Every finding on record at De la Salle Hall

Based on observations, interviews, and review of facility provided documents, it was determined that the facility failed to maintain proper kitchen sanitation practices by keeping the kitchen door closed and consistently recording water temperatures and chemical sanitizer levels, to prevent the potential development of food borne illness. This deficient practice was evidenced by the following:On 5/12/26 at 5:23 PM, during the initial tour of the facility, the surveyor walked past a door to the kitchen which was completely open to a hallway used by residents, staff, and/or visitors. The surveyor observed a staff member in the kitchen putting food onto plates. A sign on the open door indicated to keep the door closed at all times. The surveyor observed the door was held open by a magnet attached to the bottom of the door. On 5/12/26 at 5:25 PM, the surveyor toured the kitchen with the cook, who acknowledged the kitchen door to the hallway should have been closed. The cook stated he prepared the food and plated it for dinner for the residents, and another staff member used that door to take meal trays to the units, and then would bring the trays back and wash the dishes. The surveyor observed a dishwasher which the cook stated was a high-temp dishwashing machine (a type of dishwasher that uses extremely hot water during its wash and rinse cycles to clean and sanitize dishes more effectively than standard dishwashers), and a 3-bay sink (3 deep sinks specifically designated and labeled for washing, rinsing, and sanitizing, used for pots and other items that were hand washed). The dishwashing machine and 3-bay sink were currently not being used. On 5/13/26 at 10:20 AM, the surveyor toured the kitchen with the Director of Dining Services (DDS) in the presence of the Regional Director. The DDS confirmed the dishwashing machine was high-temp, and the staff running the machine checked the water temperatures at least 3 times a day. The Regional Director added that the water temperatures were checked before starting to wash dishes after each meal. The DDS stated she checked the log each evening to confirm there were no issues with the function of the machine. The DDS provided a clipboard with temperature log sheets for each month, for the surveyor to review. In the presence of the DDS and Regional Director, the surveyor observed the log sheet for May 2026. The DDS asked the cook if he checked the water temperatures yesterday, and he replied that he forgot. The DDS asked the server/utility staff member (Server #1), who was currently running the dishwasher, if he checked the water temperatures this morning. He stated he checked the temperatures and stated they were 155 degrees Fahrenheit (155 F) for the wash and 182 F for the rinse. He acknowledged he wrote the temperatures in the space for 5/12 breakfast and stated he should have written them on the 5/13 breakfast space. In the presence of the surveyor and the Regional Director, the DDS acknowledged that the dishwashing machine water temperatures had not been logged for 5/11 dinner, and 5/12 breakfast, lunch, and dinner. At that time, the surveyor, in the presence of the DDS and the Regional Director, observed the log sheet for May 2026 for the 3-bay sink. The DDS stated the temperature of the water for washing, and the chemical levels for sanitizing, were checked before the pots were washed after each meal. There were blank spaces on 5/11 dinner time, and 5/12 breakfast, lunch, and dinner times, and 5/13 breakfast time. The DDS asked Server #1 if he checked the water temperature and chemical levels in the 3-bay sink that morning. Server #1 acknowledged he did but did not log the results. On 5/14/26 at 8:49 AM, the surveyor observed the door to the kitchen completely open to the hallway used by residents, staff, and/or visitors. The cook in the kitchen acknowledged to the surveyor that the door should have been closed and closed it. On 5/14/26 at 9:07 AM, the surveyor entered the kitchen and observed a rack of utensils next to the high temp dishwashing machine. Server #2 acknowledged the utensils had been washed but she had not yet checked and logged the water temps for the dishwashing machine. She stated the temps were checked by looking at thermometers on top of the machine which indicated the wash and rinse water temperatures. Server #2 stated she checked the 3-bay sink water temperature and sanitizer level this morning but had not logged it yet. Server #2 acknowledged the reason for checking water temperatures and sanitizer levels was to be sure the dishes were all cleaned properly. Server #2 returned the rack of utensils to the area with the dirty dishes. She acknowledged she needed to check the temperatures for the water in the dishwashing machine and re-wash the utensils. Server #2 provided the log sheets to the surveyor for March 2026, April 2026, and May 2026. The surveyor observed several blank spaces on each month's log sheets, in addition to those noted above, for the dishwashing machine and the 3-bay sink, as follows: Dishwashing machine blank spaces: 3/21 breakfast3/31 dinner4/23 lunch4/27 dinner4/28 breakfast, lunch and dinner4/29 breakfast, lunch, and dinner4/30 breakfast and lunch 3-bay sink blank spaces:3/31 dinner4/9 lunch4/16 lunch4/27 dinner4/28 breakfast, lunch, and dinner4/30 breakfast, lunch, and dinner4/30 breakfast and lunch On 5/14/26 at 11:38 AM, the surveyor met with the DDS, in the presence of the Administrator, to present the above concerns. The Administrator acknowledged the surveyor's findings. The DDS acknowledged it was important to check the water temperatures and sanitizer levels to ensure proper sanitation of kitchen dishes and utensils. She acknowledged the temperatures, and sanitizer should have been checked and logged before washing the dishes from breakfast, lunch, and dinner every day. The DDS acknowledged the log sheets were important because if the temperatures or sanitizer were out of acceptable range, she checked them again and notified the maintenance department if the machines were not working properly. The DDS acknowledged that even if her staff visually checked the temperatures and sanitizer levels, if it was not logged there was no evidence of proper cleaning or sanitation for her to review. On 5/14/26 at 1:53 PM, the survey team met with the Administrator and the Director of Nursing who acknowledged the surveyor's above concerns regarding the dishwashing machine, the 3-bay sink, and the kitchen door propped open to the hallway. On 5/15/26 at 8:58 AM, the surveyor observed the door to the kitchen completely open to the hallway used by residents, staff, and/or visitors. There were no staff in the kitchen visible to the surveyor from the doorway. On 5/15/26 at 9:57 AM, the survey team met with the Administrator and the Director of Nursing. The Administrator acknowledged he observed the kitchen door open to the hallway this morning and acknowledged it must be kept closed because the kitchen is a hazardous area, in addition to many other reasons the door shouldn't be left open. The Administrator did not provide any further information. A review of the facility provided job description titled Dishwasher reflected a summary: Maintains china/dishes, pots, pans, trays, kitchen, work areas, equipment and utensils in clean and orderly and sanitary condition. One of the essential duties and responsibilities reflected.Maintain and track temperatures and chemical (sanitizer) levels as outlined by provided standards. Let supervisor know in a timely manner if levels are off. A review of the facility provided job description titled Cook reflected an essential duty and responsibility: Perform job safely while maintaining a clean and safe work environment and following correct procedures at all times. A review of the facility provided job description for the DDS, titled Chef Manager, reflected key responsibilities including maintains sanitation of equipment, supplies, and utensils. and supervise hourly food service associates. A review of the facility provided policy with the subject: Food and supply storage, revised 1/26, reflected All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The procedures included.Restrict access to storage areas to only those associates whose job responsibilities require them to retrieve items from these areas. NJAC 8:39-17.2(g), 19.7(d)

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks on new hires. This deficient practice was identified for 4 out of 14 employees (Employee #3, #4, #7, and #9) hired since the last Department of Heath recertification survey date of 12/31/24.On 5/12/26 at approximately 5:45 PM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 12/31/24 to the current date. A review of the employee personnel files revealed the following:For Employee #3, an Activities Staff with a date of hire (DOH) of 3/19/25, there was no evidence of a reference check prior to the start of employment.For Employee #4, a Certified Nursing Assistant with a DOH of 10/19/25, there was no evidence of a reference check prior to the start of employment. For Employee #7, an Activities Staff with a DOH of 3/21/25, there was no evidence of a reference check prior to the start of employment.For Employee #9, a Registered Nurse with a DOH 12/23/25, there was no evidence of a reference check prior to the start of employment. On 5/14/26 at 12:47 PM, the LNHA and Director of Nursing (DON) were made aware of the above concerns regarding reference checks for newly hired employees.On 5/14/26 at 1:06 PM, the surveyor interviewed the Business Office Manager who stated that she was responsible for employee reference checks. She stated that during the initial interview the employee would provide references for whom they would like the facility to contact. She further stated that the importance of the reference checks was because it was a state guideline. She then stated that a reference inquiry should be completed prior to their date of hire.On 5/15/26 at 9:54 AM, the survey team met with the LNHA and the DON. The LNHA acknowledged the reference checks that were not completed and further stated reference checks should be completed prior to hire. The LNHA then stated, we could do better with employee files.The facility had no additional information to present for the above concerns.A review of the facility's Abuse policy, revised 10/2022 revealed .The facility will not knowingly employ any individual who has a history of abusing other persons. Potential employees and volunteers shall be screened thoroughly through structured interviews, personal and employment reference checks, criminal background checks and contact with State licensing boards and registries, when applicable. NJAC 8:39-9.3(b)

Based on observation, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to ensure a resident's care plan, who was a known high fall risk and had sustained multiple falls, maintained documentation of the falls. This deficient practice was identified for 1 of 2 residents (Resident #7) reviewed for falls and accidents and was evidenced by the following:On 5/12/2026 at 6:24 PM, during initial tour, Resident #7 was observed in bed. The resident stated they had a fall in the past but couldn't remember when. The surveyor reviewed the electronic medical record (EMR) for Resident #7. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified macular degeneration (an eye disease that affects central vision, meaning people can't see things directly in front of them), heart failure (a chronic condition where the heart cannot pump enough oxygen-rich blood to meet the body's needs) and unspecified hearing loss.A review of the annual Minimum Data Set (MDS), an assessment tool dated 11/21/25, revealed the resident had a Brief Interview for Mental Status of 11 out of 15, indicating the resident was moderately cognitively impaired. A further review of the MDS revealed the resident had a fall since admission/entry.A review of the individual comprehensive care plan (ICCP) revealed a focus of High risk for falls r/t (related to) Confusion and macular degeneration, Date Initiated: 11/13/2024, Revision on: 11/28/2025. Further reveal of the ICCP, did not reveal the resident had an actual fall. A review of the progress notes revealed the following:On 10/16/2025 at 9:54 PM, Nurse's Note text: CNA (Certified Nursing Aid) reported to this writer that resident was sitting on buttocks with both feet extended between recliner and bed.On 12/31/2025 at 6:57 AM, Nurse's Note text: entered room to give AM meds (medications). Resident noted sitting on floor next to bed. fully clothed slippers on. On 1/14/2026 at 7:35 PM, Nurse's Note Text: Called to the room by the LPN (Licensed Practical Nurse). Resident was located on the floor, next to bed, on left side. Resident is awake and alert with baseline confusion but easily redirected.Care plan updated.A review of the Morse Fall Scale documents revealed the following:Effective date: 10/17/25 at 11:05 PM; Score: 50; Type: Post FallEffective dated: 12/31/25 at 7:00 AM; Score 90; Type: Post FallEffective date: 1/14/25 at 7:10 PM; Score 80; Post FallFurther review of the Morse Fall Scale documents (a tool for assessing a patient's likelihood of falling) revealed Section G. Scoring: Morse Fall scoring: High Risk 45 and higher. On 5/14/2026 at10:59 AM, the surveyor interviewed Registered Nurse (RN) #1, who stated he was Resident #7's assigned nurse. He stated the resident was a fall risk and had a fall but was unsure of the date. He stated the purpose of the care plan was to make sure needs are met. RN #1 stated a fall should be in the care plan and should include the date of the fall and any interventions. He accessed the EMR, in presence of surveyor, and reviewed the care plan. He was unable to locate the actual falls. During the interview, the Director of Nursing (DON) came over to assist RN #1 in finding the documentation of the actual falls. She was unable to, at that time. On 5/14/2026 at11:13AM, the DON accessed the EMR on her computer, in the presence of the surveyor. She stated Resident #7 had a history of falls and should have an actual care plan for falls. The DON stated if you select the H(history) on the care plan for High risk for falls you would see the resident has a fall 10/16/25. She was unable to locate the falls from 12/31/25 and 1/14/26 on the care plan. The DON stated the purpose of the care plan was to provide a plan for care. She stated it would be important to keep the falls on the care plan so we (the facility staff) know not to do the same thing (interventions) over again. The DON stated the MDS coordinator takes things off the care plan after 6 months. The DON stated she had to check with the MDS coordinator for the falls.On 5/14/2026 at 1145 AM, during a follow up interview, the DON stated the care plan was updated at the time of the falls for Resident #7. She stated you had to click resolved to see the actual falls. The DON showed the surveyor in the EMR, which showed the fall from 10/16/25, 12/31/25 and 1/14/26 had been on the care plan but were all resolved on 2/2/2026. The DON stated she told the MDS coordinator she wanted to go back to the old way on the care plan where we keep the dates of the actual falls. On 5/14/2026 at 1:53 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON were made aware of the above concerns.A review of facility policy Assessing Falls and Their Causes updated 4/19/2026, revealed Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.A review of facility policy Care Plans-Comprehensive updated 6/19/25, revealed Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan: .d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. NJAC 8:39-27.1 (a)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to document weekly weights as ordered in accordance with professional standards of practices. This deficient practice was identified for 1 of 12 residents reviewed for professional standards of practice (Resident #10). The deficient practice was evidenced by the following: 1. On 12/26/24 at 10:35 AM, during initial tour of the facility, the surveyor observed resident #10 in their bedroom seated in their wheelchair. At the time Resident #10 had a visitor present and reported no concerns. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but not limited to; Parkinson's Disease with dyskinesia (involuntary, uncontrolled movements), hypertension (high blood pressure), generalized muscle weakness, and dysphagia (difficulty swallowing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/24/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a cognitively intact cognition. A review of the Order Summary Report dated active orders as of 9/3/24, included a physician's order (PO) dated 9/3/24, for weekly weights every Friday. A review of the corresponding September, October, November, and December 2024 Treatment Administration Records (TAR) revealed the weekly weights were signed off as completed on 9/20/24, 9/27/24, 10/18/24, 10/25/24, 11/15/24, 11/22/24, 11/29/24, 12/13/24, 12/27/24. A further review of the October and December 2024 TAR revealed that weekly weights were blank on 10/25/24 and 12/20/24. A review of the Weights and Vitals Summary provided by the Director of Nursing (DON) revealed weekly weights were not documented for 9/20/24, 9/27/24, 10/18/24, 10/25/24, 11/15/24, 11/22/24, 11/29/24, 12/13/24, 12/20/24 and 12/27/24. On 12/27/24 at 12:57 PM, the surveyor interviewed the DON, who stated she could not provide weekly weights for the 10 dates listed above. The DON stated that the nurse completes weekly weights, signs it off on the TAR and then will document it under the weights tab in the electronic medical record (eMR). On 12/20/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the LPN or Certified Nurses Aide (CNA) can obtain weekly weights. The LPN also stated that the weights order will show up on the TAR to initial off, but they also document the weight under the weights and vitals tab. On 12/30/24 at 12:18 PM, the surveyor interviewed the Registered Dietitian (RD), who stated that she was unaware that Resident #10 was on weekly weights. The RD also stated that when Resident #10 was admitted to the facility they had a desire to lose weight and they discussed a weight goal. The RD further stated she had been monitoring the residents' weights monthly. On 12/30/24 at 1:21 PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administer (LNHA), and survey team, confirmed that Resident #10's weights were not obtained weekly as ordered. The DON stated that weekly weights should be documented in the eMR under the weights tab. The DON acknowledged that the weights should have been obtained weekly as ordered. A review of the facility's Weight Monitoring policy dated reviewed and updated 11/19/24, included residents that are on weekly weights should be weighed on the day of the week ordered . All weights will be reported to the nurse and documented in the resident's chart .RD will monitor resident's weights for any weight loss/gain. A review of the facility's Charting and Documentation policy dated reviewed and updated 11/20/24, included all services provided to the resident, progress toward the care plan goal, or any changes in the resident's medical, physical, functional of psychological condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses, and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination. This deficient practice was observed and evidenced by the following: On [DATE] from 09:22 AM until 10:06 AM, the surveyor toured the kitchen in the presence of the Dining Services Director (DSD) and observed the following: 1. In the walk-in refrigerator, there was a stack of yellow square cheese wrapped in clear plastic with no open or use by dates and no label. The DSD acknowledged there was no label and stated that there should have been a label marked with the open date and the good through date. There was one opened plastic bag of shredded cheddar cheese wrapped in clear plastic wrap with no open or use by dates and no label. There was one white plastic container containing meat, with no label and no use by dates. The container was partially covered by clear plastic wrap and the meat was visible and exposed to air. The DSD identified the meat as lamb chops and acknowledged that the container was not covered correctly and that it should have had a lid and a label with a use by date. The DSD stated that it was important, for the prevention of bacterial growth and foodborne illness, for food to have not been held longer than a specified time, and proceeded to throw the lamb chops in the trash. In a half pan on the bottom shelf of a metal rack there was one bag of defrosted chicken that the DSD stated were chicken tenders, with no label or dates. The DSD stated it was pulled last night and that it should have had a label. 2. In the walk-in freezer, there was one opened package of frozen tortillas wrapped in clear plastic, marked by manufacturer, date use by [DATE]. The DSD stated that they were expired and disposed of them into the trash. 3. In the spice area, there was one 22 ounce (oz) jar of sriracha seasoning, one 14 oz jar of Aleppo style pepper, one 16 oz jar of Ancho chile pepper, one 5 oz jar of dill weed, and one 6 oz jar of rosemary leaves, all undated and no open dates. The DSD acknowledged the spices were undated and stated, I have no idea how old they are, I just got here. The DSD threw the spices into the garbage. 4. On a metal table was the Robot Coup which the DSD stated was used then cleaned. The DSD removed the lid and inside of the cannister was clear liquid and white food debris. The DSD removed the food debris with her finger and acknowledged that the Robot Coup should not have been wet nested and stated that it could have passed bacteria. The slicer, which the DSD stated was clean, was resting in the same area. There was dried white debris on the slicer pan which the DSD scraped with her finger and then used a wet cloth to wipe the area. There was white and brown debris on the slicer base which the DSD wiped with her finger and stated, Men don't clean well. 5. Under the prep table on the bottom rack was one white cutting board with brown smudges, one yellow cutting board with gouges and brown smudges, and one white cutting board with gouges and brown smudges. The DSD acknowledged that the cutting boards should not have had smudges and gouges and stated that bacteria could have gotten into the grooves. 6. In a ,d+[DATE] size pan in the reach in refrigerator, there were four clear plastic bags of herbs. The DSD identified: one bag of rosemary with green and brown leaves; one bag of cilantro; one bag of thyme; and one bag of sage. None of the bags had a label nor any open or use by dates. The DSD acknowledged that the herbs were not labeled nor dated and stated that they should have been. The DSD threw all the bags of herbs away. 7. In the dry storage room, there were three opened bags of pasta knotted closed and two opened bags of pasta wrapped in clear plastic wrap with no opened or use by dates. The DSD acknowledged the pasta was not stored correctly and stated that they should have been marked with an open and use by date. The DSD stated that it was important to store the pasta correctly, so bugs did not get in and to ensure food was not served past expiry. 8. In the ice cream freezer, there were 20 unmarked individual covered cups of scooped ice cream with no label or use by dates. The DSD acknowledged the cups should have had a label with the use by date. On [DATE] at 12:12 PM, the Licensed Nursing Home Administrator met with the surveyors in the conference room, and was made aware of the kitchen concerns. A review of the facility policy, Storage of Food and Supplies, reviewed [DATE], revealed, Method/How To/Procedure: Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date .Discard food past the use-by, sell-by, or enjoy-by date. Cover, label and date unused portions and open packages. Complete all sections on a Unidine Universal Date Label or use an approved labeling system. Date and rotate items. Discard food past the use-by or expiration date. Refrigerated Storage Life of Food: Use manufacturer's expiration date for products before opened. If there is no expiration date on the package, add the time listed here to the date the food received. Add the time in the opened column to the date when the food is prepared or opened. Label when product is opened. A review of the facility document, 7.4 Food Protection, Facility/Equipment, created [DATE], revealed no information on equipment cleaning. NJAC 8:,d+[DATE].2(g)

Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices for donning (putting on) the appropriate Personal Protective Equipment (PPE) prior to entering an isolation room to prevent the transmission of infection for 2 of 13 residents (Resident #1 and Resident #16) positive for COVID-19. This deficient practice was evidenced by the following: 1. During an interview with the surveyor on 01/04/24 at 9:33 AM, the Infection Preventionist (IP) stated the facility was currently in a COVID-19 outbreak, but that all residents were fully vaccinated against COVID-19 with multiple booster doses as well. On 01/04/24 at 10:36 AM, the surveyor observed the District Manager Housekeeper (DMH) standing outside of Resident #1's room. Outside the resident's room, there was a three-tiered PPE supply bin next to the door which contained N95 masks, gowns, gloves, and face shields, but there wasn't any signage on the door to indicate what PPE was required to enter the resident's room. The DMH donned a N95 mask, gown, and gloves and entered the resident's room. The DMH did not don any eye protection prior to entering the resident's room. At 10:42 AM, the DMH opened the door to Resident #1's room and was observed wearing a N95 mask, gown, and gloves inside the resident's room. The DMH doffed (removed) his PPE, disposed of the PPE in the resident's room, and performed hand hygiene with alcohol-based hand rub (ABHR) before exiting the resident's room. During an interview with the surveyor on 01/04/24 at 10:44 AM, the DMH stated Resident #1 was on isolation for COVID-19 and that the PPE required to enter the resident's room included a N95 mask, gown, and gloves. The DMH further stated that there is normally a sign on the resident's door to indicate what PPE was required for the isolation room. When asked about eye protection, the DMH stated eye protection is also required in the COVID-19 isolation rooms. He then pulled out eyeglasses from his pants pocket and stated he wore eyeglasses in the resident's room. When asked if the DMH wore a face shield or goggles inside the resident's room, the DMH stated he should have worn a face shield or goggles in the COVID-19 isolation room. According to the Admission Record, Resident #1 had diagnosis of COVID-19. Review of resident's Order Summary Report, as of 01/01/24, included a physician's order, dated 12/30/23, for Contact/Droplet Isolation precautions related to positive COVID results x 10 days. Review of the resident's Care Plan, revised 12/30/23, included a focus of, Transmission Based Precautions - Fitted N95 mask, gown, face shield or goggles, and gloves to be worn Q Shift [every shift], with an intervention that, Staff will wear PPE to enter my room and perform hand hygiene. Review of the resident's Progress Notes included a Nurse's Note, dated 12/30/23 at 12:04 PM, that revealed, COVID test done, results positive. Further review of the Progress Notes included a Nurse's Note, dated 12/30/23 at 2:41 PM, that revealed, Implemented isolation/droplet precautions. During an interview with the surveyor on 01/04/23 at 10:49 AM, the IP stated that when a resident was placed on isolation for COVID-19, signs were posted on the resident's door to notify staff and visitors to Please see a nurse before entering this room, and, Transmission Based Precautions in Place, Anyone entering the room must wear: Gown, Mask: N95, Goggles/Face Shield, Gloves, and a PPE supply bin is placed outside the resident's room. The IP further stated that residents diagnosed with COVID-19 were placed on droplet precautions and the PPE required to enter that resident's room was a N95 mask, gown, gloves, and a face shield or goggles. At that time, the surveyor notified the IP of the missing signage for Resident #1's room and that the DMH did not wear eye protection while in Resident #1's room. The IP stated that the staff should have notified her that the signage was missing and that the DMH should have worn droplet precaution PPE in Resident #1's room. 2. On 01/05/24 at 10:56 AM, the surveyor observed the Infectious Disease (ID) physician standing outside of Resident #16's room. Outside the resident's room, there was a three-tiered PPE supply bin next to the door which contained N95 masks, gowns, gloves, and face shields, and there was signage on the door that included, Transmission Based Precautions in Place, Anyone entering the room must wear: Gown, Mask: N95, Goggles/Face Shield, Gloves. The ID physician donned a gown, gloves, and N95 mask and entered the resident's room. The ID physician was wearing eyeglasses but did not don eye protection, such as a face shield or goggles prior to entering Resident #16's room. At 10:58 AM, the ID physician exited Resident #16's room and performed hand hygiene with ABHR. The surveyor interviewed the ID physician at that time. The ID physician stated that Resident #16 was on isolation for COVID-19 and that the required PPE for that room included a N95 mask, gloves, and gown. The ID physician further stated that the resident's door had signage which indicated the PPE required for the room, but that he doesn't look at that sign since he already knows what PPE to wear. The ID physician then acknowledged the sign included that staff must wear eye protection, such as a face shield or goggles, prior to entering the resident's room. The ID physician further stated that it was important to wear the correct PPE for residents on isolation in order to prevent the spread of infection. According to the Admission Record, Resident #16 was admitted with a diagnosis of cerebral infarction (stroke). Review of the resident's Order Summary Report, as of 01/08/24, included a physician's order, dated 01/03/24, for, Transmission Based Precautions - Fitted N95 mask, gown, face shield or goggles, and gloves to be worn Q Shift. Review of the resident's Care Plan, revised 01/03/24, included a focus of, Transmission Based Precautions for COVID x10 days, and an intervention of, PPE and signage at room. Review of the Progress Notes included a Nurse's Note, dated 01/03/24 at 9:32 AM, which revealed, Resident c/o [complained of] sore throat. COVID swab performed . COVID positive. ID [physician] informed . placed on Transmission Based Precautions. On 01/05/24 at 11:04 AM, the surveyor notified the IP of the surveyor's observation of the ID physician. The IP stated the ID physician should have worn goggles or a face shield prior to entering Resident #16's room. Review of the facility's Outbreak Response Plan, reviewed 10/2023, included, Staff will be educated on exposure risks, symptoms, and prevention of the Emerging Infectious Disease (EID). Special emphasis will be on reviewing basic infection prevention and control, use of PPE, isolation, and other prevention strategies such as hand washing. Review of the facility's Application of Transmission-Based Precautions policy, revised 10/09/23, included, Droplet Precautions: Intended to prevent transmission of pathogens spreading through close respiratory or membrane contact with respiratory secretions. Staff caring for residents with Droplet Precautions should wear a face mask for close contact with the resident. Consider adding goggles or a face shield to protect eyes from exposure to respiratory droplets, especially when caring for residents with a significant cough or respiratory secretions. Further review of the policy included, Communication about Transmission-Based Precautions . Room entry signage indicating what type of Transmission-Based Precautions and appropriate PPE to be used. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, included, HCP [Health Care Professionals] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). NJAC 8:39-19.4(a); 27.1(a)

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to ensure safe food temperatures are maintained, and b.) store foods in a manner to ensure items are not used beyond safe use by dates. This deficient practice was evidenced by the following: On 08/18/21 at 09:15 AM, the surveyor toured the kitchen in the presence of Food Service Director (FSD) and two other surveyors and observed the following: 1. The large walk-in refrigerator with attached walk-in freezer had an August 2021 temperature log that was blank. The FSD informed the surveyor that, It got dirty, so this is new one. The surveyor asked to see the dirty one that the FSD said was completed for August 1st thru the 17th and the FSD said it ripped and he threw it away. 2. A stand-alone ice cream freezer which contained cartons of individual cups of ice cream; there was a blank temperature log for the month of August. The FSD informed the surveyor it got dirty too and ripped and I threw it away. 3. A stainless steel food prep refrigerator had a blank temperature for the month of August. Before the surveyor could ask for the temperature log, the FSD said to surveyor, Ok, I just didn't do it. 4. In the walk-in refrigerator there was a stainless-steel rack with five trays of food items. One tray had individual serving cups of rice pudding, one with individual serving cups of chocolate pudding, one tray with individual serving cups of gelatin dessert, one tray with individual serving glass cups of fresh fruit and one tray with two 10-inch pies. The pies were not covered and open to air and the fruit was open to air. None of the items were dated with a prepared or a use by date. The FSD informed the surveyor they are for today. 5. In the walk-in refrigerator there was a stainless tray with 15 stuffed pork chops on one of the bottom refrigerator racks. The pork chops were open to air and there were no prepared or use by dates. The FSD informed the surveyor, I am going to cook these, they were prepared this morning. The surveyor asked if they should be dated and covered and he responded, yea. 6. In the walk-in refrigerator there was a stainless-steel tray of cut up white potatoes, not covered and no prepared or use by dates. 7. In the walk-in refrigerator there was one opened five-pound bag of shredded mozzarella cheese approximately half full and wrapped in clear plastic wrap. There was no received by, opened, or use by dates. 8. In the walk-in refrigerator there was one opened five-pound bag of grated parmesan cheese approximately half full. There was no received by, opened, or use by dates. 9. In the small prep refrigerator there was a stainless-steel tray of 12 small plastic cups of brown thick liquid substance. The FSD said it was prune pudding. There was no prepared or use by dates. 10. In the dry storage area there was an opened five-pound bag of pancake mix approximately half full. There was no opened or use by dates. 11. In the dry storage area there were five opened five-pound bags of pasta, all approximately half or less full and wrapped in clear plastic wrap. There was no opened or use by dates. 12. In small prep fridge there were 12 slices of cooked bacon wrapped in clear wrap. There was no prepared or use by dates. 13. In small prep refrigerator there were 10 provolone cheese slices wrapped in clear wrap. There was no opened, received or use by dates. 14. In small prep refrigerator there were two sandwiches on white bread on small plates covered with plastic wrap. The FSD said they were peanut butter and jelly. Both sandwiches had a use by date of 8/16/21. 15. A large plastic bin with white flour and a large black scoop in the flour. 16. In the dry storage area there were four large cans; one fruit cocktail, one tomato sauce, and two black beans that were dented. They were not in the dented can area. When pointed out to the FSD he responded, oh and removed the cans from the can rack. On 08/18/21 at 11:40 AM, the surveyor interviewed the FSD who stated I labeled everything now. The surveyor asked if the items should have been labeled and dated prior to today and the FSD responded Yes, but I have no staff. A review of the facility's Storage of Food and Supplies policy dated December 2020, included under the section of Refrigerated Foods that food should be stored at 41 degrees Fahrenheit or below and assure compliance of this using temperature logs in each corresponding location. The policy also included to cover foods stored on ladder racks to prevent contamination. Under the section titled Method/How to/Procedure, the policy included to cover, label and date unused portions and open packages. Complete all sections on a date label or use an approved labeling system. NJAC 8:39-17.2 (g)

Based on observation, interview, and record review it was determined the facility failed to ensure the accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation. This deficient practice was identified for 4 of 4 DEA 222 forms provided, and was evidenced by the following: On 8/18/21 at 12:30 PM, the surveyor reviewed four of the facility's DEA 222 forms that were provided. The forms revealed that the facility did not complete Part 1 (last line) or complete in Part 5 the number of packages received or the date the medication was received as instructed to on the reverse side of the DEA 222 form. The inaccuracies were as follows: Order Form: # 4631: No number received # 7659: No number received # 7662: No number received and no last line completed # 7663: No number received and no date received On 08/18/21 at 12:49 PM, the surveyor interviewed the Director of Nursing (DON) who stated that one of the responsibilities of the DON was to complete the DEA 222 forms. The DON acknowledged that she had not completed the forms as required; that the last line in Part 1 was not completed prior to submitting the form. She further acknowledged when she had received narcotic mediations, she should have filled in the quantity received; as well as the date the medication was received. A review of the instructions for submission of the DEA 222 form located on the reverse side of the form included: Part 1. Purchaser Information, 2. Only one item may be entered on a single line. Enter the number of packages, the size of the package, and the name of the item. Part 5. Controlled Substance Receipt 1. The purchaser fills out this section on its copy of the original form. 2. Enter the number of packages received and date received for each line item. A review of the facility's Ordering Medications, Controlled Drug Substances in Back Up, Policy 4.8 dated effective November 2010, included: A. Match all medications with corresponding records. The policy did not include the procedure for how to the complete the DEA 222 form once the medication was received by the pharmacy. N.J.A.C. 8:39-29.7

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were properly secured and stored at all times during the medication pass observation on 8/19/2021. This deficient practice was identified for 2 of 2 nurses and 2 of 6 residents, (Resident #4 and #23) reviewed for medication storage. The evidence was as follows: 1. On 8/19/2021 at 8:14 AM, the surveyor in the presence of another surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #23. The LPN prepared ten medications which included two different eye drop medications ([MEDICATION(S)]-[MEDICATION(S)] and [MEDICATION(S)]) and oral medications for the resident. The LPN stated the eye drop medications needed to be administered at least five minutes apart from each other. The LPN choose one of the eye drop medications ([MEDICATION(S)]-[MEDICATION(S)]) and placed the other eye drop medication ([MEDICATION(S)]) on the top of the cart. The LPN then pulled the cart to the doorway, locked the cart, locked the electronic medical record and proceeded into the room to administer the medications leaving the eye drop medication ([MEDICATION(S)]) on top of the cart. There were no residents in the immediate area. On 8/19/21 at 8:29 AM, the LPN exited the room after he administered the medications to Resident #23. At that time, the surveyor questioned the LPN if he should have left the eye drop medication ([MEDICATION(S)]) on the cart, and the LPN responded he should not have. The LPN stated that he should have kept the eye drop medication ([MEDICATION(S)]) he planned to administer second in the locked medication cart while administering the first round of medications to Resident #23. On 8/19/21 at 9:37 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses had to ensure that the medication cart was locked at all times for safety. She further stated that the nurses needed to maintain a view of the medication cart at all times and never walk away from the cart with medications left on top. On 08/19/21 at 12:42 PM, the DON and the Licensed Nursing Home Administrator (LNHA) acknowledged medication should never be left on the top of the cart unattended because from a safety prospective, someone could come along and take it. 2. On 8/19/21 at 8:24 AM, the surveyor observed the Registered Nurse (RN) in the hallway in front of the dining room prepare medications for Resident #4 at medication cart #1. The RN prepared four oral medications, which included an adult low dose Aspirin 81 milligrams (mg). The RN then pulled medication cart #1 closer to the window, locked the electronic medical record, locked the medication cart, and proceeded into the dining room to administer the medications to Resident #4. On 8/19/21 at 8:26 AM, the surveyor observed the RN had left the bottle of adult low dose aspirin 81 mg on top of the medication cart. There were no residents in the immediate area of the medication cart. On 8/19/21 at 8:29 AM, the RN and the surveyor returned to the medication cart and the RN signed off on the four oral medications she administered in the electronic medical record. The surveyor picked up the bottle of aspirin 81 mg that was left on top of the cart, and the RN then realized she had left the bottle of aspirin 81 mg on top of the medication cart. The RN stated the bottle of aspirin 81 mg was not in her view after the surveyor had reviewed the medication prior to administration. The RN immediately placed the bottle of aspirin 81 mg back in the top drawer of the medication cart and stated she was supposed to make sure all medications are placed back into the cart prior to locking it. On 8/19/21 at 9:38 AM, in the presence of the survey team, the DON stated staff should never walk away with medications left on top of the cart for the safety of the residents. She further emphasized staff should not leave medications on top of the cart because a resident could come and take the medication off the cart. On 8/19/21 at 12:31 PM, in the presence of the survey team the DON and LNHA acknowledged staff was responsible to ensure everything was placed back into the medication cart prior to locking it. On 8/19/21 at 12:43 PM, the LNHA also acknowledged medications should never be left on top of a medication cart. The LNHA stated the reason was for a safety prospective as someone could come and take the medication. A review of an in-service sign in sheet provided by the LNHA dated 8/20/21 indicated that the nursing staff was educated on Medications may not be left on the medication cart unattended at any time. This is a concern for safety. A review of the facility's revised 10/2017, for Medication Administration Guidelines dated revised 10/2017 included that the medication cart will be kept within view at all times or locked when unattended. A review of the facility's Disposition of medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . NJAC 8:39-29.4(h)

Based on observation, interview, medical record review and other facility documentation, it was determined that the facility failed to implement mitigation strategies to prevent the transmission of COVID-19 by not appropriately utilizing Personal Protective Equipment (PPE) for residents identified as exposed to COVID-19 for 27 of 27 residents, and for 4 of 4 residents, Resident #4, #5, #6 and #7 who were readmitted to the facility and identified as persons under investigation (PUI). This deficient practice placed 27 of 27 residents in the facility at risk for infection. On 1/26/2021, the facility submitted a removal plan for F 880 by e-mail to The New Jersey Department of Health (NJDOH). This deficient practice was identified during a focused infection control survey on 1/25/21 and 1/26/21 and was evidenced by the following: On 1/5/21 and 1/13/21, the facility became aware that two staff members, a Certified Nurses Aides (CNA) #1 and a Licensed Practical Nurse (LPN), were confirmed positive for COVID-19 in the facility. CNA #1 worked all three shifts in the facility and was tested and confirmed positive on 1/5/21. The LPN worked 11-7 on the unit, and was tested on [DATE] and confirmed positive on 1/13/21. The facility identified the residents of the entire facility as exposed, and placed the residents on quarantine until 1/25/21, day 1 of survey. In addition, there were four residents who were readmitted to the facility and were placed on quarantine, (Resident #4 was readmitted on [DATE]; Resident #5 was readmitted on [DATE]; Resident #6 was readmitted on [DATE]; Resident #7 was readmitted on [DATE]). The DON stated that the PPE required to be worn for the exposed residents and readmitted residents were KN95/N95 with surgical mask over, goggles/face shield and gloves. The DON stated that gowns were not utilized and did not have to be worn because the residents were not showing any signs or symptoms of COVID-19, and that she was fearful of using too many gowns. The facility failed to utilize proper PPE for residents identified as exposed, and for readmissions to the facility. During the survey conducted on 1/25/21, the surveyor observed staff wearing a KN95 or N95, with a surgical mask over it and a shield as the form of PPE. There were no gowns utilized for the residents who were identified as PUI until after surveyor inquiry. The facility's failure to utilize appropriate PPE for exposed residents and readmitted residents posed a serious and immediate threat to the safety and well being of all residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/5/21 when the facility was notified of the confirmed positive staff member. The facility Administration was notified of the IJ on 1/26/21 at 3:00 PM. The evidence was as follows: 1. During an entrance conference with the surveyors on 1/25/21, at 9:29 AM, the Director of Nursing (DON) stated that the facility was under quarantine after a nurse who worked the 11-7 shift tested positive on 1/11/21. The DON stated that the facility never had positive resident cases, and all the residents tested negative for two weeks. The residents exposed were off quarantine on 1/25, day 1 of survey, except for the residents who were readmissions. The DON stated that the PPE required to be worn for exposed residents and readmissions were, N95/KN95 with surgical mask over, goggles/shield and gloves. The DON stated that gowns were not needed unless the resident had signs or symptoms of COVID-19 and was instructed on that by the facility consultant infectious disease physician. During an interview with Surveyor #1 on 1/25/21 at 9:50 AM, the Administrator stated that there was no shortage of PPE. The facility PPE was located in a storage POD outside, and that they had over bought gowns, and had adequate amounts of shields, gloves, masks N95 and KN95. The DON stated that the new admissions would have a See Nurse sign on their door for directive on what PPE was needed. Review of the facility line list for COVID-19 revealed the CNA had an onset date of 1/5 and the LPN onset date of 1/11/21. Review of the [MEDICATION NAME] test results for the CNA revealed a confirmed positive date of 1/5/21. Review of the PCR test for the LPN revealed test was collected on 1/11/21, and confirmed positive for COVID-19 on 1/13/21. Review of the Resident's #4, #5, #6, and #7's medical record revealed the following readmitted s: Resident #4 was readmitted on [DATE]; Resident #5 was readmitted on [DATE]; Resident #6 was readmitted on [DATE]; Resident #7 was readmitted on [DATE]. During tour of the unit on 1/25/2021 at 9:55 AM, Surveyor #2 observed that all the doors to the rooms on the units were closed. There was no PPE set up observed on the outside of the rooms or on the unit. Additionally, there was no signage on the unit indicating that there were any transmission based (TBP) precautions in place. Staff were observed wearing only a N95/KN95 with surgical mask, and goggles or face shield. During an interview with Surveyor #2 on 1/25/2021 at 10:00 AM, a Registered Nurse (RN) who was wearing an KN95 and a face shield, stated that since there was an exposure of a positive staff member the facility was on a lock down. The RN stated all the doors were kept closed and that the residents must stay in their rooms. The staff must wear KN95 with a mask over and a face shield or eye protection. The staff were not required to wear gowns. The RN stated Resident #5 was considered a readmission and did not know why the staff, including herself, were not wearing gowns in the room. She stated the DON would usually place PPE outside those residents' room and would inform the staff of the isolation. She stated since the residents all tested negative no gowns were needed. During an interview with Surveyor #2 on 1/25/221 at 10:45 AM, a Nursing Assistant (NA), who was assigned to Resident #5, stated she was in-serviced on PPE and wore a KN95, a surgical mask and face shield on the unit. The NA stated when residents return from the hospital, they were on isolation and the nurse on the floor would let her know. There would be PPE at the door and she would also wear a gown in the rooms. She stated since the readmissions on the unit tested negative the staff did not need to wear a gown in the resident room. She stated she did not wear a gown in the rooms since the resident's exposure to the positive staff members. During an interview with Surveyor #2 on 1/25/2021 at 11:00 AM, the Physical Therapist stated the PPE that was to be worn in the facility were KN95 with a surgical mask and a shield. She stated staff would need to wear gowns for residents on isolation and those residents would have PPE on the door with a sign to see the nurse. During an interview with Surveyor #1 on 1/25/21, at 12:01 PM, the Infection Preventionist (IP) stated that any resident who was exposed to a positive staff member would be tested , and the facility would be on total lockdown. Residents would stay in their rooms with masks on, and any staff entering would wear N95 with surgical mask over, goggles/face shield, and gloves. The IP stated gowns would not be utilized unless there was soiling or signs and symptoms of COVID-19. The IP added that any new or readmission would require the same PPE, and residents would stay in their room on observation for 14 days. The IP stated that staff were informed through report of what precautions were in place for the residents. During an interview with Surveyor #2 on 1/25/2021 at 12:15 PM and 1:05 PM, Licensed Practical Nurse (LPN) #1 stated the current residents on the unit that were readmitted were not considered to be on isolation because their tests were negative for Covid-19. She stated typically new or readmissions were on 14 day isolation and staff would need full PPE including a gown. She stated once a staff member tested positive, all the staff needed to wear a KN95, face shield, gowns and gloves. In addition, the resident's doors were all closed. Once all the residents were tested and were negative, no gowns were needed to be wore in the rooms. LPN #1 confirmed that gowns were not utilized for the residents on quarantine since the exposure of the CNA and LPN or the readmitted residents. On 1/25/21 at 12:45 PM, the DON stated that she was waiting for a call back from the infectious disease doctor regarding gown usage, and until she heard from him, that they were now going to utilize gowns for the residents who were readmitted . During an interview with Surveyor #2 on 1/25/2021 at 1:15 PM the Certified Nursing Assistant (CNA) #1, who was assigned to Resident #4, stated the PPE she wore was a KN95, with surgical mask, goggles and did not wear a gown in the rooms of the readmitted residents. On 1/25/21 at 1:23 PM, Surveyor #1 was handed a facility policy titled, Cohorting of Residents (COVID-19). Surveyor #1 read over the policy with the DON, which indicated that gowns were to be utilized when entering rooms of suspected exposure and new/readmission residents. When questioned, the DON stated that that was missed on the policy and confirmed that the facility did not utilize gowns since the CNA tested positive on 1/5/21. During tour of the unit on 1/25/2021 at 1:30 PM, Surveyor #2 observed Resident #4 and Resident #5's rooms. The doors were closed and had a sign on the door that read, Please see nurse before entering. There was PPE on the door which included gowns, gloves, and masks. Additionally, there were metal tables next to doors with additional PPE and hand sanitizer. During an interview with Surveyor #1 on 1/26/21 at 9:45 AM, (day 2 of survey) the DON stated that there was not a shortage of gowns, and that she was fearful of using too many gowns. She stated that gown use was in their policy and the facility utilized gowns prior to the facility quarantine on 1/5. The DON stated she wanted to make sure she was doing the right thing by not using gowns, and was confused after speaking with the infectious disease doctor. The DON added that staff were to wear N95 masks with a surgical mask over for the readmissions and staff were to change the mask every time they leave the room. In addition to the N95, staff were to wear shields, gowns, gloves when entering the room. During a telephone interview with Surveyor #1 on 1/26/21 at 10:50 AM, the infectious disease doctor stated he worked remotely and was initially contacted by the facility after they had a positive staff member. He stated that the facility only contacted him regarding the first positive staff member and that he talked them through the process. He stated that precautions in place for an exposed resident or new/re admission would require a N95, eye protection, gowns, gloves. He stated that he would never not recommend gown use and that he went by the CDC and state guidelines. He stated the reason for gown use was to maximize all precautions if exposed; staff could possibly spread to the next resident or other staff. During tour of the unit on 1/26/2021 at 11:00 AM, day two of the survey, Surveyor #2 observed Resident #4, #5, #6 and #7 rooms. The doors were closed and had a sign on the door that read Please see nurse before entering. Resident #4 and Resident #5 's room had PPE set up on the outside of the door which included gloves, masks, hand sanitizer and gowns. Outside of Resident #6 and #7's room was a metal table next to the door which included gowns, gloves, masks, disinfectant wipes and hand sanitizer. On 1/26/2021 at 12:30 PM, Surveyor # 2 toured and observed the PPE storage areas with the Administrator and DON and observed ample amounts of PPE which included gowns, gloves, N95, and surgical masks. The Administrator and the DON stated they had two months supplies on hand. The IJ was identified on 1/26/21 and the Administrator and DON were notified of the IJ at 3:00 PM. A removal plan was accepted on 1/27/21 which included that staff were to wear appropriate PPE for residents who are PUI which included, donning gowns, N95/KN95 masks, shields/goggles, and gowns must be worn prior to entering any room of a PUI. Signage indicating that transmission based precautions were in effect and gowns, N95/KN95 masks, shields/goggles, and gloves must be worn prior to entering the room was placed on the door of Residents #4, #5,#6, and #7. In-services were conducted on the policy and procedure regarding proper use of PPE while treating PUI. Review of a facility policy titled, Cohorting of Residents (COVID-19), reviewed and updated 11/20 and 1/21, included that following a suspected exposure, new admission, or readmission to the facility, or confirmed positive test, it is the policy of De La Salle Hall to cohort its residents. This can be accomplished by isolating the residents in their own room. 1. Signage will be posted at the entrance to the resident's room that instructs Health Care Personnel they must wear eye protection and an N95 or higher level respirator at all times (or facemask if respirator not available) when inside the resident room. Gowns and gloves should also be worn when inside the room. According to the Center for Disease Control, Considerations for new admissions or readmissions to the facility, all recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or 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, and gown. Part B- F880 remains at a deficiency at a scope and severity level of a D based on the following: Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) utilize appropriate personal proactive equipment (PPE) to prevent the potential spread of infection in accordance with the facility protocol and acceptable standards of practice, and b.) correctly administer an [MEDICATION NAME] test to test for COVID-19 for 2 of 2 surveyors. This deficient practice was identified for 1 staff member reviewed for infection control practices and was evidenced by the following: 2. On 1/25/2021 at 8:43 AM, during a rapid [MEDICATION NAME] test, the surveyors observed LPN #1 wearing a surgical mask under her KN95 mask. LPN #1 prepared the BinaxNOW rapid test and swabbed Surveyor #2's nostrils three turns in each nostril while counting out loud, and then placed the swab in the test card. At 8:47 am, LPN #1 swabbed Surveyor #1's nostrils three turns in each nostril, and placed the swab in the test card. At 8:53 am, LPN #1 began wrapping up the surveyor's tests and stated that the surveyors were both negative. At that time, Surveyor #1 questioned LPN #1 the length of the time needed to reveal the results, which she replied 15 minutes. She stated she used her phone as a timer. Surveyor #1 had revealed that she read the results at 10 and 6 minutes, LPN #1 stated, if that is what you got. At 9:01 am the LPN stated, Now you are officially negative. During an interview with Surveyor #2 on 1/25/2021 at 9:05 AM, the LPN #1 stated that she received KN95 once a week and wore her mask that way to preserve the KN95. She stated she was in-serviced on donning and doffing PPE and stated the KN95 needed to be fitted on the face and she should not have worn the mask that way. During an interview with the surveyors on 1/26/2021 at 10:15 AM, the Infection Preventionist Registered Nurse (IP/RN) stated she would not wear a surgical mask underneath an KN95/N95 because the seal would not be correct and the mask would not be effective. On 1/26/2021 at 11:20 AM, the DON provided in-services to the surveyors and stated the in-service labeled N95 mask and goggles was a competency of staff donning and doffing the masks and the goggles with her observation. Review of an in-service labeled, N95 Mask and Goggles revealed LPN #1's attendance. During an interview with Surveyor #2 on 1/26/2021 at 10:55 AM LPN #1 stated she learned how to perform the BinaxNOW testing from a RN. She stated the she either performed the test or gave instructions on how to self swab. She stated she would turn the swab in each nostril 3-5 times and then will read the results in 15 minutes. Review of a document titled, BinaxNOW Covid-19 Ag Card Quiz dated 12/1/20 , for LPN #1, revealed question 8. results should be read promptly at 15 minutes and not before. LPN #1 indicated that was true statement on the quiz. Review of the BinaxNOW COVID-19 Ag Card Technical Overview, that was provided to the surveyors, included that nasal swab sample collection included to rotate the swab 5 times or more against the nasal wall and results of tests were to be visually read at 15 minutes. NJAC 8:39-19.4(a)(2);(b)(c)(d) 8:39- 27.1(c)

Based on interview and review of facility documentation, it was determined that the facility failed to test staff for Coronavirus Disease 2019 (COVID-19) at a frequency based on the COVID-19 Activity Level Index (CALI) Weekly Report. This deficient practice was identified for 3 of 3 staff members in the facility who were reviewed for COVID-19 testing and was evidenced by the following: During an interview with the surveyor on 1/25/21 at 9:50 am, the Administrator stated that the staff were tested weekly on Mondays for COVID-19. The Administrator stated testing for staff was based on guidance form the local health department and the Executive Orders for New Jersey. The Administrator stated the current positivity was .97%. for their county, and handed the surveyor a print out from Monmouth County dated 1/24/21 which included the COVID-19 data. At that time, the surveyor reviewed the document with the Administrator which revealed that the infection rate was .97% and the county positivity rate was 11.1%. Documentation of staff testing was requested by the surveyor. A review of the staff 's most recent two COVID-19 test results, titled COVID Weekly Results for the three staff reviewed reflected the following: 1. A housekeeper tested negative for COVID-19 on 1/11/21 and 1/18/21; 2. A certified nurses aide (CNA) tested negative for COVID-19 on 1/11/21 and 1/18/21; 3. A licensed practical nurse (LPN) tested negative for COVID-19 on 1/11/21 and 1/18/21. A review of the CALI Weekly Report for the week ending January 16, and January 23, 2021, indicated that the current COVID-19 activity level for every region in New Jersey was documented as High. During an interview with the surveyor on 1/26/21 at 10:47 am, the Director of Nursing stated that the Administrator was responsible for reviewing the positivity rates for the COVID-19 staff testing. The DON stated that the testing should have been twice a week based on the increased positivity rate. Review of the New Jersey Department of Health Executive Directive No. 20-026, revised 1/6/21, included, Continued testing of staff as follows: . Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use the regional positivity rate reported in the COVID-19 Activity Level Index (CALI) Weekly Report in the prior week, as the trigger for staff testing frequency as follows: . Regional CALI Level: High/Very High - Regional Percent Positivity Rate in the past week: >10% - Minimum Testing Frequency: Twice a Week. Review of a facility policy titled, COVID-19 testing revised on 1/21, included that staff testing plan may be amended form time to time to be consistent with the most current CDC and DOH public health guidance. NJAC 8:39-5.1(a); 19.1(a)

Based on observation, interview and record review, it was determined that the facility failed to screen a visitor prior to entering the facility and failed to screen employees for symptoms of COVID-19 prior to beginning their workday. This deficiency occurred during the COVID-19 pandemic and affected 25 of 25 residents. This deficient practice was evidenced by the following: 1. On 07/16/2020 at 9:45 AM, the surveyor arrived at the front door to the facility. The front door was locked, with a sign requesting for the intercom doorbell to be rung. No one spoke through the intercom to ask who the surveyor was or why the surveyor was at the facility. The electronic doors were opened. For the next seven minutes, the surveyor was able to wander around the facility without question. The surveyor walked past two staff members who did not say anything. Once at the nurses' station, the Licensed Practical Nurse (LPN #1) questioned how the surveyor got into the facility. LPN #1 asked the surveyor to go with her back to the front entrance for screening. At the front door, she took the surveyor's temperature, recorded it on a log and asked the surveyor to perform hand hygiene. LPN #1 then escorted the surveyor to a conference room. LPN #1 failed to screen the surveyor for symptoms of COVID-19. LPN #1 stated, I do not know how you got in when our front door is always locked. Whoever pushed the button to open the door knows better. Once in the conference room, LPN #1 asked the surveyor to fill out a DLSH (De La Salle Hall) COVID-19 Visitor Screening form. The form asked 1. Have you had any international travel within the last 14 days to restricted countries? (as of 3/03/2020) include China, Iran, Italy, Japan, South Korea. 2. Do you currently have an acute respiratory infection or fever? 3. Have you had contact with someone with or under investigation for COVID-19? The facility's undated policy and procedure for COVID-19 Visitor Screening, procedure section, read as follows: 1. Upon entrance to the facility, visitors will sign in at the front door. 2. Visitors will complete a COVID-19 Visitor Screening Tool prior to accessing resident areas. 3. Upon completion, the COVID-19 Visitor Screening Tool will be submitted to facility staff to review. 4. The facility staff member will review for any positive responses. 5. A positive response is considered as a Yes response to any of the questions. 6. For the health and safety of our residents and employees, visitors will be restricted from access with any positive responses. 7. The facility will retain copies of COVID-19 Visitor Screening Tools. On 07/16/2020 at 10:22 AM, LPN #1 was interviewed. She stated their process was not to allow visitors into the facility;, however, their front door was always locked and when the doorbell was rung, the person should have been questioned through the intercom, and then a staff member would go up to the front door for their screening. The person arriving at the front door would have their temperature taken and then would be asked to wash their hands. On 07/16/2020 at 11:10 AM, the Administrator was interviewed. The Administrator stated their visitor screening process was to come to the door after someone rang the doorbell. The visitor would have their temperature taken and would be asked to wash their hands. She then referred to the DLSH COVID-19 Visitor Screening form and stated a visitor would be asked to fill it out. The Administrator stated she did not know why anyone opened the door when this surveyor arrived. A review of the Centers for Disease Control's (CDC) guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated 6/25/2020, indicated, Screen visitors for fever (temperature greater than/equal to 100 degrees Fahrenheit), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. According to the CDC, symptoms of COVID-19 include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. 2. On 07/16/2020 at 11:10 AM, the Administrator was interviewed about the screening process for employees. She stated that employees were asked to come through the front door, ring the doorbell and wait for someone to come up front to screen them. The screener would take their temperature and then the employee was asked to wash their hands. On 07/16/2020 at 11:50 AM, a Certified Nursing Assistant (CNA #1) was interviewed about the screening process for employees. CNA #1 stated, when we arrive at work, we ring the doorbell and wait for a nurse to come let us in. The nurse will take our temperature and then watch us wash our hands. After that, we are allowed to go to work. On 07/16/2020 at 12:07 PM, the Housekeeping Supervisor (HS) was interviewed about the screening process for employees. The HS stated, we all use the front door to come in to work. We are instructed to use the doorbell and wait for the nurse to come let us in. The nurse takes our temperature and we wash our hands, then go to work. On 07/16/2020 at 12:18 PM, the Certified Dietary Manager (CDM) was interviewed about the screening process for employees. The CDM stated all staff were required to come through the front door. They ring the doorbell and wait for the nurse to come let them in. The nurse would take their temperature and they would wash their hands. The nurse would ask, how are you feeling? On 07/16/2020 at 12:40 PM, the Activity Director (AD) was interviewed about the screening process for employees. The AD stated, the nurse would come to the front door to let me in. The nurse would take my temperature, watch me wash my hands and I go to work. I've never had anyone ask me about specific symptoms (of COVID-19). On 07/16/2020 at 1:03 PM, the Maintenance Director was interviewed about the screening process for employees. The Maintenance Director stated, we only use the front door when we arrive at work. The door is locked, and we wait for a nurse to come open it. The nurse takes your temperature, and we wash our hands. Then I go to work. I'm asked if I feel OK, not anything more specific. On 07/16/2020 at 2:05 PM, the Director of Nursing (DON) was interviewed about the screening process for employees. The DON stated they had not been asking specific COVID-19 symptom questions, because they assumed the employees would tell them if they were not feeling well. A review of the Centers for Disease Control's (CDC) guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated 06/25/2020, indicated, Evaluate and Manage Healthcare Personnel (HCP), Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. According to the CDC, symptoms of COVID-19 include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. NJAC: 8:39-13.1 (c)

Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to recommend a manufacturer specification to separate a calcium-containing medication with an iron medication from (MONTH) (YEAR) until (MONTH) (YEAR). This deficient practice was identified during the medication pass observation for 1 of 6 residents (Resident #3) and was evidenced by the following: On 07/17/18 at 9:16 AM, during the medication pass, the surveyor observed the Licensed Practical Nurse (LPN) administer five medications, which included two (2) tablets of Prosteon (a calcium containing medication used to promote bone health) and one (1) tablet of [MEDICATION NAME] (iron) to Resident #3. On 07/17/18 at 9:31 AM, the surveyor observed the resident in his/her room. The resident stated to the surveyor that the nurses gave him/her medications when they were due. The surveyor reviewed the medical records for Resident #3. A review of the Face Sheet (an admission summary) indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/22/18, reflected a brief interview for mental status (BIMS) score of 11 out of 15, which indicated a moderately intact cognition. A review of the physician's orders [REDACTED]. In addition, a PO dated 3/9/1018 for [MEDICATION NAME] 325 mg tablet, one tablet orally once a day. A review of the electronic Medication Administration Records (eMAR) for (MONTH) (YEAR) revealed a corresponding PO for the Prosteon and [MEDICATION NAME] were plotted for the same time of administration at 9 AM. On 7/17/18 at 1:20 PM, the surveyor and the LPN reviewed the label of the Prosteon tablets together. The label indicated that the medication was a nutritional supplement for bone health. The tablets contained 500 mg of Calcium [MEDICATION NAME] per tablet. The LPN stated that she was unsure if iron and calcium could be administered together and would have to check. The LPN added that the Consultant Pharmacist (CP) came in monthly to review the resident's charts but was not aware of how the reporting process worked. At that time the surveyor interviewed the Registered Nurse (RN), who stated that the CP made recommendations when a drug should have a cautionary warning. The nurses added the cautionary warning to the eMAR in the special instructions section. The RN added that the CP gave a report to the Director of Nursing (DON). The RN stated it was the nurses responsibility to carry out the CP recommendations which may involve contacting the physician. Further review of the eMAR for (MONTH) (YEAR) for the Prosteon PO indicated in the Special Instructions section may take own medication from home. The [MEDICATION NAME] PO had no special instructions indicated. On 07/18/18 at 10:36 AM, the surveyor conducted a phone interview with the CP. The CP stated that he was only at the facility for the month of (MONTH) (YEAR). The CP stated that iron and calcium could interact with one another which caused decreased absorption of the iron. Therefore, the timing of the two drugs would be separated. The CP added that he could not speak to the specific product of Prosteon. The CP added that any recommendations that were made would be noted in the electronic Progress Notes for June. The recommendations prior to (MONTH) (YEAR) were documented on a Consultant Pharmacist's Sheet (CPS). The CP added that the DON received a report every month of all the recommendations. Further review of the eMARs for March, April, May, and (MONTH) (YEAR) revealed the Prosteon and [MEDICATION NAME] were plotted for the same administration time of 9:00 AM. The eMAR's were signed that the resident received Prosteon and [MEDICATION NAME] medications at 9:00 AM for those months. A review of the CPS for Resident #3 indicated that a review was completed for the months of March, April, May, and (MONTH) (YEAR). The CPS indicated that for the month of (MONTH) and (MONTH) (YEAR) to follow-up on the [DIAGNOSES REDACTED]. On 7/18/18 at 1:11 PM, the survey team met with the Administrator and the DON. The DON stated that the CP for (MONTH) was new to the facility so she needed to review the CP's recommendations. The DON also stated that the Prosteon could not be obtained from the provider pharmacy and was ordered through the manufacturer. The DON stated that she would follow-up with the manufacturer. On 7/19/18 at 8:53 AM, the survey team met with the DON. The DON stated that the CP recommendation for the month of (MONTH) (YEAR) indicated to follow up and clarify the [DIAGNOSES REDACTED]. The DON also stated that the manufacturer of the Prosteon was contacted by phone on 7/18/18. The DON then stated that the documentation provided by the manufacturer via email on 7/18/19 at 03:42 PM revealed that the Prosteon should be separated from iron products by at least two hours. The DON stated that when she spoke to the manufacturer of the Prosteon there was conflicting information provided to her. She confirmed that the email from the manufacturer should be what was followed when administering the Prosteon. On 07/19/18 at 9:54 AM in the presence of the survey team, the surveyor interviewed the DON. The DON stated that the cautionary information for medications were entered in the special instructions section in the eMAR by the nurses. The DON also stated that the cautionary information was based on the information on the labels of the medications and the recommendations made from the CP. The DON added that any cautionary information should be followed. On 7/19/18 at 12:50 PM, the survey team met with the Administrator and the DON. The DON stated that the CP had done med pass in-services but there were no other in-services done regarding drug to drug interactions and cautionary information. A review of the facility's General Medication Administration Guidelines policy revised (MONTH) (YEAR), included that the nurses would review the eMAR for cautionary information and that the cautionary information will be adhered. Manufacturer specifications for Prosteon reflected to separate the iron supplement from the Prosteon by at least two (2) hours to prevent decreased absorption of the iron. NJAC 8:39-29.3(a)(1), 29.4(c)(d)(3)

Based on observation, interview and record review it was determined that the facility failed to ensure: a.) a resident who performed his/her own indwelling urinary catheter care had an appropriate individualized care plan, b.) the physician was notified and orders were in place for irrigating the indwelling urinary catheter for a verbalized history of urinary catheter blockage, c.) the re-assessment for the appropriate self-care of the indwelling urinary catheter, and d.) the policy and procedure addressed irrigating an indwelling urinary catheter. This deficient practice was identified for 1 of 2 resident's reviewed for catheter care (Resident #21), and was evidenced by the following: On 07/18/18 at 09:29 AM, the surveyor observed Resident #21 sitting upright in a chair in his/her private room. At that time, the resident agreed to be interviewed by the surveyor. The resident stated that he/she had an indwelling urinary catheter (flexible tube inserted into the bladder and used drain urine into a bag) due to his/her bladder not functioning properly for over a year. The surveyor asked if staff assisted the resident with the care of the catheter, and the resident stated that he/she performed self-care for the indwelling urinary catheter. The resident stated that he/she changed the urinary drainage bags to a new one daily and that he/she wears the leg bag during the day and applied a large drainage bag prior to going to bed at night. The resident stated that he/she cleaned the indwelling catheter tip with a disposable wash wipe when switching bags. The resident showed the surveyor the blue package of disposable wipes used to clean the indwelling catheter. The resident denied using alcohol-based wipes to clean the catheter. The resident added that he/she gets the indwelling catheter exchanged monthly by a Nurse Practitioner (NP). The resident stated that he/she has not had any urinary tract infections, even though there was an instance where the nurse needed to flush the catheter tubing when it got clogged. The resident told the surveyor that he/she had bladder distention one time that was uncomfortable and that no urine was in the bag. The resident stated that the evening nurse had to irrigate the catheter with a big syringe and that it helped unblock the catheter. The resident added that while it gave him/her anxiety to see blood in his/her urine, he/she felt comfortable with the nurse performing the irrigation, and that she always fixed the problem quickly. On 07/19/18 at 09:29 AM, the surveyor interviewed the Certified Nursing Aide (CNA) assigned to care for Resident #21. The CNA stated that he started as a full-time CNA at the beginning of (MONTH) (YEAR), and was fairly familiar with the resident. The CNA stated that the resident was very independent but will ask for assistance if needed. He confirmed the resident had an indwelling urinary catheter and that he would empty the urinary drainage bags for the resident and record the amount of urine using a urinal. He stated he then reports the amount of urine from the bag to the nurse. The CNA further added that he believed that the nurses took care of the catheter and exchanged the bags each day. He stated he did not change the bags, and that the surveyor needed to interview the resident's Licensed Practical Nurse (LPN) for how he performed care for the resident's catheter. The CNA confirmed he was just responsible to empty the urinary drainage bags and report any changes in urine color, clarity, or odors to the nurse. At 9:41 AM, the surveyor interviewed the LPN assigned to care for Resident #21. The LPN stated that the resident had an indwelling urinary catheter for years due to a [MEDICAL CONDITION] bladder (a flaccid or spastic urinary bladder caused by neurological damage). He confirmed that the resident performed his/her own indwelling urinary catheter care and went to the urologist's office to get the indwelling catheter exchanged on a monthly basis, and we irrigated it as needed if it gets clogged or did not drain properly. The LPN added that the resident cleaned it with soap and water, and although he personally has never seen the resident perform care on the catheter, he knew the resident had been taking care of it him/her-self for years. On the same day on 07/19/18 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that at times the resident does his/her own catheter care, but we encouraged staff to remind the resident of how to care for the catheter. The DON confirmed the resident had the urinary catheter irrigated and confirmed that it was not on the resident's care plan. She stated that she thought there were physician orders to irrigate the catheter. The DON stated that she would get back to the surveyor with additional information. The surveyor reviewed the medical record for Resident #21. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/15/18 reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS assessment further indicated that the resident had an indwelling urinary catheter. A review of the Physician Order Report (POR) for (MONTH) (YEAR) reflected a physician order (PO) dated 08/03/17 to cap off the indwelling urinary catheter with showers on Tuesdays and Fridays. In addition there was an order dated 04/15/18 for the indwelling urinary catheter to straight drainage for [MEDICAL CONDITION] bladder and to measure urinary output every shift. (There was no evidence of a physician order to irrigate the indwelling urinary catheter). A review of the resident's individualized, comprehensive care plan edited on 06/19/18 reflected the resident had an indwelling urinary catheter for [DIAGNOSES REDACTED]. The interventions included to assess drainage, record amount, type, color, and odor of urine. In addition, the care plan indicated that facility staff manage the resident's indwelling urinary catheter. Interventions indicated that Staff will assist resident with capping off the indwelling catheter during showers, Staff will change catheter per MD order and with consults with urologist NP, and that Staff will provide me with catheter care every shift as needed . There was no evidence within the resident's individualized care plan that addressed that the resident performed his/her own indwelling urinary catheter care. The care plan also did not address that the resident tends to have some bleeding after the replacement of the indwelling urinary catheter and episode(s) of blockage of the indwelling urinary catheter. There were no interventions to address what staff should do in the event those conditions occur again. A review of an electronic Nursing Progress Note dated 05/07/17 at 10:50 PM reflected that the resident was alert and oriented x 3 with clear speech. It reflected that the resident was independent with switching over his/her leg bag to the large night time drainage bag with aseptic technique. There was no evidence of a follow-up assessment for self-performance of his/her own indwelling urinary catheter care since 05/07/17 until surveyor inquiry. A review of the Urologist Referral Form dated 06/14/18 reflected that the resident's indwelling urinary catheter was re-inserted due to [MEDICAL CONDITION]. Instructions indicated to follow-up in one month. A review of the electronic Resident Progress Notes dated 06/14/18 at 10:42 PM reflected that Resident #21 had an indwelling catheter replaced and included that Hematuria (blood in the urine) noted with small clots . The note further included that the nurse irrigated the indwelling urinary catheter with sterile water and that the resident tolerated the procedure well. (There was no evidence within the electronic Resident Progress Notes that the resident's Attending Physician or Urologist was notified of the need to irrigate the resident's indwelling catheter and to obtain orders). A review of the follow-up Urologist Referral Form dated 7/11/18 reflected that the NP replaced the resident's indwelling urinary catheter and instructed for the resident to return in one month. A review of the electronic Progress Notes following the new replacement of the indwelling urinary catheter dated 7/11/18 at 5:25 PM, reflected that Hematuria noted with clotting in the drainage bag. The note indicated that the indwelling catheter was irrigated with sterile water, and will monitor. (There was no documented evidence that the physician was notified of the need to irrigate the indwelling catheter, the procedure the nurse used to irrigate, and how the resident tolerated the procedure.) There was no documented evidence within the Physician Order Sheets for (MONTH) (YEAR) or (MONTH) (YEAR) for physician orders to irrigate the indwelling catheter, when to irrigate the catheter and with how much sterile water. A review of the electronic Treatment Administration Record for (MONTH) and (MONTH) (YEAR) did not reflect evidence that that the indwelling urinary catheter was irrigated during those months. On 07/19/18 at 12:22 PM, the surveyor interviewed the DON who confirmed that she was responsible to create/update the resident care plans. The DON reviewed the resident care plan and confirmed it should reflect that the resident does his/her own self care of the indwelling urinary catheter. The DON added that the resident was assessed to perform his/her own catheter care in (MONTH) (YEAR) and that he/she could do it independently. The DON confirmed that the resident should be using alcohol to wipe the catheter before applying the new bag and not using the blue disposable wipes that do not contain an alcohol-based cleansing agent. The DON stated that she checks-in with the resident weekly to make sure he/she has all the catheter bags, caps and supplies he/she needs, noting because the resident also tends to hoard the supplies and reuse them. The DON confirmed that the care plan did not speak to irrigation of the catheter or that the resident has a tendency to re-use supplies. The DON stated that the resident has not had any urinary tract infections since admission to the facility. The surveyor asked the DON if the resident had a physician order for [REDACTED]. At 12:47 PM, the DON returned to the surveyor and stated that there were no physician orders to irrigate the indwelling urinary catheter. She added that she did not see orders to irrigate the catheter, but stated she knows the evening nurse did have to irrigate the catheter in the past due to hematuria. At 01:10 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN #1) who worked the day shift. The LPN #1 stated after the resident returned from having the indwelling catheter exchanged by the Urology NP during the evening shift, that the nurse usually had to irrigate the catheter if it got clogged. The LPN #1 confirmed that he has never had to irrigate the catheter during the day shift. He stated that if he had to irrigate he would use sterile water and a special syringe. He stated that he wasn't sure how much sterile water to instill, but that it would be necessary to get a physician order so he would know how to proceed. On 7/20/18 at 9:40 AM, the surveyor interviewed the DON and the Administrator in the presence of the survey team. The DON provided the surveyor a copy of the facility's policy and procedure for Indwelling Catheters revised 12/19/17. The DON and Administrator confirmed that the policy did not speak to irrigation of the indwelling catheter and confirmed that the policy should have indicated the appropriate process for nurses to follow if the catheter required irrigation. The DON confirmed that there should have been a physician order for [REDACTED]. On 07/20/18 at 09:56 AM, the surveyor conducted a phone interview with the LPN #2 who worked the evening 3 PM-11 PM shift and signed for irrigating the indwelling catheter. The LPN stated that the resident takes care of his/her indwelling catheter independently and was taught how to do it. The resident uses a new bag with each catheter change. The LPN #2 confirmed that the resident gets his/her blood thinner medication held prior to seeing the Urologist to have the catheter replaced due to the resident's history of bleeding during the catheter replacement. The LPN #2 stated that the resident had come back to the facility with hematuria and gets blood clots in the catheter tubing resulting in decreased urine flow, distention and discomfort for the resident. She added that when that has happened, she has irrigated the resident's indwelling urinary catheter with 20 milliliters (mL) to 25 mL of sterile water using a special syringe, because that was all the sterile water the resident could tolerate. She stated that one irrigating flush of the catheter would resolve the resident's discomfort and would remove any clotting that blocked the catheter from draining the urine. The LPN #2 stated that she has irrigated indwelling urinary catheters before and that the reason she did not call the physician and didn't obtain a physician order was because she was under the impression that it was a nursing intervention and that a physician order was not needed. The LPN #2 stated that the resident who would exhibit anxiety from the hematuria would tolerate the irrigation procedure well, and would actually relieve his/her fears. She added that she would document it in the Resident Progress Notes electronically. NJAC 8:39-27.1 (f)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control and hand hygiene practices to prevent the spread of infection. This deficient practice was identified for 2 of 6 resident's observed during the medication pass observation (Resident #1 and #13). The evidence was as follows: On 7/17/18 at 8:48 AM to 8:51 AM, the surveyor observed the Lisenced Practical Nurse (LPN) administer a subcutaneous injection (administration of injectable medication under the skin) of four (4) units of Humalog insulin (a short acting insulin) into Resident #1's abdomen. The LPN was wearing gloves when she administered the insulin. The LPN did not perform hand hygiene through handwashing or using an alcohol-based hand rub before applying and removing the gloves. On 7/17/18 at 8:52 AM to 8:58 AM, the surveyor observed the LPN administer insulin to Resident #13. The surveyor observed the LPN administer a subcutaneous injection of 14 units of Humalog insulin into Resident #13's left upper arm. The surveyor observed the LPN then administer a subcutaneous injection of 24 units of [MEDICATION NAME] (a long acting insulin) in Resident #13's right upper arm. The LPN was not wearing gloves when she administered both insulin medications to the resident. The LPN did not perform hand hygiene or apply an alcohol-based hand rub in between the administration of the two different insulin medications. The LPN did not perform hand hygiene before or after contact with Resident #13. On 7/17/28 at 9:20 AM, the surveyor interviewed the LPN. The surveyor asked the LPN about hand hygiene and glove use when administering insulin. The LPN stated, I don't usually wear gloves when I administer it (the insulin), but I do when I check the blood sugar. On 07/18/18 at 12:12 PM, the surveyor reviewed the facility's policy and procedures. A Review of the facility's Handwashing Policy and Procedure revised 12/19/17, included that all facility personnel should wash their hands in the following instances to prevent the spread of infection: Before applying and removing gloves; Before preparing and administering medications; Before contact with individual residents. A review of the facility's General Medication Administration Guidelines Policy and Procedure revised (MONTH) (YEAR) included that hand washing will be done before, during, and after medication pass. A review of the facility's Administrative Guidelines: Injectable Medications Policy and Procedure effective (MONTH) 2010 included that the nurse will wash hands before and after medication administration. On 7/19/18 at 8:54 AM, the survey team interviewed the Director of Nursing (DON). The DON stated that hand hygiene should be performed and gloves should be worn when administering insulin. The DON further stated that hand hygiene should be performed before and after the removal of gloves. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that an emergency medication box (E-Kit) was securely sealed. This deficient practice was identified for 1 of 1 resident units and was evidenced by the following: On 4/18/17 at 8:24 a.m., the surveyor observed the unit's E-Kit on top of an emergency medical cart (crash cart). The E-Kit was missing the breakable seal which indicated that the box had been opened. During an interview, immediately following the observation, the Licensed Practical Nurse on the unit stated she was unaware of when the E-Kit had been opened or who was responsible for checking the contents of the box. At 10 a.m. on the same day, the Director of Nursing (DON) arrived on the unit and acknowledged that the E-Kit was not properly sealed. The DON then entered the locked medication room and replaced the opened box with a sealed one. The sealed E-Kit included a complete list of medications and the expiration dates. On 4/20/17 at 9:22 a.m., the DON stated that after conducting interviews, the facility staff were unaware of when the E-Kit was opened or what was removed from it. The DON further stated that the kit should have been sent back to the pharmacy immediately after being opened. On 4/20/17 at 9:30 a.m., the surveyor reviewed documentation provided by the facility. A Unit Inspection Report indicated that on April 20, 2017 the consultant pharmacist verified that the E-Kit was sealed with breakaway lock. The facility's Emergency Crash Cart policy indicated The 11-7 Charge Nurse will ensure that the E-Kit is on the Emergency Crash Cart and that all medications are within the expiration date and that the seal on the kit is intact. NJAC 8:39-29.4(e)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate monitoring and failed to document non-pharmacological interventions for use of an as needed anxiety medication from February to April 2016 for 1 of 4 residents, Resident #4, receiving [MEDICAL CONDITION] medications. The deficient practice was evidenced by the following: On 4/7/16 at 9:30 a.m., the surveyor observed Resident #4 seated in a geri- recliner in the resident's activity room. The Social Worker was seated next to the resident assisting them to eat. At 9:35 a.m., the surveyor reviewed the record of Resident #4. The resident had [DIAGNOSES REDACTED]. The resident was prescribed multiple pain medications and [MEDICATION NAME] .5 mg, 1 tablet every 8 hours as needed (PRN) for symptoms of agitation such as hitting and yelling. The physician orders [REDACTED]. Write progress note if medication used to effect behavior. The surveyor reviewed the electronic Medication Administration Record [REDACTED]. It revealed that the resident received 29 doses of as needed [MEDICATION NAME]. The reason documented that the [MEDICATION NAME] was administered on the e-MAR was for behaviors. The nurse noted that the medication was effective for 28 of the 29 doses administered. The surveyor then reviewed the electronic progress notes from 2/9/16 to 4/7/16. The nurses documented five of the 29 times that the [MEDICATION NAME] was administered. There was no documentation in the progress notes that non-pharmacological interventions were tried. At 11 a.m., the surveyor heard the resident singing by themself in the activity room. On 4/7/16 at 12:34 p.m., the surveyor reviewed the facility's policy on Behavior Monitoring/Psychoactive. It indicated, Make note in summary: All residents taking psychoactive medications. Under Interventions it indicated: What did you do besides giving medication? Warm milk, tea, redirections and what was the outcome. Behavior worsened, unchanged, improved. Be specific. At 12:40 p.m., the Director of Nursing stated that she was responsible to document behavior monitoring summaries and had not completed them. She stated that since the resident's pain medication was changed they noticed a decrease in the prn [MEDICATION NAME] use. She added that the nurses should be documenting in the progress note after administering the prn [MEDICAL CONDITION] medication. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to remove expired medications from the active supply of medications on the medications cart and in the medication room. This deficient practice was evidenced by the following: 1. On 4/7/16 at 9:20 a.m. the surveyor observed the unit nurse administer medications to Resident #1. The resident had a physician order [REDACTED]. The nurse removed a bottle of Aspirin EC 325 mg. from the medication cart. The nurse then poured one tablet into the medication cup to administer to the resident. The Aspirin bottle had an expiration date of 3/2016. At that time the surveyor stopped the nurse from administering the medication to the resident. The nurse confirmed that the medication was expired and went to the medication room and returned with a new bottle of Aspirin EC 325 mg. tablets which was not expired. 2. On 4/7 at 11:30 a.m. the surveyor inspected the unit medication room in the presence of the Assistant Director of Nurses (ADON). In the cabinet of house supply medications the suveyor observed the following: A 12 ounce bottle of liquid Rulox (antacid) expired 10/2015 and one unopened bottle of Aspirin EC 325 mg. expired 3/2016. In the medication refrigerator in the locked controlled drug compartment the surveyor observed 15 ABH suppositories with a use by date of 2/11/16. In the facility back up box were the following: three Hyoscyamine 0.125 mg. tabs expired 3/31/16, 6 Loperamide HCL 2 mg. tabs expired 3/31/16, one Metformin HCL 50 mg. tab expired 3/31/16 and two Levothyroxine 75 mcg. tabs expired 3/31/16. At that time the ADON removed all of the above expired medications from the medication room supply and stated that the medications would be discarded. NJAC 8:39-29.4(h)

Based on interview and record review, it was determined that the facility failed to investigate a bruise of unknown origin for 1 of 1 resident, Resident #4, reviewed for alleged abuse. The deficient practice was evidenced by the following: On 4/6/16 at 10:15 a.m., during the initial tour, the nurse stated that Resident #4 had a [DIAGNOSES REDACTED]. On 4/7/16 at 9:30 a.m., the surveyor observed Resident #4 seated in a geri- recliner in the resident's activity room. The Social Worker was seated next to the resident assisting them to eat. At 9:35 a.m., the surveyor reviewed the record of Resident #4. The resident had [DIAGNOSES REDACTED]. The resident was prescribed multiple pain medications and [MEDICATION NAME] .5 mg, 1 tablet every 8 hours as needed (PRN) for symptoms of agitation such as hitting and yelling. At 10:49 a.m., the surveyor reviewed the Progress Notes which indicated that on 3/6/16 at 6:38 a.m., that when the resident lifted their sleeve, an area of discoloration measuring 7 cmx 3 cm was noticed by the nurse on the right inner forearm. On 3/17/16 at 6:21 a.m., the Progress notes indicated that the resident was noted to be very protective of the left hand and bruising was noted. On 4/7/16 at 12:30 p.m. the surveyor requested the investigative reports for the two occurrences from the Director of Nursing (DON). At 1:30 p.m., the DON stated that she only had one investigation for the incident on 3/16/16 and added that the x-ray of the hand was negative for fracture. She said that on 3/6/16, at 12:48 a.m., prior to the observation of the bruise on the forearm, the progress notes reflected that the resident had become combative, kicking, hitting and attempting to get out of the bed. She added that it was the policy of the facility to investigate all injuries of unknown origin. NJAC 8:39-9.3(b)

Based on interview and record review, it was determined that the facility failed to provide accountability for a controlled drug for 1 of 7 residents, Resident #4. The deficient practice was evidenced by the following: At 9:35 a.m., the surveyor reviewed the record of Resident #4. The resident had [DIAGNOSES REDACTED]. The resident was prescribed multiple pain medications and Ativan .5 mg, 1 tablet every 8 hours as needed (PRN) for symptoms of agitation such as hitting and yelling. On 4/7/16 at 12 noon the surveyor reviewed the Controlled Medication Utilization Record and the corresponding electronic Medication Administration Record [REDACTED]. On 4/7/16 at 12:40 p.m., the Director of Nursing stated that the nurse who was giving out medications on those dates did not correctly document electronically that the medication was given. NJAC 8:39- 29.4(h)