's failure on the PUI unit to implement the use of N95 masks, eye protection, gowns, and gloves while caring for residents, post appropriate transmission-based precaution signage designating the required PPE for staff to utilize when entering a resident's room, provide PPE bins with available PPE outside of the resident rooms and provide bins to discard the used PPE inside of the rooms exposed residents to COVID-19 infection and posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for COVID-19). The facility was notified of the Immediate Jeopardy situation on 04/28/21 at 4:15 PM. On 04/29/21, the facility submitted an acceptable removal plan to the NJ DOH. On 04/29/21, while the recertification survey was in progress, the surveyors verified the implementation of the Removal Plan and determined that the Immediacy of the Jeopardy could be removed effective 04/29/21. The deficient practice was evidenced by the following: On 04/27/21 at 8:30 AM, the surveyors entered the facility and interviewed the Infection Preventionist (IP). The IP stated that the required PPE on all units (100, 200, and 300 units) was a surgical mask and that the facility was currently not in an outbreak. The IP explained that the 200 Unit was the observation or PUI unit where the residents were quarantined for 14 days upon admission or readmission to the facility. On 04/27/21 at 10:30 AM, the surveyor observed a dry erase board, displayed on an easel, at the entrance of the 200 Unit, with a hand-written notification, Please Do Not Pass this point * Thank You. The surveyor questioned LPN #1 about the signage, and she stated, Don't worry about that. LPN #1 did not inform the surveyor that the 200 Unit was the PUI unit or the required PPE to be utilized while on the unit. While on the PUI unit, the surveyor observed that all nursing staff wore only surgical masks. The surveyor did not observe transmission-based precaution signage posted to indicate the required PPE for staff to utilize when entering a room, readily available PPE supplies (masks, gown, gloves, and eye protection), or bins located inside of each room to discard the used PPE. During an interview with the surveyor on 04/28/21 at 09:08 AM, the Director of Nursing (DON) stated that the facility was comprised of three units. The 100 and 300 Units housed long-term care residents, and the required PPE for those units were surgical masks. The 200 Unit (observation/PUI unit) housed newly admitted and readmitted residents, and the required PPE were surgical masks and gloves. The DON further stated that the facility followed the recommendations of an independent Infection Control Consultant (IC Consultant), who came to the facility sometime in February or March 2021 to complete an infection control survey. At that time, the surveyor requested a copy of the consultant's recommendations, and the facility failed to provide the surveyors with a copy. During a follow-up interview with the surveyor on 04/28/21 at 9:28 AM, the DON confirmed that the new admissions/readmissions residents on the PUI unit were quarantined for 14 days and required a negative COVID-19 test prior to admission. During an interview with the surveyor on 04/28/21 at 10:12 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility required a negative COVID-19 test prior to admitting a resident from the community as well as to quarantine the resident for 14 days upon admission. The LNHA stated that their process was based on what they had been doing and that the facility had an independent infection control survey with a private IC Consultant in February or March 2021. The LNHA stated that there should be signage on the residents' doors reflecting the required PPE and indicated that it was common knowledge with the staff and the therapists. The LNHA further stated, They know the required PPE to wear. At that time, the surveyor reviewed with the LNHA the NJ DOH Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities guidance dated March 25, 2021. The LNHA stated, I believe this is the guidance that we're following, not sure if it's the updated guidance. The surveyor inquired if new admissions/readmission residents were assessed for COVID-19 exposure prior to the resident being admitted . The LNHA stated that all residents were tested before entering the facility and required a negative COVID-19 test prior to admission. The LNHA further stated, I don't know if we ask about COVID exposure prior to the resident being admitted . At that time, the surveyor requested copies of the facility's COVID-19 policies, the IC Consultant's report, and the facility's guidance for the PUI unit. The facility failed to provide the requested documents. On 04/28/21 at 8:36 AM, while on the PUI unit, the surveyor observed Resident #246 in a wheelchair at the doorway of his/her room without pants asking the Certified Nursing Assistant (CNA) #1 for pants. CNA #1 wheeled Resident #246 back into the resident's room wearing only a surgical mask. CNA#1's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care to Resident #246. The surveyor further observed CNA #1 enter the following rooms to pass out breakfast trays: room [ROOM NUMBER] beds A and B; room [ROOM NUMBER] bed A; room [ROOM NUMBER] bed B; room [ROOM NUMBER] bed B; room [ROOM NUMBER] beds A and B; room [ROOM NUMBER] beds A and B; and room [ROOM NUMBER] bed A. At that time, the surveyor observed that CNA #1's PPE consisted of only a surgical mask. CNA #1's PPE did not include an N95 mask, gown, gloves, or eye protection while delivering breakfast trays to the aforementioned residents. On 04/28/21 at 9:15 AM, while on the PUI unit, the surveyor observed two staff members providing direct therapy care for Resident #246. Both therapists were observed wearing a surgical mask over a KN95 mask, a face shield (eye protection), and gloves but not a gown. When interviewed at that time, the Occupational Therapist stated that the PPE required on the PUI unit was a mask with a face shield and only gloves when touching the resident but not a gown. On 04/28/21 at 9:07 AM, while on the PUI unit, the surveyor observed CNA #1 feeding two residents (Residents #21 and #341) in the same room. CNA #1's PPE consisted of only a surgical mask that was positioned below the nose. When interviewed at that time, CNA #1 stated the mask should cover the nose. CNA #1's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care (feeding) to Residents #21 and #341. On 04/28/21 at 9:30 AM, while on the PUI unit, the surveyor observed CNA #2 removing breakfast trays from several resident rooms on the PUI unit wearing only a surgical mask positioned below the nose. CNA #2 was not wearing an N95 mask, gown, gloves, or eye protection. When interviewed at that time, CNA #2 stated that the PUI unit housed residents with admissions and readmissions from the hospital, the community, long-term care, and assisted living. CNA #2 further said that the staff needed to wear only a surgical mask on the PUI Unit. On 04/28/21 at 11:22 AM, while on the PUI unit, the surveyor observed Resident #246's spouse visiting in the room without wearing a mask. The surveyor further observed the mask was lying on the bed. When interviewed at that time, Resident #246's spouse stated, Ooh, and donned the mask lying on the bed. On 04/28/21 at 11:24 AM, while on the PUI unit, the surveyor observed LPN #2 at the medication cart gathering supplies to obtain a resident's blood glucose level. LPN #2 enter Resident #342's room without performing hand hygiene or donning gloves, obtained the resident's blood glucose level, and exited the room without performing hand hygiene. At that time, the surveyor observed that LPN #2's PPE consisted of only a surgical mask. LPN #2's PPE did not include an N95 mask, gown, gloves, or eye protection while providing direct care to Resident #342. When interviewed at that time, LPN #2 stated, I was educated on hand hygiene but don't work here that much. Also, at that time, during an interview with the surveyor, LPN #3 stated that hand hygiene should be performed when entering and exiting the resident's room. LPN #3 further noted that hand hygiene should be performed before obtaining a blood glucose level on a resident, gloves should be worn during the procedure, and hand hygiene should be performed after finishing the procedure. During a follow-up interview with the surveyor on 04/28/21 at 11:34 AM, the DON stated that anyone going into a PUI room was required to wear gloves. A surgical mask and hand hygiene should be performed when entering and exiting resident's rooms. The DON further stated that an independent IC Consultant advised that a surgical mask was the only PPE required on the PUI unit. At that time, the surveyor requested a copy of the IC Consultant's report, and the facility failed to provide the requested report. On 04/28/21 at 12:43 PM, the IP provided the name of the IC Consultant but was unable to provide the IC Consultant's report. The IP stated that she was not present on the date the IC Consultant was in the facility but stated that the IC Consultant did not recommend that gowns were to be worn on the PUI Unit. The surveyor requested a copy of the COVID-19 guidance that the facility followed for the PUI unit; The facility failed to provide the guidance. On 05/03/21 at 11:55 AM, the survey team interviewed the LNHA, DON, and IP. The IP stated that the facility followed the guidance from the NJ DOH if they needed to cohort residents. The IP further noted that the facility followed COVID-19 infection control guidelines from the CDC, but they usually followed the NJ DOH guidelines because they were more stringent. The IP further stated that the facility discussed all updated guidance concerning COVID-19 infection control during morning and weekly meetings, which included all upper management staff, and stated, We make decisions as a group. The IP further stated that the Admissions Nurse Liaison ensures that all admissions had a negative COVID-19 test 72 hours prior to admission and were housed under observation for 14 days on the PUI unit. The IP then stated that on the PUI unit, the staff were to don gowns, gloves, surgical mask, and face shield before entering a resident's room and remove the PPE upon exiting the room, disposing of the PPE in a trash can located inside the resident's room. The IP stated that staff were to wear a surgical mask and face shield in the hallway of the PUI Unit. During the same interview, the DON stated that all new admissions and readmissions were placed on the 200 Unit on droplet precautions (precaution used to prevent the spread of respiratory illnesses) for 14 days. The IP stated that she was unsure if the Admissions Nurse Liaison addressed COVID-19 exposure prior to a resident's admission. During an interview with the survey team on 05/03/21 at 12:15 PM, the Admissions Nurse Liaison stated that all residents required a negative COVID-19 test within 72 hours prior to admission. The Admissions Nurse Liaison further noted that all residents were assessed for COVID-19 exposure by reviewing and discussing the medical record with the clinical team at the hospital. The Admissions Nurse Liaison added that if a resident had any potential exposure to COVID-19, the facility would not admit the resident to the facility. On 05/03/21 at approximately 1:30 PM, the LNHA provided the surveyors with a copy of the IC Consultant's report. The LNHA stated that the report was dated 03/25/21. The LNHA provided pages 4, 5, and 6 of the IP Consultant's report to the surveyors. He stated that pages 1, 2, and 3 contained an internal quality report for a different area of the facility. At that time, the facility was unable to provide the surveyors with the COVID-19 guidance they were following. The surveyor reviewed pages 4, 5, and 6 of the IC Consultant's report dated 03/25/21, which revealed the following recommendations: - Institute a formal hand hygiene surveillance program. - Re-educate staff on the appropriate use of gloves for standard precautions and transmission-based precautions. - Create a policy for face shield use, cleaning and disinfection, and storage if reused. Staff members should wear eye protection when residents can't comply with source control mask-wearing, such as those within their dementia unit. - Ensure that all staff is wearing appropriate masks. - Identify exposed individuals, test, and quarantine appropriately. The IC Consultant's report further revealed, Recommendations include but are not limited to full enforcement of source control masking, proper use of PPE, social distancing, appropriately isolating symptomatic residents, and education regarding cleaning and disinfection. During an interview with the survey team on 05/03/21 at 02:00 PM, the IP stated that she reviewed the 03/25/21 IC Consultant's report and that the facility was following the IC Consultant's recommendations. The IP further noted that, this correlated with the guidance we were following. A review of the facility's undated Outbreak Response Plan under the heading Isolation and Cohorting Isolation revealed that when the facility is in an outbreak, Anyone entering the room will don appropriate PPE before entering, in accordance with the current guidelines from the NJDOH, CDC or CMS. Most commonly, this would be face mask, gloves, gowns, and eye protection. A review of the facility's Isolation- Initiating Transmission Based Precautions policy, reviewed 04/01/21, revealed that When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): a) Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used; . d) Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions: (1) The signage informs staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instructions to see a nurse before entering the room. e) Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; . g. Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room. 4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occurs after criteria for discontinuation are met. e. Restrict or ban admissions . A review of the facility's Isolation - Categories of Transmission-Based Precautions policy, reviewed 04/01/21, revealed under the heading Droplet Precautions 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 7. Signs - The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. A review of the NJ DOH/CDS Guidelines dated 03/24/21 titled Updates on Covid-19 Infection Prevention & Control Recommendations revealed Appropriate PPE - UNCHANGED All recommended COVID-19 PPE should be worn during care of residents under quarantine, which includes the use of: - N-95 or higher-level respirator (or well-fitting facemask if a respirator is not available) - Eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) - Gloves - Gown A review of the facility's Handwashing/Hand Hygiene policy, reviewed 04/1/21, revealed to Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: - Before and after direct contact with residents - After contact with blood and bodily fluids - After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident - Before and after entering isolation precaution settings - Before and after assisting a resident with meals The facility continues to remain out of compliance for F880 but at a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy. NJAC 8:39-19.4