Based on observations, interview, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that policies and procedures were developed and implemented to mitigate the spread of infections, and b.) documented on-going staff education and in-services were completed to combat breaks in infection control practices. The multiple observed breaches in infection control practices by multiple facility disciplines, were identified on 02/08/23, 02/09/23, and 02/10/23 on 4 of 4 resident care Wings. This posed a serious and immediate threat to the health, safety and well-being of all residents who resided at the facility due to the lack of infection control oversight provided by the LNHA, which resulted in an Immediate Jeopardy (IJ) that began on 02/08/23 and was identified on 02/10/23 at 4:07 PM. The LNHA was notified of the IJ situation on 02/10/23 at 4:08 PM. The failure of the LNHA to ensure the facility operated in a manner that ensured residents were cared for and an environment that enabled residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being posed a serious and immediate threat to the health, safety, and welfare of staff and all residents who resided at the facility in compliance with federal, state and local requirements as outlined in the Center Executive Director Job Description,. A removal plan was accepted on 02/13/23 at 10:17 AM. The survey team verified the removal plan on 02/13/23 at 12:33 PM. A review of the facility's Center Executive Director Job Description provided on 02/10/23, included but was not limited to the following; Position Summary: The Center Executive Director is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Center Executive Director administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents. Works in close collaboration with the Center Nurse Executive to assure high quality clinical outcomes. Ensures staff participate in orientation and training programs .relative policies and procedures, and that such training is properly documented. Refer to: F880, F886 Findings include: On 02/08/23 at 11:12 AM during entrance conference, the LNHA stated the facility was currently in a COVID-19 outbreak. The outbreak began 10/23/22, and the facility currently had 27 COVID-19 residents on four of the four resident care Wings. The survey team requested multiple documents, one of which was the facility staff in-service and education information. On 02/08/23, during tour of the facility, the survey team observed isolation transmission-based precaution (TBP) resident rooms on 4 of the 4 resident care Wings. The surveyor observed Resident #31's room on the 2nd wing. Resident #31's room did not have any TBP signage affixed to the resident's door, or Personal Protective Equipment (PPE) containers outside the room and readily available. The surveyor observed Resident #88's room on the 1st wing. Resident #88's room did not have any TBP signage affixed to the resident's door, or PPE containers outside the room and readily available. The surveyor conducted medical record reviews which included, but were not limited to, Resident #31 had a physician's order dated 12/08/22 to be placed on contact precautions (procedures that reduce the risk of the spread of infections through direct or indirect contact) for Extended spectrum beta-lactamases (ESBL - an organism which is among those responsible for antibiotic resistant strains) of the urine every shift. Resident #88 had a physician's order dated 01/04/23 to be placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA - a cause of staph infection that is difficult to treat because of resistance to some antibiotics) of the sacral wound every shift. On 02/08/23 at 10:58 AM on the 1st wing, Surveyor #1 and #2 observed a laundry aide walking down the hall wearing a PPE gown which was not secured in the back, an N95 mask and eye protection. The laundry aide entered a COVID-19 positive resident room and through an open door, the surveyors observed her touched multiple environmental surfaces, including the furniture. The laundry aide exited the room without first removing her gloves and perform hand hygiene. On 02/10/23 at 9:28 AM in the presence of three surveyors, the LNHA, Director of Nursing (DON), and Assistant Director of Nursing Infection Preventionist (ADON IP) were interviewed and made aware of the situation concerning the two residents who had not been placed on TBP as per physician's orders. The LNHA, DON, and ADON IP acknowledged they were not aware of the two residents being on TBP and that there was no signage affixed to the resident's room doors to alert staff of the required PPE to wear to protect themselves and other residents. The ADON IP stated the facility kept an antibiotic listing but, infections were not tracked for every patient unless an antibiotic was ordered. The LNHA was not aware of no documented tracking of residents on TBP despite an ordered antibiotic. On 02/10/23 at 12:58 PM, the survey team asked the LNHA a second time for the staff education book. The LNHA stated, I thought I told you I gave you all the education I had to give. When asked if the few in-services she gave encompassed the entire staff, the LNHA stated she was not sure and I guess I can have nursing give you the book to see. On 02/10/23 at 1:23 PM, the ADON IP and Registered Nurse (RN) in training for IP, were being interviewed. The ADON IP stated in-services and education for the staff on Infection Control was done, on and off and whenever I get a chance. She further stated that there were not always sign in sheets kept to document who attended or the content of education or in-services. The LNHA was not aware of the lack of completed, documented education, in-services, and competencies for the facility staff. On 02/10/2023 at 10:49 AM on Wing 4 of the facility, a surveyor observed a housekeeper wearing an N95 mask and a face shield. The housekeeper was observed in the doorway of a COVID-19 positive resident room which had signage on the door to indicate what the TBP was and what PPE was required. The housekeeper had not donned a PPE gown or gloves. The housekeeper was using his bare hands to tie a plastic bag that contained used, soiled PPE gowns. The housekeeper then brought the plastic bag filled with soiled PPE gowns out into the hallway and placed the bag on top of the housekeeping cart. The surveyor asked the housekeeper what the process was for collecting soiled gowns in resident rooms that were on droplet precautions or any transmission-based precautions (TBP)? The housekeeper stated that he followed directions from his administrator (LNHA). On 02/10/23 at 2:27 PM, the LNHA and DON were being interviewed. The surveyor asked who was responsible for overseeing the Infection Control program? The DON stated she and the LNHA were responsible. The LNHA was present and agreed. On 02/22/23 at 10:00 AM the LNHA was interviewed in the presence of the survey team. regarding her job decription. The surveyor asked if the LNHA was responsible for everyong in the facility and she stated, ultimately yes and the surveyor inquried if that included infection control and the LNHA stated yes. The surveyor asked what her role in infection control was, the LNHA stated to make sure we have an infection preventionist. On 02/22/23 at 10:04 AM, the surveyor asked if the LNHA was aware that there was no one assuming the ADON IP's role when she had been out. The LNHA sated it would have then deferred to the DON. When asked if the LNHA was aware that all COVID-19 testing was not completed as indicated. The LNHA stated honestly, not. The surveyor asked the LNHA if she should have been made aware and she staetd absolutely, things should have been communicated to me so I could have strategized. A review of the facility provided, Outbreak Investigation / Management policy and process revised 02/01/23, included, but was not limited to 6. Notify: 6.1. Administrator 7. Implement control measures based on signs, symptoms, diagnosis, mode of transmission, and location in the Center. 8. Conduct staff education/competencies as needed regarding disease outbreak and mode of transmission. 10. Monitor for effectiveness of investigation and control measures until cases cease to occur or return to usual levels. The LNHA failed to ensure these directives were being followed. A review of the facility provided, Infection Control Policies and Procedures for COVID-19, effective 03/27/20 and revised 12/07/22. The Policy revealed: General Standard Precautions: 9. Follow CDC published guidance related to the use of facemasks, respirators, gowns, gloves, and eye protection. Education: 31. Provide COVID-19 education as indicated to employees, patients, and visitors. The LNHA failed to ensure these directives were being followed. NJAC 8:39- 19.1(a); 19.2(a)(c)

Part A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility, who has been in an active COVID-19 outbreak status since 10/23/22, failed to ensure: a.) a system was in place and followed to prevent the spread of multidrug resistant infections (organisms resistant to multiple antibiotic treatments including Methicillin Resistant Staph Aureus [MRSA], extended spectrum beta-lactamase [ESBL], vancomycin resistant enterococcus [VRE]) and COVID-19 (a deadly virus), and b.) facility policies and current infection control guidance was followed to limit the spread of infection. The breaches in infection control practices were observed by the survey team on 02/08/23, 02/09/23, and 02/10/23, for 4 of 4 Resident Wings and was evidenced by the following: Reference: Centers for Medicare and Medicaid Services Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH DATE: August 26, 2020 REVISED 09/23/2022. Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022. The facility's system wide failure to ensure that infection control practices were implemented to mitigate the spread of MRSA, ESBL, VRE, and COVID-19 posed a serious and immediate risk to the health, safety and well-being of all residents who resided at the facility. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that began on 02/08/23 and was identified by the survey team on 02/10/23 at 4:07 PM. The Administrator was notified of the IJ on 02/10/23 at 4:08 PM A removal plan was accepted on 02/13/23 at 10:17 AM. The survey team verified the removal plan on 02/13/23 at 12:33 PM. On 02/08/23 at 9:08 AM during tour of the facility, surveyor #1 observed Resident #31's room on the 2nd Wing. Resident #31's room did not have any transmission-based precaution (TBP) signage, or PPE (personal protective equipment, including gowns, gloves, etc.) containers outside of the room and readily available. Surveyor #1, entered the room and attempted to interview Resident #31 at that time and the resident was confused and unable to be interviewed. On 02/02/23 at 10:00 AM, surveyor #1 returned to Resident #31's with a Certified Nursing Assistant (CNA) to perform an incontinence check. There was no PPE signage, or PPE available at the resident's room at that time. The surveyor entered the room with the CNA. The CNA was wearing an N95 respirator mask (filters out 95% of airborne particles), eye protection and gloves, and proceeded to re-position the resident, who was awake, and then check the resident's incontinence brief (disposable brief designed to collect urine and feces). The CNA completed the entire task without wearing a PPE gown. Surveyor #1 reviewed the medical record for Resident #31. Resident #31 was admitted to the facility with diagnoses which included but were not limited; to urinary tract infection and sepsis. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 11/21/22, revealed Resident #31 required extensive assistance of at least one staff for toileting; was always incontinent of bladder and bowel and did not have any urinary or bowel appliances. A review of a physician's order dated 12/08/22, revealed the resident was ordered to be placed on contact precautions (procedures that reduce the risk of spread of infections through direct or indirect contact) for ESBL of the urine every shift. A review of the facility provided urinalysis with a culture and sensitivity test, Lab Results reported 12/02/22, revealed organism identification to include ESBL. A review of the Medication Administration Report (MAR) for December 2022 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered / completed from 12/08/22 through 12/31/22. A review of the MAR for January 2023 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered/completed from 01/01/23 through 01/31/23. A review of the MAR for February 2023 revealed Contact Precaution due to ESBL in urine, with a start date of 12/08/22. There was no end date documented for the order, and staff were signing off as administered/completed from 02/01/23 through 02/10/23, when the MAR was printed. A review of the on-going resident Care Plan (CP) including resolved areas, revealed no focus area, goal or interventions for or related to contact precautions and/or ESBL of the urine. On 02/08/23 during tour of the facility, Surveyor #1, #2, and #3 observed Resident #88's room which was located on the 1st Wing. Resident #88 did not have TBP signage or PPE readily available outside the resident's room. A review of Resident #88's medical record revealed a physician's order dated 01/04/23 to be placed on contact precautions for Methicillin-resistant Staphylococcus Aureus (MRSA - a cause of staph infection that is difficult to treat because of resistance to some antibiotics) of the sacral wound every shift. On 02/08/23 at 8:40 AM on the 4th Wing, Surveyor #3 observed a Registered Nurse (RN) entering a COVID-19 positive resident room. The RN was wearing only an N95 (a respirator mask that filters 95% of airborne particles) mask and eye protection. The COVID-19 positive room had signage posted on the door which indicated what the TBP were and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included, but was not limited to, performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The RN failed to follow the posted guidance and don (put on) a PPE gown or gloves. On 02/08/23 at 9:15 AM on the 2nd Wing, Surveyor #1 observed CNA #1 who was wearing an N95 mask and eye protection. CNA #1 donned a PPE gown, but failed to secure the back of the gown, and failed to don gloves. CNA #1 proceeded to pick up a meal tray and then entered a COVID-19 positive resident room. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE needed to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. Surveyor #1 also observed CNA #2 wearing an N95 mask and eye protection. CNA #2 picked up a PPE gown and entered the same COVID-19 resident positive room without first donning the PPE gown as indicated by signage. On 02/08/23 at 9:20 AM, Surveyor #1 observed the Director of Nursing (DON) on the 2nd Wing. During an interview at the time, the DON stated the staff should put all the required PPE on before entering a room. She stated the PPE gown needed to be secured in the back to keep the person protected, and that once someone entered a TBP room, they would be considered dirty. The DON stated she would send the Assistant Director of Nursing Infection Preventionist (ADON IP) over. On 02/08/23 at 9:28 AM, the ADON IP and the RN in training for IP arrived on the 2nd Wing. Both were made aware of the surveyor's observations. The surveyor observed both were wearing N95 masks and eye protection. The ADON IP stated staff must put the required PPE on outside of the TBP room and then tie the PPE gown in the back for protection. At that time, Surveyor #1 observed the ADON IP enter the same COVID-19 positive resident room without wearing a PPE gown or gloves. The COVID-19 positive room had signage affixed to the door which indicated what the TBP was and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. On 02/08/23 at 9:37 AM, CNA #2 exited the 2nd Wing COVID-19 positive resident room and was interviewed by Surveyor #1 at that time. CNA #2 stated she had worked at the facility for 26 years and had been educated on PPE. CNA #2 stated she thought she was in the way, so she stepped inside the room to don her PPE gown. CNA #2 stated should not have entered the room without first putting on the PPE in order to protect herself and the residents. On 02/08/23 at 9:39 AM, CNA #1 exited the 2nd Wing COVID-19 positive resident room and was interviewed by Surveyor #1. CNA #1 stated she had worked at the facility for 31 years and had received training on PPE. CNA #1 stated she should have been wearing gloves, and that the PPE gown should have been tied in the back, but sometimes the ties become loose. Surveyor #1 asked what the process would be in the PPE gown became loose while in a TBP room. CNA #1 stated she should put her PPE gown in the hamper and then get a new one. On 02/08/23 at 9:50 AM on the 3rd Wing, Surveyor #3 observed the RN training for IP in the hallway. The RN donned gloves to pick up trash from the floor and then disposed of the trash. She then removed the gloves and touched a resident meal tray and had not performed hand hygiene or changed gloves. Surveyor #3 approached the RN training for IP and interviewed her. The RN stated, I probably should not have touched his/her tray. The RN then used the ABHR located in the hallway to sanitize her hands. On 02/08/23 at 10:28 AM on the 1st Wing, Surveyor #2 observed CNA #3 exit a COVID-19 positive room wearing gloves and an N95 mask which had been positioned down on her face not and was not fully covering her nose. The COVID-19 positive resident room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. CNA #3 was carrying a meal tray that was not bagged and proceeded to place the meal tray directly on top of the shredder bin that was located in front of the nurse's station in the common area accessible to all nursing wings, and where residents were gathered. CNA #3 was observed moving the N95 mask up on her face multiple times. During an interview at that time, CNA #3 stated to the surveyor that normally she would have taken off her gloves, and that she had been fit tested for her N95 mask, but that it kept sliding down on her face. CNA #3 further stated there were no meal tray trucks, so she placed the meal tray on the shredder box. At 10:33 AM, Surveyor #2 observed CNA #3 enter the staff bathroom to wash her hands. CNA #3 turned on the water, applied soap and lathered her hands for 10 seconds with her hands under the running water. During an interview at that time, CNA #3 stated to the surveyor that the process was to lather her hands for 20 seconds. On 02/08/23 at 10:58 AM on the 1st wing, Surveyor #1 and #2 observed a laundry aide while she was walking down the hall and wearing a PPE gown which was not secured in the back, an N95 mask and eye protection. The laundry aide then entered a COVID-19 positive resident room and through an open door, the surveyors observed her touch multiple environmental surfaces including a dresser, and folded clothes, and proceeded to go to the other side of the room and touch other surfaces, including the furniture. She exited the room without first removing gloves, and performing hand hygiene. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The laundry aide did not perform hand hygiene upon exiting the room and proceeded to continue to wear the same gloves as she walked to the hallway of Wing #1. During an interview at that time, the laundry aide stated she had worked at the facility for 25 years and had been educated on PPE. The laundry aide confirmed it was her practice to wear the PPE gown through the hallway and stated the PPE gown should be tied in the back for protection. The laundry aide stated, Sorry I forgot when asked about if she should have been wearing gloves through the hallway. On 02/08/23 at 11:12 AM, during the entrance conference conducted with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the survey team was informed that the facility was currently experiencing a COVID-19 outbreak and there were 27 COVID-19 positive residents. The facility provided line list verified the COVID-19 outbreak began on 10/23/22. On 02/08/23 at 12:25 PM on the 2nd wing, Surveyor #1 observed a recreation aide wearing an N95 mask, eye protection and a PPE gown. The recreation aide entered a COVID-19 positive resident room (Resident #95) without wearing gloves and was carrying a lunch meal tray. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The recreation aide placed the meal tray on the resident's over bed table and then moved the over bed table towards the resident with her bare hands. At 1:08 PM, the recreation aide exited the room and was interviewed by Surveyor #1. She stated she had worked at the facility for 33 years and had been educated on PPE and COVID-19. She further stated, I didn't see gloves. It was my mistake, sorry. On 02/09/23 at 9:08 AM, Surveyor #1 observed Resident #31's room and there was no TBP signage or PPE readily available. At that time the surveyor reviewed the medical record for Resident #31 which revealed an order dated 12/08/22 for contact precaution for ESBL of the urine. On 02/09/23 at 9:13 AM on the 3rd Wing, Surveyor #3 observed RN #2 wearing an N95 mask and eye protection. RN #2 donned a PPE gown and gloves and entered a COVID-19 positive resident room. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was required to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. RN #2 then exited the COVID-19 positive resident room wearing the same PPE gown which was not removed prior to exiting the room. On 02/09/23 at 11:39 AM, during an interview with Surveyor #1 and #2, the DON, in the presence of the LNHA, stated the facility had completed infection control audits and staff was educated to mitigate the spread of infection. The surveyors inquired to the DON for any documentation regarding the audits and education. The DON was unable to provide documentation and stated that the facility recently implemented a form that was used for audits, and the DON stated I don't know if they are always using it [form]. On 02/09/23 at 11:43 AM, the ADON IP stated she had been in contact with the Local Health Department (LHD) either, today, yesterday or the other day. She stated that the LHD had provided her with the Communicable Disease Services (CDS), COVID-19 Patient/Resident Management in Post-acute Care Settings guidance dated 01/23/23. On 02/09/23 at 12:30 PM, Surveyor #3 observed a resident who had tested positive for COVID-19 and was seated in the facility Atrium at a table. The surveyor went to the 3rd Wing to verify that resident was the COVID-19 positive resident who was on TBP. The resident's room door was observed open. Staff were not aware that the resident had left the room and was seated in the Atrium waiting for the lunch tray. The RN in training for IP observed the resident in the Atrium and then escorted the resident back to the unit. While being escorted to his/her room, Surveyor #3 heard the resident coughing. The staff confirmed that the resident was symptomatic and had been complaining of a headache also. During a subsequent surveyor interview, the RN in training for IP did not know or was not aware that the table the COVID-19 positive resident was sitting at, needed to be disinfected. On 02/10/23 at 7:43 A.M. to through 8:22 A.M. on the 2nd Wing, Surveyor #1 observed a Registered Nurse (RN) #1 during a medication administration and observed the following: RN #1 walked up and down the 2nd Wing, administered medications to five residents and was within arm's length of the residents. The RN wore her eye protection on the top of her head offering no eye or face coverage or protection during her medication administration. At 8:22 AM, during an interview with Surveyor #1, RN #1 stated eye protection should be worn down over the eyes for protection. On 02/10/23 at 8:36 AM, RN #1 entered Resident #31's room. RN #1 was wearing an N95 mask and eye protection. RN #1 then picked up a pillow from floor with gloves on, helped the resident take a sip of their protein drink by touching the resident's head and environment, and then administered medications. RN #1 was not wearing a PPE gown and there was no TBP signage on the door. Surveyor #1 had conducted a medical record review on 02/09/23, for Resident #31 and there was a physician's order for contact precautions to be observed. On 02/10/23 at 9:28 AM in the presence of three surveyors, the LNHA, DON, and ADON IP were interviewed in the conference room. The DON stated there were no TBP residents other than COVID-19 positive on the 1st wing, 2nd wing, or 3rd wing. The DON stated there were only two residents located on the 4th wing with TBP other than COVID-19. The DON further stated that someone would let her know if there was an abnormal test result requiring TBP that she was not aware of. The DON stated that the staff would talk in clinical meeting and the physician would decide what TBP to order. After that, it would be the ADON IP's responsibility to put the signage up or have the nurse on the unit place the signage on the door. The DON stated the information would be communicated in the shift to shift report. The ADON IP stated nurses give report to other nurses and CNAs and that would be how the staff would know about TBP. The DON stated that contact precaution would require a PPE gown, gloves, N95 mask and eye protection; and that enhanced barrier and droplet precautions required everything PPE. The ADON IP stated the facility kept an antibiotic listing but, infections were not tracked for every patient unless an antibiotic was ordered. A review of the facility provided list, Resident's on precaution other than COVID-19 undated, but provided on 02/10/23, revealed two residents and their room numbers. The surveyor team identified that the first resident noted was on contact precautions for clostridium difficile (C diff - a contagious bacterium), and the second resident noted was on contact precautions for C diff, and VRE. Resident #31 and Resident #88 were not included on the facility provided list as the DON, ADON IIP, and LNHA were not aware of the physician ordered contact precautions for MRSA and ESBL. On 02/10/23 at 9:58 AM, Surveyor #1 interviewed RN #1 who stated there were no residents that required contact precautions on the 2nd Wing. RN #1 stated she would know that information because there would be signs posted on the door and the ADON IP would have put up the signs. On 02/10/23 at 9:59 AM, CNA #5 stated to the surveyor that there were no other residents on TBP besides COVID-19 on the 2nd wing. She further stated that if there were any other residents requiring TBP, the nurse would let the CNAs know during report and there would be a sign on the door also. On 02/10/2023 at 10:49 AM on Wing 4 of the facility, Surveyor #4 observed a housekeeper wearing an N95 mask and a face shield. The housekeeper was observed to don a PPE gown and gloves, enter a resident room, picking up soiled gowns and collecting soiled gowns in a see-through plastic bag. The housekeeper doffed (removed) his PPE gown and gloves inside the resident room, brought the bag with soiled PPE out into a cart in the hall and next sanitized his hands. The housekeeper was next observed in the doorway of a COVID-19 positive resident room wearing an N95 mask and face shield. The COVID-19 positive room had signage on the door to indicate what the TBP was and what PPE was to be worn. The signage indicated Special Contact and Droplet Precautions for special respiratory circumstances and included but was not limited to; performing hand hygiene before and after patient contact, contact with environment and after removal of PPE; and wear an N95 respirator, gown, face shield and gloves upon entering this room. The housekeeper had not donned a PPE gown or gloves. The housekeeper was using his bare hands to tie a plastic bag that contained used, soiled PPE gowns. The housekeeper then brought the plastic bag filled with soiled PPE gowns out into the hallway and placed the bag on top of the housekeeping cart. Surveyor #4 asked the housekeeper what the process was for collecting soiled gowns in resident rooms for residents were on droplet precautions or any transmission-based precautions (TBP)? The housekeeper stated that he followed directions from his administrator. The housekeeper was unwilling to answer any additional questions from the surveyor and stated, please let me get back to work and do my job. On 02/10/23 at 11:30 AM, Surveyor #3 observed CNA #4 in the 3rd Wing hallway. CNA #4 reached inside a TBP room and picked up the breakfast meal tray without donning gloves. On 02/10/23 at 11:35 AM, Surveyor #3 observed a breakfast meal tray bagged and placed on the 4th Wing hallway shredder. Surveyor #3 read the name and verified the tray came from an isolation TBP resident room. On 02/10/23 at 12:02 PM, Surveyor #4 asked the LNHA what the process was for collecting used or soiled gowns from COVID-19 positive resident rooms and other TBP resident rooms. The LNHA stated that she would have to check what the process was and would provide the surveyor with the policy. On 02/10/23 at 2:00 PM, the LNHA provided the surveyor with a policy on the laundry process for collecting biohazard laundry. A review of the policy titled, The Laundry Process dated 01/01/2000, indicated that the Laundry Department was responsible for the safe and proper collection, cleaning, and distribution of linens within the nursing home. At designated times, laundry workers using a large bin with lid, marked For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linen. The policy did not indicate for housekeeping to collect soiled gowns from COVID-19 positive resident rooms or other TBP resident rooms. On 02/10/23 at 12:58 PM, the survey team again requested from the LNHA staff education on infection control. The LNHA stated, I thought I told you I gave you all the education I had to give. Surveyor #1 asked if the few in services she provided encompassed the entire facility staff. The LNHA stated she was not sure and, I guess I can have nursing give you the book to see. At 1:23 PM, the ADON IP and RN in training for IP were in the conference room with three surveyors. The ADON IP stated in services and education for staff regarding infection control was on and off and whenever I get a chance. The ADON IP stated there was not always a sign in sheets to identify who received education or what the education was provided. At 1:25 PM, Surveyor #3 inquired if a resident tested COVID-19 positive and had a room mate, what would the process be. The ADON IP stated the facility would remove the roommate without COVID-19 and place them into another room. She stated if the roommate was unvaccinated, they would, test them, move them, monitor them, and place them on empiric TBP which means if they become symptomatic, they would be put on isolation until the facility could be sure they were not COVID-19 positive. The ADON IP stated the staff were educated to care for the well resident first unless, something comes up. She stated that trying to have dedicated COVID-19 staff was, challenging, which means very difficult. We (facility) don't have enough staff sometimes. The RN in training for IP stated that as long as the staff followed the TBP, they should be ok. At 1:38 PM, the ADON IP stated the COVID-19 outbreak started the end of October (2022) and, we are not in the big numbers of COVID. When asked what she had implemented since the start of the outbreak, the ADON IP stated, we have a form of auditing. She stated supervisors also do education and, I think there are in services on the nursing units. On 02/10/23 at 2:12 PM in the presence of three surveyors, the DON stated that since the facility outbreak, the facility had tried to have dedicated COVID-19 staff but were unable to. The DON acknowledged that all four wings had both well and ill residents. The LNHA was also present and stated that the facility did not have enough equipment to provide dedicated equipment to residents on TBP. On 02/14/2023 at 11:03 AM during an interview with Surveyor #4, the Director of Housekeeping stated that housekeeping was responsible for picking up soiled gowns from COVID-19 positive resident rooms. He stated the process was to don a PPE gown, gloves, N95 mask, and face shield to enter the room. The resident's bin for disposal of soiled PPE gowns had a plastic bag. The housekeeper would tie the dirty bag and hand the bag to a second person outside the room. The second staff would be holding a clean plastic bag for the housekeeper to drop the tied bag of soiled gowns into so it would be double bagged. The second person standing outside the room would then dispose of the double bagged linen into the linen bin in the hallway. The Director of Housekeeping demonstrated the process and showed the surveyor the different bins in the hallway of Wing 1. One bin for trash, two bins for soiled gowns and/or linen, and a third bin for resident's personal clothes. A review of the facility provided, Outbreak Response Plan, undated, included but was not limited to 1.b. Control Measures .frequent COVID-19 in-services and handwashing as well as PPE education and competencies. A review of the facility provided, Outbreak Investigation/Management policy and procedure revised 02/01/23, included but was not limited to Purpose to manage and contain disease/condition outbreak when identified. Case definitions included MDROs and COVID-19. 7. Implement control measures based on signs, mode of transmission. Measures may include standard and transmission-based precautions. 8. Conduct station education/competencies include hand hygiene, donning and doffing PPE, transmission precautions, MDRO. A review of the facility provided, Modified Enhanced Barrier Precautions revised 11/15/21, included but was not limited to Policy: In addition to standard precautions, modified enhanced barrier precautions and contact precautions will be used for MDROs. 5. post the appropriate enhanced barrier precautions or contact precautions sign on the patient's room door. Contact Precautions: required PPE: gloves and gown (don before room entry, doff before room exit; change before caring for another patient) face protection may also be needed if performing activity with risk of splash or spray. 9. Before exiting room, remove and place PPE in trash and perform hand hygiene upon exiting room. 16. Document: type of precautions in care plan. Specific MDRO identification in special instructions section of [redacted] (electronic medical record). Review of the CDS, COVID-19 Patient/Resident Management in Post-acute Care Settings guidance dated 01/23/23, provided to the ADON IP by the LHD, included but was not limited to, When resources permit, facilities should dedicate equipment to individual cohorts. Equipment should not be shared between individuals on TBP and those cared for with standard precautions. If this is not possible, equipment should be used by rounding in a well to ill flow to minimize the risk of cross-contamination. A review of the facility provided, COVID-19 policy and procedure revised 12/07/22, included but was not limited to Policy: in addition to standard precautions, special droplet and contact precautions will be implemented for patients suspected or confirmed with COVID-19. Special droplet and contact precautions requires wearing a N95 respirator upon entry .in addition to the recommended PPE. Definition: all recommended PPE (gown, gloves, eye protection, respirator) while present in the room. Infection Surveillance: 6.2 during an outbreak, the COVID-19 screen will be completed each shift. Part B The non-compliance remained on 02/27/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Based on observation, interview, record review and document review it was determined that the facility failed to ensure the faciliy policy for infection surveillance during an outbreak was followed by completing a COVID-19 resident screening each shift (for 4 of 4 Wings), and ensure staff performed hand hygiene as indicated on 1 of 4 Wings. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, QSO-20-38-NH DATE: August 26, 2020 REVISED 09/23/2022. Centers for Disease Control and Prevention, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 23, 2022. On 02/08/23 at 11:22 AM, during the entrance conference held with the facility Administrator (LNHA) and Director of Nursing (DON), the LNHA informed Surveyor #2 that the facility was currently experiencing an outbreak that began on 10/24/22. The DON informed the surveyor that there were currently twenty-seven COVID positive residents. Surveyor #2 inquired about any COVID-19 testing in progress and the DON stated that per facility policy employees and residents were tested twice per week on Tuesday and Thursday, and only employees would be tested for a COVID-19 exposure. On 02/09/23 at 11:33 AM, the LNHA provided