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Based on documentation review, interviews, and observations, it was determined that the governing body failed to demonstrate that it is effective in carrying out its responsibilities for the operation and management of the hospital. It did not provide necessary oversight and leadership as evidenced by the lack of compliance with the Condition of Participation:

482 CFR 482.13 Patient Rights

482 CFR 482.42 Infection Prevention and Control and Antibiotic Stewardship

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.

Findings include:

An Immediate Jeopardy (IJ) under the requirement of 482.13 Patient Rights was identified on 2/22/23 and 2/23/23 at 2:00 PM.

The facility failed to identify ligature risks in the patients environment. (Cross-refer to Tag 0144)

The facility failed to identify safety risks in the patient environment. (Cross-refer to Tag 0144)

The Administrator and Assistant Administrator were informed of the IJ and were provided with the IJ template on 2/23/23 at 3:52 PM. A removal plan was requested at that time.

An acceptable removal plan was not received by the end of survey on 2/24/23.

On 3/17/22 an IJ removal visit was conducted. The facility mitigated the ligature risks identified by ensuring all patient bathroom doors remain locked at all times until the ligature risks can be corrected. The bathroom doors will be opened upon request of the patient and used only with same sex staff supervision, for safety of the patient. This included patient rooms and patient shower rooms. The facility also provided In-Servicing with all necessary staff on both 15 minute checks as well as the fact that direct supervision will need to be done when patients use the bathroom. The facility provided additional staff (a minimum of one additional staff member) on each shift to assist patients with using the bathrooms.

It was determined that the facility fully implemented their Plan of Correction (PoC) for the IJ deficiencies and the IJ was removed as of 3/17/23 at 10:21 AM.

Based on observations, staff interviews, and review of facility documents, it was determined that the facility failed to provide a safe and ligature free environment for patients.

Findings include:

On 2/22/23, in the presence of Staff (S) 15, the following was observed during a tour of the units:

At 12:20 PM, in Cornerstone West (CSW) Bathroom #3: Surveyors observed the water selector valve in the patient shower when in the upright position poses a ligature risk. The water selector valve was a single metal bar type selector which can provide an anchor point.

At 12:20 PM, during an interview, S15 confirmed patients are left alone in the shower room.

At 12:40 PM, Cornerstone East (CSE): Woman's Shower has an emergency release installed on the door jamb which allows access to the Shower Room without a key. Inside this Shower Room public restroom style privacy enclosure is installed around the toilet. This enclosure has multiple areas that pose a ligature risk. These areas include the top and bottom hinges and top and bottom fasteners that connect the sides of the privacy enclosure. There are gaps around all edges of the enclosure that pose ligature risks. Patients can create a knot out of clothing, sheets, shower curtain, or other articles of clothing to strangulate.

A patient can access this room without staff knowledge due to the emergency release mechanism that is installed on the door jamb.

S15 confirmed these findings are present in the CSE Woman's Shower Room.


43209


On 2/22/23, during a tour of the CSE unit the following ligature risks were identified:

At 11:00 AM, in unoccupied patient room 332, Bed B had an unsecured mattress with two black elastic secure bands at the end of the mattress.

At 12:15 PM, in occupied patient room 27, Bed A had an unsecured mattress with two black elastic secure bands at the end of the mattress.

On 2/23/23 at 10:55 AM, during a tour of CSE, with S2, the following ligature risks were observed and confirmed by S2:

Thirteen hinged toilet seats in the patients private bathrooms: E038, E035, E033, E031, E030, E029, E028, E027, 332, and the shared Women's Bath/Shower, and Men's Shower Room.

Twelve paper towel dispensers, with ligature points located where the paper towels are removed from the dispenser, in the private patient bathrooms: E038, E035, E033, E031, E030, E029, E028, E027, 332, and shared Women's Bath/Shower.


45589


On 2/23/23 at 10:42 AM, during a tour of CSW, in the presence of Staff #4, the following ligature risks were observed:

Thirteen hinged toilet seats in the private patient bathrooms: CW84, CW82, CW80, CW78, CW76, CW74, CW72, CW70, CW68, CW66, CW62, CW60, CW56, and the common shared bathroom/shower rooms BR2, BR3, and BR4.

Thirteen paper towel dispensers, with ligature points located where the paper towels are removed from the dispenser, in the private patient bathrooms: CW84, CW82, CW80, CW78, CW76, CW74, CW72, CW70, CW68, CW66, CW62, CW60, CW56, and common shared bathroom/shower rooms BR2, BR3 and BR4.

Thirteen bathroom exhaust vents with open louvers, in the private patient bathrooms: CW84, CW82, CW80, CW78, CW76, CW74, CW72, CW70, CW68, CW66, CW62, CW60, CW56, and in the common shared bathroom/shower rooms BR 2, BR3, and BR4.

Three shower rod holders, with gaps between the holder and the wall exposing the center screw, were observed in the patient private bathrooms: CW56 and CW60, and in the common shared bathroom BR3.

The risks identified above pose a ligature risk as patients can create a knot out of clothing, sheets, shower curtain, or other articles of clothing to strangulate.

On 2/22/23 at 10:36 AM, during a tour of CSE with S2, a soiled sanitary napkin receptacle was observed in the soiled utility room, lying on a table with a note that states, "Removed from room by [Patient Name]." During an interview with S2, he/she stated that Patient (P) 17 removed the sanitary napkin receptacle from the wall because he/she was "upset about it being in the room." A review of P17's medical record confirmed the incident, the nursing progress note states, "2/8/23...pt [patient] took out the small sanitary towel disposal garbage bin from [his/her] bathroom... ."

On 2/23/23 at 10:55 AM, during a tour of CSE the following safety risks were identified:

Twelve paper towel dispensers, capable of being removed from the wall by patients, in the private patient bathrooms E038, E035, E033, E031, E030, E029, E028, E027, 332, and shared Women's Bath/Shower.

One soiled sanitary napkin receptacle hanging on the wall in the women's shower room.

On 2/23/23 at 10:42 AM, during a tour of CSW the following safety risks were identified:

Thirteen paper towel dispensers capable of being removed by patients, in the private patient bathrooms CW84, CW82, CW80, CW78, CW76, CW74, CW72, CW70, CW68, CW66, CW62, CW60, CW56, and common shared bathrooms BR2, BR3 and BR4.

Loose soap dispensers in the patient private bathrooms: CW74, CW66, CW56.

Loose mirror shelf in the patient private bathrooms: CW70, CW72 and CW74.

The risks identified above pose a safety risk as patients can remove these items and use them to harm themselves or others.

The Governing Body Meeting Minutes dated 2/14/22, 4/18/22, 7/18/22 and 10/17/22 were reviewed and failed to identify the ligature and/or safety risks.

The Environment of Care Rounds dated 8/9/22, 8/23/22, 9/13/22, 9/27/22, 10/11/22, 10/25/22, 11/7/22, 11/22/22, 12/6/22, 12/27/22 1/10/23 and 1/24/23 were reviewed and failed to identify the ligature and safety risks.

The above findings were confirmed with S15 on 2/23/23 at 11:00 AM and again at exit conference.

An Immediate Jeopardy (IJ) was identified on 2/22/23 and 2/23/23 at 2:00 PM.

The Administrator and Assistant Administrator were informed of the IJ and were provided with the IJ template on 2/23/23 at 3:52 PM. A removal plan was requested at that time.

An acceptable removal plan was not received by the end of survey on 2/24/23.

On 3/17/22 an IJ removal visit was conducted. The facility mitigated the ligature risks identified by ensuring all patient bathroom doors remain locked at all times until the ligature risks can be corrected. The bathroom doors will be opened upon request of the patient and used only with same sex staff supervision, for safety of the patient. This included patient rooms and patient shower rooms. The facility also provided In-Servicing with all necessary staff on both 15 minute checks as well as the fact that direct supervision will need to be done when patients use the bathroom. The facility provided additional staff (a minimum of one additional staff member) on each shift to assist patients with using the bathrooms.

It was determined that the facility fully implemented their Plan of Correction (PoC) for the IJ deficiencies and the IJ was removed as of 3/17/23 at 10:21 AM.

Based on observation, staff interviews and review of facility documents, it was determined that the facility failed to ensure safe practices for medication administration by: 1) failure to confirm a patient's identity prior to medication administration; and 2) failure to document reason and effects of an administered PRN (as needed) pain medication, in accordance with facility policy.

Findings include:

1. Reference: Facility policy titled, "Medication (Drug) Administration - Procedure" dated 5/10/17 states, " ...A. Administrating Medications ...4. Check the patient's ID [identification] bracelet or identify the patient by the MAR [Medication Administration Record] photograph and address each patient by name ..."

On 2/23/23 at 12:57 PM, on the Cornerstone West (CSW) Unit, during observation of a medication pass, Staff (S) 38 was observed administrating medications to two of two Patients (P) (P26 and P27) without confirming the patients' identification prior to the medication administration. Upon interview S38 stated, "We get to know the patients. Some have been here for a year or more."

2. Reference: Facility document titled, "Charting of Medications or Refused/Omitted or STAT [immediately]/Single Dose IM [intramuscular]" dated 03/18/2019 states, " ...Medication Nurse 1. Charting of Medications ....4. PRN medications must include reason for administration. Results are documented in the Nursing Note ..."

On 2/24/3 at 11:09 AM, on the CSW unit, review of Medical Record (MR) 25 revealed documentation under "PRN Medications" stating that on 2/23/23, Tylenol 650mg (milligrams) was administered orally at 7:30 PM. Further review of the medical record revealed no evidence of a reason for or the effects of the medication.

On 2/24/23 at 2:36 PM, S1, S2, S4 and S15 confirmed the above.

N.J.A.C. 8:43G-18.6(d)
N.J.A.C. 8:43E-6.4(e)

Based on observations and staff interviews, it was determined that the facility failed to ensure that parenteral medications are prepared in a safe manner, in accordance with accepted standards of practice.

Findings include:

Reference: The Centers for Disease Control and Prevention (CDC) FAQs regarding Safe Practices for Medical Injections, https://www.cdc.gov/injectionsafety/providers/provider_faqs_med-prep.html, states, " ...Medications should be drawn up in a designated clean medication preparation area that is not adjacent to potential sources of contamination, including sinks or other water sources. Water can splash or spread as droplets more than a meter from a sink. In addition, any item that could have come in contact with blood or body fluids, such as soiled equipment used in a procedure, should not be in the medication preparation area ... The medication preparation area should be cleaned and disinfected on a regular basis and any time there is evidence of soiling. In addition, there should be ready access to necessary supplies (such as alcohol-based hand rub, needles and syringes in their sterile packaging, and alcohol wipes) in the medication preparation area to ensure that staff can adhere to aseptic technique ..."

Reference: The Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last update: May 2019 Page 84, states, " ... IV.H.1. Use aseptic technique to avoid contamination of sterile injection equipment1002, 1003. Category IA ..."

On 2/22/23 at 10:53 AM, in the Medication Room located on the Cornerstone West (CSW) Unit, Staff (S) 16 indicated that parenteral medications were prepared on the countertop immediately adjacent to the sink.

On 2/22/23 at 11:05 AM, in the medication room located on the CSW Unit, in the presence of S4 and S16, S17 was observed preparing a syringe of Ativan (an anti-anxiety medication) for a patient on the countertop immediately adjacent to the sink. This was not in accordance with CDC guidelines.

In addition, it was observed that areas of the laminate countertop were worn through to the wood below. This is not a cleanable surface.

These findings were confirmed by S4 and S16 on 2/22/23 at 11:10 AM.

N.J.A.C. 8:43G-13.4(a)
N.J.A.C. 8:43G-14.1(d)(1)(iii)(8)

Based on random observations, facility policy review, medical record review, and staff interviews, it was determined that the facility failed to ensure: 1) policies and procedures that address the maintenance and security of the emergency carts containing medications and supplies are developed and implemented; 2) patient specific medications are returned to the pharmacy or destroyed after the physician's order is discontinued, in accordance with facility policy; and 3) policies and procedures that address medication error prevention when patients have the same or similar name are developed and implemented.

Findings include:

1. Reference: Facility policy titled "Crash Cart" dated 2/14/20 states, "Crash Cart will be checked monthly for expired/contaminated supplies and maintenance of par levels. Charge nurse is responsible for restocking after a code is complete. ...Crash Cart will be monitored monthly by nursing Supervisor... "

During a facility tour conducted on 2/22/23 between 10:30 AM and 1:30 PM, in the presence of Staff (S) 4, it was determined that the facility had two crash carts containing emergency medication, equipment, and supplies, one located in the Cornerstone East (CSE) unit and one located in the Cornerstone West (CSW) unit.

On 2/22/23 at 11:37 AM, the crash cart on the CSW unit was inspected. The medication container was secured by a plain plastic breakaway lock without numbers. The crash cart daily check logs located on the counter top next to the crash cart dated 1/1/23 to 2/22/23 contained a column to record the break away lock number. The documentation on the log stated "no number." During an interview on 2/22/23 at 11:40 AM, S4 stated that he/she was not sure how the nursing staff ensured that the medication container was secure and unadulterated if the breakaway locks were not numbered.

On 2/22/23 at 11:44 AM, before leaving the CSW unit, S16 confirmed that he/she could secure the opened crash cart because he/she had access to additional break away locks that were stored in the medication room. The facility could not ensure the security of the medication container that was part of the crash cart.

On 2/22/23 at 1:01 PM, in the CSE unit, the crash cart and emergency supplies were inspected. During an interview, S15 confirmed that the breakaway locks securing the cart were not numbered. S15 stated that the locks used to have numbers on them, and the nurses checked that the locks weren't changed on a daily basis to ensure security. S15 confirmed that the unnumbered locks could not be monitored to ensure the security of the crash cart.

On 2/22/23, further review of the crash cart monitoring logs revealed that the monthly checks of medications and supplies required by facility policy, were not documented. On 2/22/23 at 2:00 PM, one year of documentation of the monthly checks was requested.

During an interview on 2/24/23 at 11:00 AM, S2 stated that the contracted pharmacy provider staff members check the medications stored in the crash cart every two months and nursing staff checked the supplies quarterly. However, review of the Pharmacy and Therapeutics Committee Meeting Minutes, dated 4/22/22, state, " ...Cornerstone requests that [pharmacy provider name] resume delivering medications to the medication room instead of the door due to COVID ... Recommendations/Action [pharmacy provider name] will check if services may resume ..."

During the same interview on 2/24/23 at 11:05 AM, when presented with the documentation found in the meeting minutes, S2 confirmed that the contracted pharmacy provider staff did not enter the facility during 2022 to check the emergency carts due to COVID. S2 then stated that nursing staff checked the emergency medications found in the crash cart monthly during 2022, however documentation was not kept. The facility failed to ensure that monthly checks of the crash cart were completed and documented.

On 2/24/23, S2 provided the documentation of the checks of the supplies kept in the crash carts conducted by nursing staff. The "Crash Cart Audit/PI" forms for the year 2022 were reviewed. The "Crash Cart Audit/PI" forms indicated that the supplies in the crash cart on the CSE unit were checked four times in 2022 (3/6/22, 6/19/22, 9/11/22, and 12/4/22) and the supplies in the crash cart on the CSW unit were checked four times in 2022 (3/6/22, 6/18/22, 9/11/22, and 12/3/22). During an interview on 2/24/23 at 11:10 AM, S2 confirmed these finding and stated that the checks were completed quarterly. This is not in accordance with facility policy referenced above, which requires monthly checks.

The facility policy for the maintenance of the crash carts failed to include: the process to check the emergency medications that involves the pharmacy provider, the process used to check the defibrillator, and other emergency equipment kept with the crash cart.

N.J.A.C. 8:43G-23.2(a)(5)

2. Reference: Facility policy titled "Disposal of Non-Controlled Medications" dated 2/14/20, states, " ... All medications that are discontinued or expired will be removed from the refrigerator, medication rooms, or other place of storage and sent back to Pharmacy. Medication that is not eligible for return to the pharmacy will be destroyed ...."

During a facility tour conducted on 2/22/23, in the presence of S4, discontinued patient labeled medications were found stored in the CSW unit medication room and the CSE unit medication room, not returned to the pharmacy or destroyed in accordance with facility policy.

On 2/22/23 at 11:15 AM, stored in a cabinet located in the CSW Unit medication room, the following was found:

One box containing three manufactured syringes of Enoxaparin 40 mg (milligrams)/ 0.4 ml (milliliters) (a blood thinner), labeled for Patient (P)11. Review of Medication Administration Record (MAR) #11 with S16, indicated that the physician's order for Enoxaparin was discontinued on 1/31/23.

One bag containing 12 manufactured syringes of Enoxaparin 40 mg / 0.4 ml (milliliter), labeled for P12. Review of MAR #12 with S16, indicated that the physician's order for Enoxaparin was discontinued on 1/31/23.

One sealed vial of Haloperidol Decanoate for injection 100 mg/ml (an antipsychotic) labeled for P3. Review of Medical Record #3 indicated that the physician's order for Haloperidol was discontinued on 1/30/23.

During an interview on 2/22/23 at 11:20 AM, S16 confirmed these findings and stated that the medications should have been returned to the pharmacy or destroyed, not available for use in the medication room.

On 2/22/23 at 12:15 PM, stored in a medication cart located in the Medication Room on the CSE Unit in the presence of S7, a bag labeled for P14 containing two tablets of Benztropine 1 mg was found. Review of Medical Record #14 indicated that P14 was discharged from the facility on 2/2/23. On 2/22/23 at 12:20 PM, S7 confirmed this finding and stated during an interview that the medication should have been returned to the pharmacy.

N.J.A.C. 8:43G-23.6(d)

3. On 2/22/23 at 10:50 AM, during a tour of the Medication Room on the CSW Unit in the presence of S4 and S16, two patient labeled medication drawers, P8 and P9, were marked with orange stickers. The two patients had the same first name and the same last initial. When S16 was interviewed about the orange stickers, he/she stated that the facility instituted a name alert process to prevent medication errors for patients who have similar names. S16 explained that the process included placing the orange stickers on the patient labeled medication drawers and the pages of the paper MAR.

Review of the corresponding MARs with S16, revealed that the MAR for P9, admitted to the facility on 2/10/23, contained orange alert stickers, however the MAR for P8, admitted to the facility 12/21/22, lacked orange alert stickers. S16 confirmed this finding at approximately 10:52 AM and stated that both MAR 8 and MAR 9 should have orange alert stickers.

On 2/22/23 at 2:00 PM, a policy that addresses the name alert process was requested. On 2/24/23 at 11:55 AM, Staff #1 confirmed that the facility did not have a policy for this process.

N.J.A.C. 8:43G-23.2(a)(5)

Based on random observations, staff interviews, and facility policy review, it was determined that the facility failed to ensure that policies and procedures that address the use of multidose vials are implemented.

Findings include:

Reference: Facility policy titled "Storage of Medications and Multidose Vials" dated 2/14/20, states, " ...All multidose vials of medication will be dated when opened by the nurse. ...All multidose vials will be discarded 28 days after opening."

During a facility tour on 2/22/23 at 11:55 AM, in the Medication Room located on the Cornerstone East (CSE) Unit in the presence of Staff (S) 7, one opened multidose vial of Humulin 70/30 (insulin) labeled for Patient (P) 13, was found stored without a beyond use date. On 2/22/23 at 11:57 AM, S7 confirmed this finding and stated that the vial should have been dated with a beyond use date when it was first opened. S7 could not determine when the vial was opened or when the contents of the vial should have expired.

N.J.A.C. 8:43G-23.6(i)

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases.

Findings include:

1. The facility failed to ensure that the individual responsible for infection prevention and control is appointed by the governing body based on the recommendations of medical staff leadership and nursing leadership. (Cross-refer to Tag 748)

2. The facility failed to ensure that infection control policies and procedures are implemented and developed that address the prevention and control of parasitic infections within the hospital. (Cross-refer to Tag 749)

3. The facility failed to ensure a sanitary environment is maintained throughout the facility. (Cross-refer to Tag 750)

4. The facility failed to ensure that an infection prevention and control program that reflects the scope and complexity of the services is developed and implemented. (Cross-refer to Tag 751)

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure that the individual responsible for infection prevention and control is appointed by the governing body based on the recommendations of medical staff leadership and nursing leadership.

Findings include:

On 2/22/23 at approximately 9:55 AM, during the entrance conference, it was identified that Staff (S)15 was the infection prevention and control lead for the facility.

On 2/23/23 at 2:15 PM, during an interview, S15 stated that he/she started as the infection control lead in October of 2019. S15 added that he/she attended the APIC (Association for Professionals in Infection Control) conference in 2019. During the interview, S15 stated that he/she was not certified in infection control (CIC). Upon review of the S15's personnel file, it was revealed that there was no job description related to his/her role as the infection control lead. Upon request, S15 was unable to provide evidence that he/she was appointed by the governing body based on recommendations of medical staff leadership and nursing leadership.

The above findings were confirmed with S1, S4, and S15.

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure that infection control policies and procedures are implemented and developed that address the prevention and control of parasitic infections within the hospital.

Findings include:

On 2/23/23 at approximately 11:00 AM, during an interview with Staff (S)15, it was revealed that on 2/6/23 a patient (Patient (P) 3) in the Cornerstone West (CSW) side was identified to have a lice infestation. P3 and the roommate were treated and all the patients in the unit were checked for lice according to S15.

At approximately 12:35 PM, a review of P3's medical records revealed that the patient had a history of homelessness and was admitted into the facility on 1/4/23 from an acute care facility. Upon review of the initial admission assessment documentation, there was no evidence that the patient was checked for lice.

At 2:15 PM, during an interview with S15, he/she stated that a full body assessment is performed upon admission, including checking the patient's head for lice.

At 2:23 PM, an interview with S36 (an admission nurse) was conducted. During the interview S36 stated that he/she checks for lice, hair pins, if any contrabands in the hair, and information will be documented in the assessment form.

Upon request, S4 and S15 were unable to provide a policy and procedure concerning nursing assessment, identification, documentation, and procedures to control parasitic infection.

The above finding was confirmed with S15 upon discovery and with S1, S2, and S4 during the exit conference.

Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure a sanitary environment is maintained throughout the facility.

Findings include:

On 2/22/23 at 10:46 AM, during a tour of the Cornerstone East (CSE) Exam Room, a blue metal cart was observed with adhesive residue, peeled paint exposing a brown rust-colored surface, and peeling stickers. Upon interview with Staff (S)2, he/she stated that the cart is the emergency cart containing emergency supplies.

At 11:06 AM, during a tour of the facility, on the Cornerstone West (CSW) unit, in Room CW145, a Seclusion Room, the mattress had peeling stickers which renders the surface to be uncleanable. The floor in the seclusion room had brown and black stains.

At approximately 11:15 AM, in the CSW Treatment Room, in the presence of S2 and S20, the following was observed: a defibrillator that had adhesive residue with black lint, a green chair with black stains on the seat and frayed upholstery, a blue chair with black/brown stains on the seat area, the floor had brown discoloration throughout, and upon walking into the room the floor surface was noticeably sticky.

At approximately 11:30 AM, in the Dining/Activity Room, in the presence of S2, the following was observed: three green upholstered chairs with stains, the sink, cupboard, and countertop area contained remnants of peeled stickers and adhesive residue, and the cupboard handles had brown grime and black particles.

Environmental rounds for the last six months were reviewed and none of the above findings were identified by the facility.

The above findings were confirmed with S2 upon discovery and with S1 and S4 during the exit conference.


45589


At 11:00 AM, during tour of the CSE Unit Exam Room, in the presence of S2, the following was observed:

Adjacent to the exam table on the floor two corrugated boxes, containing laboratory specimen containers, were observed stacked on the floor.

On the counter directly adjacent to the sink was a small white porous plastic basket with unopened culture swabs, blood collection tubes, one package of Quick Combo Pads, and a used dirty paper towel.

Scattered debris and a sticky brownish substance were observed on the counter behind the sink faucet.

Adjacent to the sink cabinet was a black plastic locked box, the top covered with dust and debris. Two corrugated boxes were stacked on top.

At 11:02 AM, upon interview, S2 stated that the black box contained supplies for COVID testing and that it was no longer being utilized.

At 11:19 during a tour of the CSW Unit Exam Room, in the presence of S20, in the "storage closet" behind the entrance door, two corrugated boxes containing PPE (personal protective equipment) were observed stored on the floor. S20 stated that the storage was an overflow room.

At 11:32 AM, during a tour of the CSW Unit Dining /Activities Room, in the presence of S20, along the wall adjacent to the entry doors, was a line of cabinetry with the doors all containing inset door pulls. On the inside bottom of the cabinet door pulls, a sticky brownish substance and debris was observed. At the end of the cabinetry was a metal sink, scattered debris was observed behind the faucet.

At 11:35 AM, upon interview, S20 stated that the patients are provide with wipes after meals and they wipe down the tables. S20 further stated that housekeeping cleans the dining area after meals.

On 2/24/23 at 2:36 PM S1, S2, S4 and S15 confirmed the above.

On 2/22/23 at 10:46 AM, during a tour of the CSE Unit Exam Room, in the presence of S2 and S5, the following expired items were observed on the countertop:

Greater than 25 Microtest lab specimen collection tubes with an expiration date of 5/16/22.
Greater than 5 Bacti-Swab culture tubes with an expiration date of 1/19/22.
Greater than 5 blood collection tubes with an expiration date of 1/31/22.
One opened pack of Quick Combo Pad with an expiration date of 12/04/22.

At 10:52 AM, upon interview, S5 stated that the room was used during the admission of new patients, blood draws, vital signs, and exams such as dental. S2 confirmed the above.

N.J.A.C. 8:43G-13.4(a)
N.J.A.C. 8:43G-13.4(d)
N.J.A.C. 8:43G-13.4(k)

Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that an infection prevention and control program that reflects the scope and complexity of the services is developed and implemented.

Findings include:

On 2/23/23 at approximately 11:00 AM, upon request, Staff (S)4 and S15 were unable to provide an infection prevention and control program and plan that reflects the scope and complexity of the services provided in the facility.

At 11:57 AM, S15 confirmed that there was no infection control program for 2021, 2022, and 2023.

The above finding was confirmed with S15 upon discovery and with S1, S2, and S4 during the exit conference.

N.J.A.C. 8:43G-14.1(d)