Based on observation, interview, and pertinent facility documents, it was determined that the facility failed to ensure narcotic medications were secured under double lock. This deficient practice was identified in 1 of 2 medication storage rooms observed (Cove nursing unit), and was evidenced by the following: On 10/15/24 at 11:11 AM, the surveyor, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN) observed the Cove nursing unit's medication storage room. Upon entering, the surveyor opened the unlocked medication refrigerator (med fridge), and inside was the unlocked narcotic medication lock box. The narcotic medication lock box contained 57 dronabinol 5 milligram capsules (a controlled medication used to treat weight loss). At that time, UM/LPN confirmed that the controlled medications should be stored under two secured locks. On 10/15/24 at 12:18 PM, the surveyor interviewed the Director of Nursing (DON), who stated narcotic medications should be stored under two secured locks to prevent drug diversion. The DON confirmed that the dronabinol in the Cove nursing unit medication storage room should have been stored with two secure locks. On 10/17/24 at 12:34 PM, the surveyor, in the presence of the DON and the survey team, interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed that the narcotic medication stored in the Cove nursing unit's med fridge were not considered stored under double lock. A review of the facility's Controlled Substance Storage policy with effective date of February 2019, Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment separate from all other medication or per state regulation. The access system to controlled medication is not the same as the system giving access to other medications (the key that opens the compartment is different from the key that opens the medication cart.) If a key system us used, the medication nurse on duty maintains possession of the key to controlled substance storage areas .Controlled-substances that require refrigeration are stored within a locked box within the refrigerator, this box must be attached to the inside of the refrigerator in such manner that prevents its removal from the medication room . NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows: On 10/11/24 at 10:11 AM, the surveyor in the presence of the Director of Culinary Management (DCM), toured the kitchen and observed the following: 1. In the walk-in freezer, a box of chocolate chip premade dough cookies, a box of beef patties, and a box of vegetable burgers. The boxes were open, there were no dates when to use by, and the the bags inside the boxes were unsealed and the products were covered in ice crystals. The DCM could not speak to when the boxes were opened. 2. In the kitchen, the ice machine had black sediment on the output flap in the interior of the machine. The DCM wiped the flap with a white paper towel revealing it had a wipeable black colored sediment. When the surveyor asked the DCM what it was, the DCM responded it was black mold, and it needed to be cleaned immediately. On 10/11/24 at 10:20 AM, the surveyor interviewed the DCM, who stated that the freezer items should have been labeled with an opened date, and if only part of the bag was used, the bag should be resealed and labeled. The DCM stated that labeling ensured that it was used in a timely fashion to prevent waste, and sealing it prevented contamination, ice crystals, and food borne illness. On 10/17/24 at 12:34 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON) and survey team acknowledged the concerns. The LNHA provided no additional information. A review of the facility provided Refrigerators and Freezers policy dated revised November 2022, included this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .6. Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference. 7. All food is appropriately dated to ensure proper rotation by expiration dates. received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated on food that are open .9. Supervisors are responsible for ensuring food items in pantry, refrigerators and freezers are not past use by or expiration dates . A review of the facility provided Ice Machines and Ice Storage Chests dated revised January 2012, included ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .ice making machines, ice storage chests/containers, and ice can all become contaminated by [ .] c. colonization by microorganisms .to help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions [ .] f. clean and sanitize the tray and the scoop daily . NJAC 8:39-17.2(G)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of electronic medical records (EMR), and review of facility provided documentation, it was determined that the facility failed to report an unexpected death to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #76), reviewed for unexpected death. The deficient practice was evidenced by the following: A review of the EMR revealed that Resident #76 had diagnoses which included but was not limited to; dependence on renal dialysis [the clinical purification of blood by dialysis to substitute for the normal function of the kidney], vascular dementia with behavioral disturbances, and anxiety disorder. Resident #76 had a perma-catheter [a dialysis access site] located on the right upper chest area. The most recent Quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated [DATE], documented a Brief Interview of Mental Status (BIMS) of 08 out of 15 which indicated moderate cognitive impairment. The MDS further documented that Resident #76 required extensive assistance for Activities of Daily Living (ADL) except for eating which required supervision only. The MDS documented the resident received hemodialysis while a resident at the facility. The Order Listing Report included an order to assess the dialysis site for signs and symptoms of infection/bleeding every shift, and that the resident was socially inappropriate by yelling to exhaustion. The on-going patient centered Care plan included a focus area of renal insufficiency initiated [DATE], with interventions that included to check the access site for evidence of infection, swelling or excessive bleeding. A review of the Progress Notes (PN) included but were not limited to the following: Dated [DATE], a Licensed Practical Nurse (LPN) #1 documented a Situation Background Appearance and Review (SBAR - a summary), which included but was not limited to; Situation: 1. patient perma-cath to right chest wall was dislodged. 3. Situation has gotten worse. Appearance: 2. Pulse - unable to determine, O2 [oxygen] sats [saturation] 73 % (normal saturation level would be between 95% - 100%). Interventions: 3.e. call for 911 and 3.f. emergency medical transport. A PN dated [DATE], documented by the LPN included but was not limited to; at around 11 PM .a Certified Nursing Assistant (CNA) noticed blood on the resident's blanket Observed bleeding with right upper chest perma-cath pulled out Cardio Pulmonary Resuscitation (CPR) initiated .ambulance personnel arrived and continued CPR, resident pronounced [deceased ] by [name redacted] physician at 11:27 PM. On [DATE] at 12:17 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that she had spoken to the nurse regarding the situation on [DATE] but did not document the conversation. The DON further stated it was not a usual occurrence and that she should have asked for an investigation. The DON stated that the incident had not been reported to the NJDOH. On [DATE] at 12:02 PM, the Licensed Nursing Home Administrator (LNHA) stated that Resident #76 had died at the facility because his/her perma-catheter came out on [DATE]. The LNHA further stated there was no investigation completed to determine a causal factor and that the situation should have warranted an investigation. She stated that after thinking about it, she had realized it was an unusual occurrence and it should also have been reported to the NJDOH. On [DATE] at 1:35 PM, the DON stated, I should have investigated, and I should have reported [to NJDOH]. A review of the facility provided, Rapid Response Protocol, revised [DATE], included but was not limited to; Steps to Follow Immediately when an Event Occurs: determine if event is reportable to state regulatory agencies. Rapid Response Trigger Events: unexpected death. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to develop a person-centered baseline Care Plan (CP) for residents within 48 hours of admission/readmission. The deficient practice was identified for 2 of 20 residents (Resident #69 and #61) reviewed for CP and was evidenced by the following: a.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. The surveyor observed an indwelling urinary catheter tube and collection bag present [a tube used to drain urine from the kidneys into a collection bag] and attached to the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the facility therapy gym. The surveyor observed a urinary catheter tube and collection bag attached to the side of the resident's wheelchair. A review of the electronic medical record (EMR) revealed that Resident #69 had been recently readmitted to the facility. Resident #69 had diagnoses which included but was not limited to; chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. A review of the Order Listing Report, as of 10/5/23, included an order dated 09/13/23 for staff to monitor urinary catheter output on every shift. There were no further orders regarding Resident #69's indwelling urinary catheter. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for both September 2023 and October 2023 through discharge revealed that staff documented the catheter output, however, the MARs and TARs failed to document and indicate any additional information, including care, regarding the urinary catheter. A review of the Resident #69's person-centered on-going CP failed to include any information initiated upon readmission regarding the use of an indwelling urinary catheter, goals, or interventions. On 10/06/23 at 8:39 AM, during an interview with Surveyor #1, the Director of Nursing (DON) stated the process of a CP was that upon a resident's admission the facility would identify things which included risks, pain, falls, diabetes, and urinary catheters. She stated those things should be documented on the CP and that the purpose of the CP was for staff to know how to take care of resident. The DON further stated the CP would include interventions and goals so the staff would be able to evaluate and make changes as needed. The DON stated that care plans were reviewed on Thursdays by the Interdisciplinary Team which included nursing, therapy, and the social worker. On 10/10/23 at 8:27 AM, Registered Nurse Unit Manager (RN UM) stated that Resident #69 had an indwelling urinary catheter upon readmission. She stated that the staff would perform daily catheter care, monitor urinary output, ensure the catheter and bag would not touch the floor, and perform perineal [area surrounding genitals] care. The RN UM stated the information would be documented on the TAR and also in the CP. The RN UM accessed the CP and then acknowledged the information regarding the catheter was not documented. On 10/10/23 at 9:14 AM, the DON stated the indwelling urinary catheter would be documented on the resident's CP. The CP would inform the staff how to take care of the indwelling urinary catheter. On 10/12/23 at 2:02 PM, concerns were discussed with the Licensed Nursing Home Administrator (LNHA) and the DON. On 10/13/23 at 9:44 AM, the DON provided a resolved CP for Resident #69. The CP documented date initiated: 10/06/23. The DON acknowledged the CP was not developed upon Resident #69's readmission to the facility but it should have been. b.) On 10/04/23 at 9:13 AM, during the initial tour of the facility, the surveyor observed and interviewed Resident #61 in his/her room. The resident was awake and alert and able to be interviewed. At that time, the resident stated to the surveyor that he/she fell at home and was readmitted to the facility for follow up care. The surveyor observed a urinary catheter drainage bag along with the dignity bag lying on the floor. On 10/05/23 at 9:40 AM, the surveyor returned to the unit and observed the urinary catheter drainage bag hung on the bedrail and the privacy was bag touching the floor. On 10/05/23 at 10:40 AM the surveyor reviewed the medical record of Resident #61 which revealed that the resident required the use of an indwelling urinary catheter, the rationale or the diagnosis for the indwelling urinary catheter was not provided. The admission evaluation dated 07/03/23 reflected that Resident #61 had an indwelling urinary catheter in place. The physician order sheet dated 07/04/23 reflected a telephone order dated 07/04/03 for urinary catheter care and catheter output every shift. A review of Resident #61's CP indicated that the resident did not have a CP related to the inddwelling urinary catheter care, or the care related for maintenance of the urinary catheter drainage bag. According to the (MDS) Minimum Data Set assessment dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. According to the MDS dated [DATE] and 07/03/23 Resident #61 was not coded as having a Foley Catheter. On 10/05/23 at 10:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that the resident had a wound and had a urinary catheter since admission. The LPN stated that if a resident had a urinary catheter for wound healing or urinary retention, that it should be reflected in the CP. The surveyor reviewed the CP along with the LPN and the LPN was unable to locate a care plan for the urinary catheter or any interventions and directives for the staff to follow to care for/and maintain the urinary catheter and the drainage bag to prevent complications and maintain function. On 10/06/23 at 9:30 AM, the surveyor interviewed the Unit Manager (UM) regarding the urinary catheteere care. The UM provided a urology consult which revealed that the resident had a [brand name] urinary catheter in place and the UM could not provide the rationale for the catheter. The UM reviewed the resident's CP in the presence of the surveyor. There was no focus, goals or interventions for the urinary catheter. A CP for the urinary catheter was developed, after surveyor inquiry, on 10/06/23. On 10/10/23 at 10:39 AM, the surveyor interviewed the DON in the presence of the survey team and the Administrator. The DON stated if a resident had a urinary catheter in place, a CP for catheter care should have been initiated. A review of the facility provided, Care Plans, Comprehensive Person-Centered, edited 04/25/22, included but was not limited to; 7. The care planning process will: b. includes an assessment of the resident's strength and needs. 8. a. include measurable objectives and timeframes. b. describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. f. includes goals upon admission and desired outcomes. h. incorporates identified problem areas. i. incorporates risk factors. L. reflects treatment goals, timetables, and objectives in measurable outcomes. m. identifies the professional services responsible for each element of care. n. aids in preventing or reducing decline in the resident's functional status. p. reflects recognized standards of practice for problem areas and conditions. q. includes medical or nonmedical care appropriate. 10. Identifying problem areas developing interventions that are targeted and meaningful to the resident are the endpoint of the interdisciplinary process. 14. The Interdisciplinary Team must review and update the care plan: c. when the resident has been readmitted to the facility from a hospital stay. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to revise comprehensive person-centered Care Plans for 2 of 20 residents (Resident #76 and #63) reviewed for care planning. The deficient practice was evidenced by the following: a.) A review of the electronic medical record (EMR) revealed that Resident #76 had diagnoses which included but were not limited to; dependence on renal dialysis [the process of purifying blood when the kidneys are not functioning properly], major depressive disorder, anxiety, and vascular dementia without behavioral disturbance. The most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate care, dated [DATE], included but was not limited to; a Brief Interview of Mental Status (BIMS) of 08 out of 15 which indicated the resident was moderately cognitively impaired. Section E0200 indicated the resident had no behaviors. The Order Listing Report dated [DATE] through [DATE], included but was not limited to; socially inappropriate yelling to exhaustion. A review of the on-going patient centered Care Plan included but was not limited to; a focus area of at risk for adverse effects related to the use of anti-anxiety medication initiated [DATE]. The CP revealed a focus area of cognitive loss related to vascular dementia and end stage renal disease initiated [DATE]. The CP revealed a focus area of at risk for behavior symptoms related to dementia-restlessness, initiated [DATE]. The CP revealed a focus area of renal insufficiency. A goal was to have no complications related to dialysis devices or treatments, initiated [DATE] and revised [DATE]. The CP failed to be revised to identify the resident's behaviors of dislodging his/her dialysis access or the expressed feelings towards not wanting to go to dialysis. A review of the EMR Progress Notes (PN) revealed the following: On [DATE] the Social Worker (SW) documented she had spoken to the resident's family regarding the resident's feelings towards dialysis. At this time, resident will continue dialysis and IDT [Interdisciplinary Team] and the family will continue communication. On [DATE], the Licensed Practical Nurse (LPN) #1 documented the resident had dislodged his/her dialysis access port located to the right chest. The resident was noted to be bleeding profusely. On [DATE], LPN #1 documented resident was found trying to remove his/her perma-catheter [dialysis access]. On [DATE], LPN #2 documented that Resident #76 had been found with his/her perma-catheter dislodged, bleeding, cardiopulmonary resuscitation (CPR) started, 911 emergency services called, and the resident was pronounced deceased by the emergency services physician. The resident was also noted with occasional yelling/screaming. On [DATE] at 11:38 AM, the LPN Unit Manager (LPN UM) stated the resident was very confused and would try to ambulate unassisted. She further stated that the Dialysis center reported a behavior that the resident attempted to remove his/her colostomy [a surgically created opening to empty the contents of the colon into a bag]. On [DATE] at 11:39 AM, the Certified Nursing Assistant (CNA) stated that Resident #76 would try to pull out his/her dialysis perma-catheter. The CNA stated, I would tell him/her not to touch it. The CNA stated that before the resident's privately hired companion aide would arrive, the CNA would bring Resident #76 to the nurse's station to be monitored for trying to pull out the dialysis perma-catheter. On [DATE] at 11:38 AM, during an interview with a surveyor, the SW stated the resident wasn't oriented and at times did not want to go to dialysis. The SW stated the resident only verbalized this once or twice. She further stated she was not aware that the resident had ever pulled out his/her dialysis perma-catheter and that if that had happened, she would expect there to have been an Interdisciplinary Team meeting. On [DATE] at 12:02 PM, the Licensed Nursing Home Administrator (LNHA) stated that Resident #76 had been sent to the hospital on [DATE], for dislodging the dialysis perma-catheter. She stated that she did not recall if she was present in the morning meeting for clinical issues regarding [DATE], but that she would expect that issue to have been discussed. The LNHA stated that when a resident was sent to the hospital, the team would discuss if anything could have been done in house prior to the transfer. The LNHA stated that she had been aware of other instances when the resident dislodged the perma-catheter and that if an investigation had been completed, there would be a rationale and interventions would have been put into place to prevent recurrence. On [DATE] at 1:35 PM, the LPN UM stated that there was documentation in the EMR that Resident #76 would pull at the perma-catheter and that it was like a behavior. A review of the facility provided email Subject Clinical Rounds [DATE], sent [DATE], included but was not limited to; [Resident #76] pulled perma-catheter last night and went to emergency room. A review of the facility provided email Subject 11-7 Shift rep [report] 9/15, sent [DATE], included but was not limited to; [Resident #76] admission perma-catheter reinserted - still attempts to pull out perma-catheter. A review of the facility provided email Subject 3-11 report, sent [DATE], included but was not limited to; [Resident #76] pulled his/her perma-catheter and then he/she was coded, pronounced [deceased ] at 11:27 PM. 2. The surveyor reviewed Resident #63's clinical record on [DATE] at 12:55 PM. The admission Face Sheet reflected that Resident #63 was admitted to the facility with diagnoses which included but were not limited to; difficulty walking, muscle weakness, anoxic brain damage (brain damage caused by lack of oxygen to the brain) and dysphagia. The admission Minimum Data Set (MDS) an assessment summary dated [DATE], revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Section M of the MDS which addressed skin condition, revealed that Resident #63 was assessed as being at high risk for pressure sores. Resident #63 scored 12 on the Braden Scale indicative of being at high risk. According to the skin assessment performed on admission ([DATE]), Resident #63 was admitted with redness to the sacrum. There was no documented open area. The surveyor reviewed Resident #63's Care Plan (CP). The CP initiated on [DATE] contained a Focus area for :At risk for alteration in skin integrity related to immobility. The Goal was for Resident #63 to remain free of breakdown within limits of disease process. The CP Interventions included: Barrier cream to perineal/buttocks as needed. Initiated [DATE]; Encourage and assist to reposition; use assistive devices as needed. Initiated [DATE]; and Therapy evaluation and treatment per physician orders. Initiated [DATE]. Further review of the Progress Notes revealed the following entries dated: [DATE], timed 15:34 [3:34 PM], Resident is dependent with all care. Hoyer lift for transfers from bed to [recliner chair]; [DATE], timed 17:26 PM [5:26 PM], Sacral DTI (deep tissue injury), no open wound, fungal rash. fungal rash - sacrum; [DATE], timed 15:36 PM [3:36 PM], Resident #63 was seen on wound rounds on [DATE] noted with DTI to sacrum with dark discoloration . Measures 3 centimeters (cm) x 3 cm. Recommendations: Low Air Loss mattress. Roho cushion to wheelchair and repositioning. [DATE], skin Note: Resident was seen on skin round for evaluation and treatment of wounds. measures 3 cm x 3 cm. Noted with discoloration. Discussed with staff to continue to offload. Recommendations: Low Air Loss mattress, Roho cushion and repositioned. Skin Note of [DATE]: Visited by wound care unstageable [full thickness skin and tissue loss] pressure injury measures: 2.5 cm x 3 cm x 0.2 cm. debridement performed (removal of dead tissue).Mattress and offloading. The facility provided the Low Air Loss Mattress on [DATE] after the resident developed an unstageable pressure sore to the sacrum. The wound care order was to change the dressing daily and when soiled. Review of the nurses' notes from [DATE] through [DATE] did not reflect when wound care was provided and the wound condition and was only documented when the Wound Care Team visited. On [DATE] Resident #63 developed an additional wound on the left ischium area with the following measurements: 3 cm x 3 cm x .1 cm. The wound was classified as an irritant contact dermatitis, with macerated periwound. Recommendations: Increase dietary protein, and dietary supplement. Offloading: Recommend turning and positioning as per standard of care. Avoid positioning which places direct pressure to the wound site. Low Air Loss Mattress with turning and positioning measures in place. Recommend limiting continuous time spent sitting to less than 2 hours per session on an appropriate pressure reducing surface. The recommendations were not added to the CP for Resident #63. On [DATE] the surveyor observed Resident #63 in bed positioned in supine position from 10:49 AM to 12:30 PM. The facility did not have measures in place to evaluate when the resident was last turned or cared for. On [DATE] at 10:52 AM, the surveyor observed wound care with the Licensed Practical Nurse. The sacral wound had the following measures: 2.5 cm x 2.5 cm x 0.2 cm. The wound on the left ischium measures: 5.5 cm x 4.75 cm x 3 cm. Both wounds were noted with necrotic and slough tissue and emitted a foul odor. The observed wound conditions were not documented after wound care. The nurses only initialed that wound care was completed. Following the wound care, the surveyor interviewed the UM regarding the wound. Upon inquiry she stated she had not observed the wound for two weeks. An interview with the Infection Preventionist on [DATE] at 12:15 PM, revealed that stated she constantly reminded staff the importance of following the recommendations from wound care practitioners. Upon inquiry, she could not comment on the rationale for not having measures in place to prevent the wound from worsening. [DATE] at 10:44 AM, the surveyor interviewed the Registered Nurse IP regarding how Resident #63's Plan of Care was communicated to the CNA. The IP stated that that in the morning the Unit Manager gave reports to the nurses and the CNAs. She further added that all information regarding a residents care was entered and accessible to staff under Task on the Electronic Plan of Care (E-POC). On [DATE] at 2:02 PM, the above concerns were addressed again with the LNHA and the DON. The facility had no additional information to provide. A review of the facility provided, Care Plans, Comprehensive Person-Centered, edited [DATE], included but was not limited to; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Policy Interpretation and Implementation: 8. h. incorporate identified problem areas. n. Aid in preventing or reducing decline in the resident's functional levels. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 11. Care Plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration between the resident's problem areas and their causes, and relevant clinical decision making. 14. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident's condition. NJAC 8:39-11.1; 11.2(e)(i); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c.) On 10/06/23 at 6:30 AM, Surveyor #2 observed a staff member standing in front of a medication cart in the middle hall of the first unit. The staff member was identified as the Registered Nurse Supervisor (RNS) who had been working the 11:00 PM to 7:00 AM shift. The RNS had his computer open and informed Surveyor #2 that he was in the middle of preparing and pouring a pain medication for a resident. Surveyor #2 asked if he would be administering any other residents any medication and the RNS stated he would be administering a Tylenol (a pain and fever reducing medication) to a different resident. On 10/06/23 at 6:33 AM, the RNS exited the first resident room and documented in the computer. The RNS next walked into another resident's room. Surveyor #2 stood by the medication cart and could hear the RNS talking to the resident. On 10/06/23 at 6:37 AM, the RNS exited the second resident room. Surveyor #2 was still standing at the medication cart. Surveyor #2 asked about observing the administration of the Tylenol. The RNS stated he had already administered the medication. When inquired how that was done since he had not returned to the medication cart to obtain the medication, the RNS stated he had it ready and with him. Surveyor #2 asked for clarification. The RNS stated, it was pre-poured. At that time, the RNS stated that it was not the facility procedure to pre-pour medications and carry them around because the medications could easily get mixed up. On 10/06/23 at 9:42 AM, the DON was made aware and stated that the nurses know better and should never pre-pour medication. The DON stated that by pre-pouring medication, the medications could become mixed up and possibly be given to the wrong resident. On 10/10/23 at 11:13 AM, the DON stated that the pharmacy consultants would assess the nurses yearly with medication administration competencies. The DON stated that she was unable to find a previous competency for the RNS, but that the consultant pharmacy conducted an observation with him on 10/06/23. A review of the facility provided, Administering Medications policy edited 5/21/19, included but was not limited to; 10. Check the label three times to verify the right resident, right medication, right dosage, right time, and right method before giving the medication. 12. The expiration/beyond use date is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 19. The medication cart is kept closed and locked when out of sight. No medications are kept on top of the cart. NJAC 8:39-11.2(b), 29.4 (a)(b) Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to: a.) the administration of medications and b.) adhering to facility policy for Medication Administration. The deficient practice was identified on 2 of 2 Units observed for medication pass administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a . On 10/07/23 at 7:18 AM, during an observation of the medication administration cart on the [NAME] Unit with the Licensed Practical Nurse (LPN) who worked the 11:00 PM -7:00 AM shift and the Registered Nurse (RN ) assigned to the 7:00 AM-3:00 PM shift, revealed an orange pill was stored in a medication cup inside the top drawer. Both nurses were at the medication cart ready to start the narcotic count. The Licensed Practical Nurse (LPN) who worked the night shift stated that the medication could have been Benadryl, but the RN then identified the medication as Protonix (acid suppressing medication). The RN pulled a box from the middle drawer and opened one of the pills and verified that the pill as Protonix. Both nurses declined that they placed the open medication inside the medication cart. b. On 10/06/23 at 7:45 AM, the surveyor informed the Registered Nurse (RN) 07:00-3:00 PM shift she would be followed for medication pass administration. The Registered Nurse ( RN ) poured 1 tablet of Metoprolol (medication used to control hypertension) for Resident #60. Resident #60 was in the hallway. The nurse escorted the resident to the room and left the medication on top of the medication. cart. The surveyor observed one resident in the hallway and one ancillary staff. The surveyor remained next to the medication cart and informed the Unit Manager who just exited from another room in the hallway. The Unit Manager verified that one pill was in the medication cup and the nurse was not around. The Unit Manager removed the cup from the medication cart and went to the room to get the nurse. The nurse indicated that she forgot. On 10/07/23 at 9:15 AM during an interview with the Unit Manager, she stated that was not the facility protocol. She went on to state that medications should not be left unattended on top of the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This deficient practice was identified for 1 of 1 resident (Resident # 47) reviewed for ROM and was evidenced by the following: On 10/04/23 at 09:30 AM, during the initial tour, the surveyor observed Resident (R #47) in bed watching television and the resident expressed some concerns with receiving restorative care to maintain physical function. During the lunch meal R #47 was observed in bed with his/her meal tray and was observed eating independently. On 10/05/23 at 9:15 AM, observation revealed some possible limited range of motion to bilateral lower extremities and increase in tremors observed during resident interview. Resident #47 stated that he/she would like to get out of the bed and attend physical therapy, and get out of the room. Resident #47 indicated that he/she informed the Unit Manager that he/she would like to get out of the bed two weeks ago and nothing was done. The surveyor reviewed Resident# 47's electronic medical record (EMR). Resident (R #47) was admitted to the facility with diagnoses which included but were not limited to: Morbid obesity, muscle weakness, type 2 diabetes mellitus with unspecified complications, difficulty in walking, Addisonian crisis (an emergent adrenal crisis) and tremors. A review of the Quarterly Minimum Data Set with assessment reference date (ARD) of 09/18/23, found R #47 was coded with functional limitation in range of motion to the lower extremity (impairment on both side). In Section O. Special Treatment and Program, the coding for Restorative Nursing Program found R #47 was coded 0 (zero) for the number of days each of the following restorative programs were performed for at least 15 minutes a day in the last 7 (seven) calendar day, passive range of motion, active range of motion, and splint application. A review of the Restorative Nursing Communication Form dated 07/21/23 had the following recommendations: Active/ Active Assistive Range of Motion to bilateral lower extremities. Ankle pumps, hip flexion, hip abduction and short arc Quads. The goal was to maintain and prevent decline in the resident's range of motion to enable good hygiene and prevent skin breakdown. On 10/10/23 at 10:12 PM, following the conversation with Resident #47 regarding their concerns, the surveyor interviewed the CNA who cared for Resident #47. The surveyor asked when was Resident #47 was last transferred out of bed to the recliner chair. The CNA stated, It had not been done since I have been here. The CNA added, usually he/she would get out of the bed with physical therapy. Upon further inquiry, the CNA added that restorative care had not been completed due to not having enough staff since the CNA assigned to complete restorative care had to take on a resident assignment and could not perform restorative care duties. On 10/10/23 at 10:15 AM, the surveyor interviewed the Unit Manager regarding restorative care and out of the bed and Range of Motion (ROM). The UM revealed that the facility had a restorative program that could not be fulfilled due to staffing issues. The UM stated that following admission, Resident #47 refused to get out of the bed with a mechanical lift due to an incident that occurred that day. However, the UM confirmed that Resident #47 requested to get out of the bed 2 weeks ago but there was no chair to accommodate the request. The UM further stated that Resident #47 needed a special chair to get out of the bed. Regarding Passive Range of Motion exercise, The UM stated that the Certified Nurse Aides (CNAs) were responsible for performing range of motion and would document Restorative Care in the computer software. On 10/10/23 at 10:15 AM, the UM provided a copy of the restorative care and it had not been completed for Resident #47. According to the order, Resident #47 was transitioned to restorative care on 07/21/23. On 10/10/23 at 11:07 AM, the surveyor interviewed the Physical Therapy (PT) Director and inquired regarding the restorative process. The PT Director confirmed that Resident #47 was transitioned from Occupational therapy to restorative process on 07/21/23. Prior to discharge, the restorative CNA would be trained and the contract will be presented to the UM who will sign also the contract. The PT Director stated that he was not made aware of a request for a special chair and would assist if he was made aware. The PT Director informed the surveyor that he would address the concern today referring to 10/10/23. On 10/10/23 at 11:30 AM, with the assistance of the CNA, the [NAME] (CNA software where care was documented) was reviewed. CNA reported entries were made when restorative care was completed. The surveyor reviewed the documentation and could not find any entries for restorative care. The surveyor then inquired if the software included refusal. The CNA demonstrated that they could document refusal. The surveyor then inquired if Restorative was documented for the month of September, the CNA confirmed that there was no documentation for restorative care. On 10/10/23 at 11:45 AM, the surveyor requested the restorative documentation book for review, there was no documentation regarding Resident #47 receiving restorative care as ordered. The UM confirmed there was no documentation. She elaborated that restorative nursing could not be assigned due to staffing shortages. The UM stated, if they do not have enough CNAs on the floor, the restorative CNA had to provide resident care. According to the document provided, Resident #47 received one session of restorative care on 10/03/23. On 10/11/23 at 10:38 AM, the surveyor observed Resident #47 in bed. Resident #47 stated that he/she was very happy. Resident #47 informed the surveyor that he/she was out of the bed for 2 hours yesterday. The surveyor observed there was now a special chair in the room. The resident stated, it feels very good to get out of the bed. The CNA and the PT director facilitated the transfer out of the bed. I have been waiting for 3 months for that. On 10/12/23 at 2:20 PM, the facility was made aware of the concerns with restorative care. On 10/13/23 at 9:54 AM, during an exit interview with the DON and Licensed Nursing Home Administrator (LNHA). They confirmed they were unaware that restorative care was not being completed. The LNHA stated every CNA was responsible for completing restorative care. NJAc 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility provided documentation, it was determined that the facility failed to provide treatment and services to limit the potential of infection for 2 of 2 residents (Resident #69 and #61) reviewed for the use of indwelling urinary catheter [a tube used to drain urine from the kidneys]. The deficient practice was evidenced by the following: A.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. Surveyor #1 observed a urinary catheter tube draining into a urinary catheter bag with a privacy bag over it on the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the therapy gym. The surveyor observed the urinary catheter with the catheter bag on the side of the resident's wheelchair. A review of the electronic medical record (EMR) revealed that Resident #69 had been admitted and readmitted to the facility. Resident #69 had diagnoses which included but were not limited to; chronic kidney disease, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of the Order Listing Report, active orders as of 10/05/23, included an order dated 09/13/23 to monitor urinary catheter output every shift. There were no other orders regarding the indwelling urinary catheter. A review of the Treatment Administration Record (TAR) for September 2023, revealed the staff were monitoring the catheter output every shift. The TAR and Medication Administration Record (MAR) did not document any other care or information regarding the urinary catheter. A review of the TAR and MAR for October until discharge revealed the staff were monitoring the catheter output every shift, but no other documented care or information regarding the urinary catheter. A review of the patient centered on-going Care Plan included but was not limited to; a focus are of Activities of Daily Living (ADL) care deficit related to weakness with interventions including assist of 1 to 2 persons with ADLs. The care plan failed to include any other information regarding the risks, care, or interventions of the indwelling urinary catheter. On 10/06/23 on 9:09 AM, the Registered Nurse Infection Preventionist (RN IP) stated that any resident with an indwelling urinary catheter should have orders which document the catheter size, to change the collection bag when soiled changed frequently because they get dirty, and to flush the tubing as needed. On 10/10/23 at 8:22 AM, the Licensed Practical Nurse (LPN) caring for Resident #69 stated the indwelling urinary catheter had been removed on 10/6/23. She reviewed the orders on the TAR and stated there were no orders to flush or do care, just to empty the catheter. On 10/10/23 at 8:27 AM, the RN unit manager (RN UM) stated the resident had the indwelling urinary catheter upon readmission to the facility. She stated the procedure would be for an order for daily catheter care, to monitor output, be sure the collection bag was not touching the floor, and for perineal care. The RN UM accessed the current MAR and TAR and acknowledged there were only orders to monitor the output every shift. She further stated, I guess we don't know if it's [indwelling urinary catheter care] done it's not on there [documented on the MAR or TAR]. On 10/10/23 at 9:14 AM, the Director of Nursing (DON) stated the procedure for indwelling urinary catheter care would be documentation of the balloon number [the inflated device to hold the catheter in the bladder] and the diagnoses. She stated the care would consist of checking the output, securing the tubing, observing the urinary drainage, providing flushes as needed, and perineal care. Surveyor #1 made the DON aware of the lack of orders besides monitoring the output. The DON stated, the care is part of the routine, the nurses should just know to do it. The DON further stated that the care plan would also inform the staff of how to care for the resident with an indwelling urinary catheter and the indication of use. The DON stated the order for indwelling urinary catheter care would be in the TAR and that's where it would be documented. B.) During the initial tour of the facility on 10/04/23 at 10:29 AM, the surveyor observed Resident #61 awake and lying supine in bed. The surveyor observed the catheter drainage bag along with the dignity bag (used to keep an indwelling urinary catheter's drainage bag concealed for resident privacy). The surveyor observed both the urinary drainage bag and attached tubing lying directly on the floor next to the resident's bed. On 10/05/23 at 10:40 AM, the surveyor reviewed the medical record of Resident #61 which revealed that the resident had an indwelling urinary catheter, the rationale or the diagnosis for the indwelling urinary catheter was not provided. The admission evaluation dated 07/03/23, reflected that the resident had an indwelling catheter in place. The physician order sheet dated 07/04/23, reflected a telephone order dated 07/04/03, for catheter care and catheter output every shift. An entry dated 09/20/23, revealed a physician order for the resident to receive an oral antibiotic (Bactrim DS 800-160 milligrams ) twice daily for five days to treat a Urinary Tract Infection (UTI). The surveyor also observed that the resident had a history of a UTIs having been diagnosed with a UTI on 09/04/23. On 10/05/23 at 9:06 AM, the surveyor observed Resident #61 lying in bed. The urinary drainage bag was in the privacy bag which was secured to the frame of the bed. The privacy bag was resting directly on the floor. The surveyor reviewed the resident EMR. The admission Face Sheet (an admission summary), reflected that Resident #61 had diagnoses which included but were not limited to: pressure Ulcer of sacral region, unstageable, sepsis, difficulty in walking and muscle weakness. Resident #61's admission face sheet did not include urinary retention as a diagnosis. According to the Minimum Data Set (MDS), dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. Normal score 15. The admission and the Quarterly Minimum Data Set assessment dated respectively 05/26/23 and 07/03/23 did not reflect that Resident #61 had an indwelling urinary catheter in place. Review of the Care Plan for Resident #61 initiated on 07/03/23 with no revision date, did not have a Focus for catheter care. The Physician Order Sheet, dated 10/12/23, revealed a telephone order for the indwelling urinary catheter dated 07/04/23. The order did not include the catheter size and when the catheter should be changed. The surveyor reviewed the care plan with the Unit Manager. A focus for indwelling urinary catheter was not addressed into the care plan until 10/06/23. On 10/12/23 at 2:20 PM the above concern was discussed with the Director of Nursing (DON). The DON provided the surveyor with a copy of the facility's policy entitled, Catheter Care: Indwelling Catheter which revealed the following: Perineal Care edited 4/25/22, included but was not limited to; Purpose: to provide cleanliness and comfort to prevent infections and skin irritation. Documentation: 1. Date and time care was given. 2. Name and title of individual providing care. 7. Signature and title of person recording the data. Catheter Care, Urinary, revised 08/22, included but was not limited to; Purpose: to prevent urinary catheter-associated complications. Preparation: 1. Review the resident's care plan to assess for special needs. Perineal Care. Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Documentation: 1. Date and time catheter care was given. 2. Name and title of individual giving the care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color, clarity, and any odor. 9. Signature and title of the person recording the data. NJAC 8:39-19.4(a), 27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to ensure opened multi-use medication vials stored inside of the medication cart was labeled and dated with an open and expiration date upon opening. This deficient practice was observed during a medication storage review and was evidenced by the following: On 10/06/23 at 7:20 AM, in the presence of the Registered Nurse and the Licensed Practical Nurse (LPN), the surveyor reviewed the inventory of medications and treatment products in the Medication Administration Cart. Upon review of the medication cart contents the surveyor observed one opened and undated multi-use dose of Insulin Lantus pen for Resident #47. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial and pen-injector 28 days after opening. The surveyor then observed two glucometer strips were opened and not dated on two medications carts. On 10/06/23 at 7:40 AM, the surveyor asked the Registered Nurse the facility's process for dating medications upon opening. The nurse stated that all multi-dose vials were to be dated when they were opened. The RN indicated that she had not checked the date of opening on insulin vials in the medication administration cart at the beginning of her shift. She mentioned that per training and competency, every nurse should put the date of opening on multi-dose medications. When interviewed, at that time, the LPN stated the medication should have been dated when opened. NJAC 8:39-29.4

Based on interview and document review, it was determined that the facility failed to provide education and assess staff competencies for staff who provided care for residents who received dialysis [a type of treatment used to clean the blood when kidneys do not function properly] as identified as a special care need in the Facility Assessment. The deficient practice was evidenced by the following: A review of the closed medical record for Resident #76 revealed that the resident was found with a dislodged hemodialysis [the clinical purification of blood by dialysis, a substitute for the normal function of the kidney] perma-catheter on 09/10/23, and required emergency transport to the hospital. On 10/12/23 at 8:36 AM, the surveyor reviewed the Facility Assessment completed on 03/14/23 as a result of a change in facility administration, and was provided during the entrance held on 10/04/23. The Purpose revealed to determine what resources are necessary to care for residents competently during regular 24/7/365 operations and during emergencies to ensure that each resident maintains or attains their highest practicable physical, mental, and psychosocial well-being; Part 2: Services and care we offer based on our residents' needs revealed Other special care needs . Dialysis; Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, 3.4 Staff training/ education and competencies: An annual education plan is developed for all staff based on job title. (See attachment 2- Education Plan). On 10/12/23 at 8:38 AM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a copy of the referenced 19 page 2023 Annual Education Plan which revealed: The education plan is a tool to aid in the delivery of required training topics and competency assessments. The document did not reveal any training or competencies related to Dialysis. On 10/12/23 at 9:33 AM, the surveyor interviewed the LNHA regarding the purpose of the Facility Assessment (FA). The LNHA stated the FA was to determine the type of beds the facility needed and for emergency preparedness. The LNHA stated the education topics were generated at the Corporate Office. The surveyor asked if the FA was specific for the population of the facility and the LNHA stated, yes, it was reflective of the population of the facility. The surveyor asked about dialysis being listed as a population of residents and should there be education/competencies that reflected that? The LNHA stated that the facility takes dialysis patients and the nursing competencies should include dialysis. The LNHA stated that there was currently no staff educator at the facility and the Director of Nursing was filling the role. On 10/12/23 at 9:43 AM, the surveyor interviewed the DON regarding staff education. The DON stated she was responsible for staff education since she started in February 2023, and would also look for any competencies completed by the former staff educator. The DON stated the former staff educator did not have signed competencies. When asked if it would be important to have competencies for specific residents, the DON stated 100% agree that it would be important to complete competencies on nursing for dialysis residents and also for residents with catheters. On 10/12/23 at 11:47 AM, the DON provided nursing competency binder for nurses for respiratory therapy and was unable to locate any other competencies for dialysis. NJAC 8:39-33.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #162687 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to: a) provide appropriate incontinence care, and personal hygiene care for 2 of 20 residents (Resident #55 and #63) on 1 of 2 resident units, and b) failed to offer nail care to a resident who was dependent assistance from staff for care (Resident #61). The deficient practice was evidenced by the following: 1. On 10/04/23 at 10:05 AM, the surveyor observed Resident #55 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry the resident stated he/she had not been provided with incontinence care since last night. At 10:20 AM, while conversing with the resident, a Certified Nursing Assistant (CNA) entered the room, informed the surveyor that she was from Hospice and would provide care to the resident. The surveyor informed both the resident and the CNA the purpose of the visit. The Resident agreed to be checked for incontinence care. The CNA positioned the resident to the left side and removed the sheet to expose the resident's incontinence brief. The incontinence brief was soaked with urine. The resident had a green T-shirt on which was also soaked with urine. The bedding including the blue pad to protect the bed was also soaked with urine. That same day, at 10:45 AM, the surveyor entered Resident #63's room. The surveyor observed the resident in bed. Resident #63 was nonverbal and the head of bed was elevated. The room was untidy. The surveyor left the room and informed the Registered Nurse (RN) that she would like to check Resident #63 for incontinence care. The CNA reported to the room and informed the surveyor that Resident #63 was a heavy wetter. The CNA positioned the resident to the left side and the surveyor observed that Resident #63 was saturated with urine. The blue pads including the bedding were saturated with urine. The surveyor also observed that the resident had some redness on the back and buttocks. The resident had two wounds, one on the sacrum and the ischium area (part of the hip bone) and the dressings were saturated with urine. On 10/04/23 at 12:30 PM, the surveyor returned to the room and observed the resident was in the same position. The surveyor observed the resident had not been provided with mouth care yet. At 11: 45 AM, the surveyor continued the unit tour. The surveyor observed Resident #61 in bed, the resident was alert and able to maintain a conversation. The surveyor observed that Resident #63's nails were long with a brown coated substance underneath the fingernails. On 10/05/23 at 10:42 AM, the surveyor performed an incontinence round with the CNA and noted that Resident #63 was soiled with dry feces on the perineal area. The resident indicated that he/she had not received care yet. On 10/04/23 at 9:13 AM, the surveyor observed Resident #61 in bed, the nails were long an jagged with a brown coated substance underneath the finger nails. On 10/05/23 at 10:42 AM, the surveyor observed Resident #61 in bed, the CNA was at the bedside providing care and observed the resident's nails were not trimmed or cleaned. On 10/06/23 at 8:45 AM, the surveyor observed Resident #61, after morning care had been provided, with nails long and jagged, and a brown substance was under [NAME] the finger nails. On 10/06/23 at 9:09 AM the surveyor interviewed a random CNA who stated, for dependent residents, she provided care from head to toe. It is important for the residents to get care to prevent decline and help with the quality of life. ADLs (Activities of Daily Living) covered hygiene, dressing, and nail care as needed. Nail care entailed filing and cleaning underneath the nails. Nail care was explained during orientation. Nail care was not included in the documentation in the electronic medical record. Nail care was not also covered under ADLs. On 10/06/23 at 9:23 AM, the surveyor interviewed the Unit Manager (UM) who stated that she was not aware of a policy for nails care and where it would be documented. She stated that is basic care. The surveyor escorted the UM to the room where we both observed that Resident #61's nails were long and a brown substance noted underneath the finger nails. The UM stated, to the resident your nails needed to be trimmed and the resident responded, yes. On 10/11/23 at 10:15 AM, during a second interview with the UM she confirmed the CNAs were to provide nails care during morning care. An interview with the CNA who cared for Resident #61 revealed that nail care was not included in the [NAME] [resident care guide] but nails should be checked and cleaned as part of the morning care. On 10/11/23 the surveyor visited Resident #61 and observed that the nails were trimmed and cleaned. The resident stated, it feels good and showed their hands to the surveyor. On 10/12/23 at 10:10 AM the surveyor returned to the [NAME] Unit. A strong urine odor was permeated from the hallway while approaching Resident #55's room. The surveyor entered the room and observed a CNA at the bedside. The CNA informed the surveyor that he just reported to the room to care for Resident #55 and observed that the bedding including the mattress was saturated with urine. The surveyor left the room and asked the Licensed Practical Nurse (LPN) to verify the condition of the room. The LPN stated, it smelled like urine to me. The CNA had the resident positioned to the left side. The resident's brief was saturated with urine and covered with feces. The mattress was wet with urine. The CNA informed the surveyor that the Hospice aide had not reported to work this morning and he would care for Resident #55. On 10/12/23 at 11:30 AM, an interview with the UM revealed that the Hospice Aide reported to work at 12:00 PM on 10/11/23 and today did not report to work yet. She could not comment on whether or not the facility's staff had provided care to the resident this morning. On 10/12/23 at 10:19 AM, the surveyor entered Resident #61's room. The surveyor performed an incontinence care with the CNA. The surveyor observed that Resident #61 incontinent brief was saturated with urine although Resident #61 had an indwelling urinary catheter in place. Also noted dry feces in the perineal area. On 10/12/23 at 10:25 AM, during an interview with the CNA, the CNA revealed that she provided care to Resident #61 this morning and the brief was saturated with urine. Upon inquiry, the CNA stated that she forgot to report to the nurse that the catheter was leaking. Resident #61 had an unstageable sacral wound and the dressing was observed saturate with urine. The surveyor left the room and informed the Unit Manager that the indwelling urinary catheter was leaking. On 10/12/23 the surveyor reviewed the resident's electronic medical record (EMR) for Resident #55. Resident #55's admission Record (AR) revealed, Resident #55 was admitted to the facility with diagnoses which included but were not limited to: Difficulty in walking, generalized muscle weakness, Parkinson's Disease and Bipolar Disorder and irritable bowel syndrome. The Quarterly Minimum Data Set (MDS) assessment tool dated 08/14/23, revealed that Resident #55 was severely cognitively impaired. Resident #55 received a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #55 was totally dependent on staff for care. Review of the Care Plan for Resident #55 initiated on 08/01/22, included a Focus for ADL Self Care Deficit related to: physical limitations and weakness post hospitalization. The goal was for Resident #55 to be clean, dressed and well-roomed daily to promote dignity and psychosocial well-being. The interventions were to assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan did not indicate when staff were to provide care to the resident, or the frequency for staff to turn and reposition the resident. On 10/12/23 the surveyor reviewed Resident #61's EMR which revealed the following: Resident #61 was admitted to the facility with diagnoses which included but were to limited to: Pressure Ulcer of sacral region, unstageable, sepsis, difficulty in walking and muscle weakness. According to the (MDS) Minimum Data Set, dated [DATE], Resident #61 had a BIMS score of 10 out of 15 indicative of moderate cognitive impairment. The MDS also indicated that Resident #61 required extensive assistance for Activities of Daily Living (ADL) and was always incontinent of stool. However, a conversation with Resident #61 revealed that he/she was awake and alert and able to make his/her needs known. The CNA confirmed that Resident #61 was very alert and able to participate with care. Review of the Care Plan for Resident #61 initiated on 07/03/23 with no revision date, revealed a focus for ADL self-care deficit related to physical limitation and neurological deficiencies related to Parkinson's disease. The goal was for Resident #61 to be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. To have ADL (Activity of Daily Living) met with staff assistance. The interventions included: Assist to bathe and shower as needed. Assist with daily hygiene, grooming, dressing, oral care and eating as needed. On 10/12/23 at 10:30 AM, the surveyor interviewed the CNA who cared mostly for the resident on 10/04/23, 10/05/23, 10/06/23, 10/11/23 regarding Resident #61's care. The CNA revealed that Resident #61 was able to feed her/his self after set-up, able to assist with turning and able to make his/her needs known. When asked regarding the resident nail care, the CNA did not have any comments. On 10/12/23 the surveyor reviewed Resident #63's EMR which revealed the following: Resident #63 was admitted to the facility with diagnoses which included but were not limited to: Difficulty walking, muscle weakness, anoxic brain damage and dysphagia. The admission Minimum Data Set (MDS)dated 05/24/23, revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 00 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Resident #63 had a care plan initiated on 05/18/23 and revised 05/26/23 for urinary incontinence. The goal was for resident #63 will have no complications due to incontinence. Resident #63 also had a care plan for ADL self-care deficit related to recent hospitalization post cardiac arrest with anoxic brain with the following goal: Resident #63 will be maximum assist with bed mobility upon discharge. Resident #63 will be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. The interventions included bilateral upper 1/4 rails, occupational and physical therapy evaluation and treatment per physician's orders. Resident #63 had a care plan for palliative care initiated 06/09/23 with the following goals: Will be comfortable, will have advance directives honored by staff. One of the interventions included to encourage and assist to reposition as needed for comfort. Staff confirmed that Resident #63 was totally dependent on staff for care, was nonverbal and all needs must be anticipated. (The care plan did not include any directive to direct care staff regarding Resident #63's specific person-centered care requirements for ADL care). On 10/06/23 at 3:47 PM the surveyor conducted a telephone interview with Resident #63's Representative (RR). The RR stated she had concerns with the care and discussed the concerns with the Registered Nurse (RN) on the first floor. The RR stated that he/she had noticed a decline in the care and that Resident #63 would be soiled and observed large amount of secretions on the clothing when he/she had visited in the evening. The RR further stated that Resident #63 did not have any wounds upon admission and was informed that the resident had the first wound after Resident #63 was left in the chair for extended periods of time. The second wound was also developed at the facility per the RR. The RR stated during visits in the evening, the resident would be soiled and needed to be changed. When the RR informed the staff, the staff would state that this is not their time yet and Resident #63 would have to wait. When inquired if the issue was reported to the nurse, the RR stated when the resident was on the first floor, that he/she had reported the incident to the nurse. On 10/10/23 at 09:38 AM, the surveyor interviewed the RN that the RR reported the concerns regarding the care. The RN indicated that she could not recall the incident and did not inform the Director of Nursing of the RR concerns with the care. The above concerns with incontinence and nails care were discussed with the DON and the Licensed Nursing Home Administrator during the survey, and again on 10/12/23 at 2:20 PM. The surveyor then asked the DON who was responsible to coordinate the hospice care with the facility as Resident #55 was observed soiled for 2 days, and staff indicated that the hospice aid did not report to the facility on time for 2 days. The DON stated that the UM was responsible to monitor and ensure that residents were provided with incontinence care. NJAC 8:39- 27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that preventive measures to prevent and promote healing of pressure ulcers were in place and consistently followed. This deficient practice was identified for (Resident #63), 1 of 4 residents reviewed for pressure ulcers and was evidenced by the following: During the initial tour on 10/04/23 at 10:45 AM, the surveyor observed Resident #63 lying in bed. Resident #63 was nonverbal, the head of the bed was elevated with the side rails in the upper position. The surveyor performed an incontinence tour with the Certified Nursing Assistant (CNA) and observed that Resident #63 was saturated with a yellow color substance. The incontinent brief was saturated, the blue pads to protect the bed along with the pull sheet was saturated. Resident #63 had two dressings, the sacral dressing and the dressing on the ischium which were both saturated with a yellow color substance. The CNA informed the surveyor that Resident #63 was a heavy wetter when inquired regarding the last time Resident #63 was changed, the CNA stated that she changed the resident at 8:00 AM. The surveyor reviewed Resident #63's electronic medical record (EMR) on 10/06/23 at 12:55 PM. The admission Face Sheet reflected that Resident #63 was admitted to the facility with diagnoses which included but were not limited to: Difficulty walking, muscle weakness, anoxic brain damage and dysphagia. The admission Minimum Data Set (MDS) an assessment summary dated 05/24/23, revealed that Resident #63 was severely cognitively impaired. Resident #63 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which addressed ADLs revealed that Resident #63 required extensive assistance of two persons physical assist for bed mobility and transfer and one person physical assist for personal hygiene. Section M of the MDS which addressed skin condition, revealed that Resident #63 was assessed as being at high risk for pressure sores. Resident #63 scored 12 on the Braden Scale indicative of being at high risk. According to the skin assessment performed on admission ( 05/18/23), Resident #63 was admitted with redness to the sacrum. There was no open area. The surveyor reviewed Resident #63's Care Plan (CP). The CP formulated on 05/18/23 had a Focus for: At risk for alteration in skin integrity related to immobility. The Goal was for Resident #63 to remain free of breakdown within limits of disease process. Interventions included: Barrier cream to perineal/buttocks as needed. Initiated 05/18/23. Encourage and assist to reposition; use assistive devices as needed. Initiated 05/18/23. Therapy evaluation and treatment per physician orders. Initiated 05/19/23. Laboratory values dated 05/19/23 revealed Albumin 3.5 normal 3.5-5.2 Protein Total 6.1. normal 6.4-8.3. Prealbumin dated 05/25/23 was 24 normal value 20-40 mg/dl. Further review of the Progress Notes revealed the following entries in the EMR: -05/24/23 timed 15:34 Resident is dependent with all care. Hoyer lift for transfers from bed to [recliner chair]. 17:26, Sacral DTI (deep tissue injury), no open wound, fungal rash. fungal rash - sacrum. -05/26/23 timed 15:36 PM, Resident #63 was seen on wound rounds on 05/25/23 noted with DTI to sacrum with dark discoloration. Measures 3 centimeters (cm) x 3 cm. Recommendations: Low Air Loss mattress., Roho cushion to wheelchair and repositioning. -06/01/23 skin Note: Resident was seen on skin round for evaluation and treatment of wounds. measures 3 cm x 3 cm. Noted with discoloration. Discussed with staff to continue to offload. Recommendations: Low Air Loss mattress, Roho cushion and repositioned. -Skin Note dated 05/05/23 Right hip small blood blister 0.5 cm x 0.4. Area dark red purple in color. -Skin Note of 06/08/23: Visited by wound care Unstageable pressure injury measures: 2.5 cm x 3 cm x 0.2 cm. debridement performed (removal of dead tissue). On 05/26/23 the wound care recommendations were to have a Low Air Loss Mattress and offloading. The facility provided the Low Air Loss Mattress on 06/09/23 after the resident developed an unstageable pressure ulcer to the sacrum. A wound care order was to change the dressing daily and when soiled. Review of the nurses' notes from 06/25/23 to 10/12/23 did not reflect when wound care was provided and the wound condition except when the Wound Care Team visited. On 07/27/23 Resident #63 developed another wound on the left ischium area with the following measures: 3 cm x 3 cm x .1 cm. The wound was classified as an irritant contact dermatitis, with macerated periwound. Recommendations: Increase dietary protein, and dietary supplement. Offloading: Recommend turning and positioning as per standard of care. Avoid positioning which places direct pressure to the wound site. Low Air Loss Mattress with turning and positioning measures in place. Recommend limiting continuous time spent sitting to less than 2 hours per session on an appropriate pressure reducing surface. The recommendations were not added to the care plan. On 06/04/23 the surveyor observed Resident #63 in bed positioned in supine position from 10:49 AM to 12:30 PM. The facility did not have a system in place to evaluate when the resident was last turned or cared for per the recommendations. On 10/11/23 10:52 AM, the surveyor observed wound care with the Licensed Practical Nurse. The sacral wound had the following measures: 2.5 cm x 2.5 cm x 0.2 cm. The wound on the left ischium measures: 5.5 cm x 4.75 cm x 3 cm. Both wounds were noted with necrotic and slough tissue. The sacrum had a foul odor when the dressing was removed. None of the observed wound conditions were documented after the observed wound care. The nurses only initialed that wound care was completed. Following the wound care, the surveyor interviewed the UM regarding the wound. Upon inquiry she stated she had not observed the wound for 2 weeks. An interview with the Infection Preventionist on 10/11/23 at 12:15 PM, she stated that she constantly reminded staff the importance of following the recommendations from wound care. She could not comment on the rationale for not having measures in place to prevent the wound from worsening. On 10/10/23 at 10:44 AM, the surveyor interviewed the Registered Nurse IP regarding how Resident #63's Plan of Care was communicated to the CNA. The IP stated that that in the morning the Unit Manager gave reports to the nurses and the CNAs. She further added that all information regarding a resident care was entered and accessible to staff under Task on the Electronic Plan of Care (E-POC). On 10/12/23 at 11:28 AM, the surveyor again interviewed the Unit Manager regarding the order on the wound care recommendations to off-load and reposition Resident #63. The Unit Manger stated that staff should check and reposition the resident every 2 hours and as needed. The surveyor asked the Unit Manager how she would know if the resident was checked and repositioned every 2 hours, she did not have any comment. On 10/12/23 at 12:30 PM the Unit Manager provided a log where the CNAs documented that Resident #63 was turned and repositioned x 1 every shift. There was no documentation in the clinical record regarding Resident #63's being checked and repositioned every 2 hours. The facility was informed of the above concerns for Resident #63 on 10/12/23 at 2:20 PM. A review of the facility's policy for Pressure Ulcers/ Skin Breakdown- Clinical Protocol revised April 2018, indicated the following: Assessment and Recognition The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss and a history of pressure ulcer (s). In addition, the nurse shall describe and document/ report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses. Monitoring During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. (The policy was not being followed. Staff failed to review the care plan and implement interventions identified to reduce/prevent pressure ulcer. Resident #63 sacral wound had not improved. Resident #63 developed another wound on 07/2723. There was no revision made to the care plan.) NJAC 8:39-27.1 (e)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents highest practical wellbeing by failing to a) provide necessary services to maintain activity of daily living (ADLs) and b) failing to provide restorative nursing services to residents. This deficient practice was identified for 3 of 5 (Residents #55, #63 and #47) and expressed by 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced as follows: Refer to F677 & F688 a) On 10/04/23 at 9:35 AM, the surveyor interviewed an unsampled resident saying there is never enough staff. The unsampled resident stated all the shifts are short staffed and especially on night shift. The unsampled resident stated aides say I don't have time to do that. I got too many people. On 10/04/23 at 9:54 AM, the surveyor interviewed the CNA stated she has 10 residents to care for today and that 10 residents are the max over 10 is too much. The CNA stated she goes without a break or lunch because she cannot take short cuts during care for the residents. The CNA stated 7 out of 10 residents needed total assistance. The CNA also stated she cannot get all her work completed with 10 residents. On 10/04/23 at 10:05 AM, the surveyor observed Resident #55 in bed. Upon inquiry the resident stated he had not been changed since last night. At 10:20 AM, while communicating with the resident the CNA entered the room. The CNA informed the surveyor that he/she is from hospice and provides care for the resident. The Resident agreed to be checked for incontinence and the brief, resident's T-shirt, and blue pad protecting the bed were all saturated in urine. On 10/04/23 at 10:45 AM, the surveyor observed Resident #63 in bed and noted the resident was nonverbal. The surveyor left the room and informed the (RN) Registered Nurse that she would like to check Resident #63 for incontinence care. The CNA positioned the resident to her left side and noted the resident was saturated with urine, including the blue pad protecting he bed. On 10/04/23 at 12:30 PM, the surveyor returned to Resident #63's room and observed the resident in the same position. The surveyor observed the resident had not been provided mouth care yet. It was also observed that the resident's nails were long with a brown coasted substance underneath the fingernails. On 10/06/23 from 10:50 AM to 11:18 AM, a surveyor conducted a resident counsel meeting with five unsampled residents. When asked about staffing, five of five residents stated the attention in care has gotten worse and things used to be more detailed. The residents stated they felt like the care was being rushed, staff was always in a hurry and interactions with residents were less. Five of five resident agreed that the quality of care wasn't good. One resident stated staff seemed like they just didn't want to be there and could care less. Another resident stated that he/she was under the impression that the night shift was hiding from the residents. b) On 10/05/23 at 9:15 AM, the surveyor observed Resident #47 which revealed some possible limited range of motion to bilateral lower extremities and increase in tremors observed during resident interview. Resident #47 stated that he/she would like to get out of the bed and attend physical therapy, and get out of the room. Resident #47 indicated that he/she informed the Unit Manager that he/she would like to get out of the bed two weeks ago and nothing was done. The surveyor reviewed Resident# 47's electronic medical record (EMR). Resident (R #47) was admitted to the facility with diagnoses which included but were not limited to: Morbid obesity, muscle weakness, type 2 diabetes mellitus with unspecified complications, difficulty in walking, Addisonian crisis (an emergent adrenal crisis) and tremors. A review of the Quarterly Minimum Data Set with assessment reference date (ARD) of 09/18/23, found R #47 was coded with functional limitation in range of motion to the lower extremity (impairment on both side). In Section O. Special Treatment and Program, the coding for Restorative Nursing Program found R #47 was coded 0 (zero) for the number of days each of the following restorative programs were performed for at least 15 minutes a day in the last 7 (seven) calendar day, passive range of motion, active range of motion, and splint application. A review of the Restorative Nursing Communication Form dated 07/21/23 had the following recommendations: Active/ Active Assistive Range of Motion to bilateral lower extremities. Ankle pumps, hip flexion, hip abduction and short arc Quads. The goal was to maintain and prevent decline in the resident's range of motion to enable good hygiene and prevent skin breakdown. On 10/10/23 at 10:12 PM, following the conversation with Resident #47 regarding their concerns, the surveyor interviewed the CNA who cared for Resident #47. The surveyor asked when was Resident #47 was last transferred out of bed to the recliner chair. The CNA stated, It had not been done since I have been here. The CNA added, usually he/she would get out of the bed with physical therapy. Upon further inquiry, the CNA added that restorative care had not been completed due to not having enough staff since the CNA assigned to complete restorative care had to take on a resident assignment and could not perform restorative care duties. On 10/12/23 at 1:09 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding staffing. The LNHA stated that the DON and Staffing coordinator usually was responsible for the staffing. The LNHA stated that she was aware of the state regulations for staffing requirements. The DON and Staffing Coordinator reviewed the staffing and based on the census and acuity changes would be made. The LNHA said, I believe they are meeting the minimum staffing requirement. NJAC 8:39 - 5.1 (a); 27.1 (a)

Based on interview and document review, it was determine that the facility failed to ensure that sufficent staffing was identified by the Quality Assurance and Performance Improvement (QAPI) program, and the QAPI policy was followed to identify adequate staffing as a concern that was expressed by 5 of 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 10/06/23 at 10:50 AM, two surveyors conducted a resident council meeting with five unsampled residents. Five of five residents stated that call bell response was excessive and up to 1-2 hours at times, and one unsampled resident stated that he/she would take him/herself to the bathroom because staff was just not around. The residents (5/5) stated that the quality of care provided from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM was not good and that staff seemed like they did not want to be there and could care less. 10/12/23 at 1:12 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI process. The LNHA stated QAPI was for self-identifying concerns in the building, and asked if staffing was identified as an area for monitoring. The LNHA stated that the staffing coordinator provided a daily staffing report and staffing sheets. The LNHA confirmed, and stated no there was no QAPI specific to staffing and the LNHA stated she would provide the surveyor with a list of the current QAPIs. On 10/12/23 at 1:43 PM, the LNHA provided a list of eighteen current QAPIs and staffing was not listed as a current QAPI. On 10/13/23 at 9:15 AM, the surveyor again asked the LNHA if there were any current QAPIs related to staffing. The LNHA stated the staffing coordinator was completing a monthly staffing report related to the current state requirements, but not a QAPI. A review of the facility provided QAPI plan goals revealed II. Scope: . The QAPI plan includes policies and procedures use to: identify and use date [data] to monitor outcomes, establish goals and thresholds as a performance measurement, identify and prioritize opportunities for improvement and systematically analize the root cause of issues and opportunities for improvement . The Quality Assurance and Performance Improvement (QAPI) Program- Covernance and Leadership policy, Revised March 2020 Revealed: 4. The responsibilities of the QAPI Committee are to: a. Collect and anylyze performance indicator data and other information; b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services. NJAC 33.2(c)13; 33.3

Based on observation, interview and document review, it was determined that the facility failed to ensure: a) the dish machine was functioning properly and washing and sanitizing at appropriate temperatures, b) foods were consistently labeled with a use-by date, c) the kitchen walls and environment were maintained in a clean and sanitary manner, and d) hair restraints were appropriately worn to contain exposed facial hair to prevent the spread of potential infection and food borne illness. The deficient practice was evidenced by the following: On 10/04/23 at 8:59 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. The FSD was observed wiping down spice containers and was wearing a beard restraint that did not cover his mustache. The surveyor inquired as to the uncovered facial hair and the FSD stated I think mustaches are allowed. 2. The walk-in refrigeration unit contained: - Vanilla, Strawberry and Chocolate 4-ounce nutritional drinks that were not labeled with a use-by date. The FSD stated they were good for one week and they should be labeled. - An unopened 5-pound package of feta cheese. The FSD could not locate a use-by date and stated he did not know when it expired, and it should be dated. -An opened box of individual cream cheese packages without a use-by date and the FSD was unable to locate a use-by date. - One gallon of chocolate syrup without a use-by date. - One container of blue cheese dressing without a use-by date. - One gallon jar of jalapenos with a received date of 5/5/23 and no use-by date. - A box that contained 3 logs of partially frozen ground beef without a use-by date or date the item was pulled from the freezer. The FSD stated I cannot tell when it was pulled. -A 5-pound box of fresh mushrooms that had a received date of 09/18 and no use-by date. The FSD stated should have had a sticker. 3. The walk-in freezer contained: -One package of pre-molded puree beef, one shrimp and one vegetable that were all undated, and were not labeled with a use-by date. - One package of frozen sliced deli ham that was undated with a use-by date. 4. Four loaves of undated white bread and four packages of dinner rolls were located on a rack. The FSD stated I thought they had a date, and stated we should be putting dates on it. 5. Two of three of the ceiling vents in the cooking/food preparation area had visible dark dust like debris extending outward of the vent area. 6. At 9:42 AM, the dish machine was observed in use and staff was in the process of cleaning multiple acrylic type drink pitchers. The surveyor was informed that the wash temperature should reach 150 degrees Fahrenheit (F) and the rinse temperature should reach 180 F. At that time the rinse gauge for the dish machine was visibly distorted and filled with condensation and was not be moving. Upon surveyor inquiry and with the FSD present, the food service staff (FSS) repeated the wash cycle with the pitchers in the dish machine, and the wash temperature gauge did not rise above 125 F, and the rinse gauge was unable to be read due to condensation. The FSD requested to drain the dish machine and refill to see if that would rectify the problem. The FSS (#1) drained and re-filled the dish machine with water. When asked the FSS when the gauge became filled with condensation, the FSS stated it had been like that for several days. At 9:44 AM, the dish machine was again observed in use and the wash temperature was at 110 F, and not reaching the 150 F as indicated and the rinse gauge was unable to be read. The FSD then stated, we may need paper [referring to shutting down the malfunctioning dish machine] and the FSD stated he would contact the service provider. At that time, the surveyor observed a clip board posted in the kitchen with the dish machine temperatures for 10/04/23 which revealed Breakfast, Wash Standard greater than or equal to 150 F, with Rinse Standard greater than or equal to 180 F, which repeated for Lunch and Dinner. Breakfast was documented with Wash 165 F, and Rinse 180 F with initials next to it, Lunch was documented with Wash 165, Rinse 185 and initialed and Dinner was also documented with the Wash 160 and Rinse 185, and also initialed. On 10/04/23 at 2:10 PM the surveyor conducted a second observations of the dish machine which was in use and two FSS (#1 & #2) were operating the dish machine and confirmed that they were cleaning the lunch dishes. At that time, the surveyor observed that the rinse gauge was now clear and the temperature was reaching above 180 degrees F and there was now steam observed coming from the dish machine. The FSS #1 stated that the wire and the thermostat had been changed. The surveyor, in the presence of the FSD, observed that the Wash temperature was still not meeting 150 F while the dish machine was in use and was at 120 F. FSS #2 was also observed with a beard restraint that did not fully cover his facial hair and was removing clean dishes from the dish machine. When inquired about the Wash temperature, the FSD confirmed that the dish machine was still not meeting the wash temperature and regarding the beard restraint, the FSD stated there was only one size of beard restraint. On 10/5/23 at 11:42 AM, the Liscensed Nursing Home Administrator (LNHA) provided the surveyor with two Extra Service Request documents from the company that services the dish machine. One was dated 10/04/23 and timed at 2:13 PM which revealed. The Rinse temperature gauge was not displaying correctly and Guage corroded and had humidity inside. Replaced and now measuring correctly. A second Ectra Service Request dated 10/05/23 at and timed at 10:11 AM revealed Wash tank temperature not reaching 150 F and High limit switch sensor was not working correctly not letting the heating contactor to engage. The Photos included Thermostat replaced and adjusted. 10/05/23 at 12:32 PM, the surveyor conducted a telephone interview with the dish machine service technician (ST) regarding the dish machine. The ST stated he was contacted on 10/04/23 a second time after he was already at the facility and changed the dish machine gauge because there was corrosion in the rinse gauge and that would be the only way that the facility would know if the temperature was reaching the appropriate level. The ST stated that he did not look at the Wash temperature on the first service call. The ST stated that he needed to adjust the Wash temperature gauge and there was adjustments that needed to be made since the set points needed to be changed. The surveyor asked the ST if the facility should have been using the dish machine when the temperatures were not meeting the requirements. The ST stated that the facility should only be using the dish machine when it meets the proper temperatures and confirmed that he was not contacted regarding any concerns with the dish machine meeting the required temperatures until 10/04/23. On 10/10/23 at 10:28 AM, the surveyor conducted a follow-up kitchen observation during meal preparation, accompanied by the Registered Dieititian (RD) and observed: 1. The walls in the kitchen were visibly soiled with splatter type debris throughout the kitchen and there was debris under the preparation tables and toward the back of the kitchen by the bread rack. The RD confirmed the surveyor's observations and stated that the areas needed to be addressed. 2. A black cart, containing a case of soda that was identified for resident use, was visible soiled. 3. The plastic wrap container on the preparation table was visible soiled with stains. 4. The area by the dish machine area between the cooking battery, adjacent to a steamer, contained a rack that was identified as containing clean pans. The steamer which was indented as needing repair was dripping liquid onto the clean items. 5. The walk in refrigeration unit gasket was lifted. The surveyor reviewed the following policies which revealed: The Food Receiving and Storage Polidy, Revised November 2022, Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). The Preventing Food Borne Illness- Employee Hygiene and Sanitary Practices Policy Revised November 2022, Hair Nets, 15. Hair nets or caps and/ or beard restraints are worn when cooking, preparing or assembling food as to keep hair from contacting exposed food, clean equipment, utensils and linens. The Sanitization Plicy Revised November 2022, 5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: a. High-Temperature Dishwasher (Heat Sanitization): 1. Wash temperature (150-165 F) and 2. Rinse temperature (180 F) . ; or 165 F for stationary rack, single temperature machine. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for a resident who is on daily weight in accordance with professional standards of nursing practice for 1 of 5 residents (Resident #79). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: On 5/17/2022 at 10:10 AM, the surveyor observed Resident #79 at the bedside alert and able to respond to the surveyor's question appropriately. The resident was stable, had no shortness of breath, and denied discomfort at that time. The resident stated he/she had weight fluctuations since admission due to cardiac issues with no negative effect. The surveyor reviewed the medical records of Resident #79. The Resident Face Sheet sheet revealed medical diagnoses including but not limited to: Encounter for surgical aftercare following surgery on the circulatory system, acute on chronic combined systolic and diastolic congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), paroxysmal atrial fibrillation (type of irregular heartbeat), and presence of a pacemaker (is a small device that's placed/implanted in the chest to help control the heartbeat). The most recent admission Minimum Data Set (AMDS) an assessment tool used to facilitate care, dated 4/14/2022 with a Brief Interview for Mental Status (BIMS) score of 15 of 15, which means that the resident's cognition was intact. The AMDS showed that the resident had no shortness of breath. The May 2022 order summary report revealed an order dated 4/12/2022 for daily weights and to call the medical doctor (MD) for a weight gain of 3 lbs/day or 5 lbs/week and the weight to be taken in the morning. The electronic weight records revealed the following dates with 3 lbs/day or 5 lbs/day weight gain: 5/16/2022 05:29 127.6 Lbs 5/15/2022 05:38 117.2 Lbs 5/14/2022 06:17 124.6 Lbs 5/13/2022 05:55 124.4 Lbs 5/12/2022 06:46 117.6 Lbs 5/1/2022 05:25 129.2 Lbs 4/30/2022 05:54 128.1 Lbs 4/29/2022 06:39 128.6 Lbs 4/28/2022 05:11 125.0 Lbs During an interview of the surveyor on 5/19/22 at 11:10 AM, Licensed Practical Nurse (LPN) #1 stated once we get the medical parameters for the patients and there is an order to alert the doctor; I will call or text the doctor to alert them of what is going on with the patient and write a skilled nursing note in [name redacted]. LPN#1 further stated that the daily weight is taken during the 11 PM- 7 AM shift. On that same date and time, LPN#1 could not speak to why the doctor was not alerted of the resident's weight gain on 4/29/22, 5/13/22, and 5/16/22 when there was a weight gain of at least 3 lbs/day and there was no documentation on the electronic medical records indicating that the doctor was alerted of the weight gain. On 5/20/22 at 09:17 AM, the surveyor interviewed the 1st floor Unit Manager/Register Nurse#1 (UM/RN#1) regarding the above dates that the resident had weight gain and the MD was not called. UM/RN #1 could not speak to why there was no documentation alerting the doctor of the weight gain but did acknowledge there should have been documentation. On 5/23/22 at 10:27 AM, the surveyor conducted a phone interview with 11 PM-7 AM RN/Supervisor, (RN/S). The RN/S stated that he was familiar with all Resident # 79's orders and acknowledged the daily weight is taken on their shift. The RN/S further acknowledged that on April 29th, May 13, and 16th the resident had a weight gain of at least three pounds and the doctor was not contacted, and was unable to provide reasons why this occurred. On 5/23/22 at 10:40 AM, the surveyor made multiple attempts to conduct phone interviews with LPN#2 and #3 who had been assigned to Resident # 79 during the 11 PM-7 AM shifts on 4/29, 5/13, and 5/16/22. On 5/26/22 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the patient's weights are discussed in the morning meeting daily, but could not recall resident #79 weight being discussed on April 29, May 13, and May 16. The DON further stated, that they were not sure why the weight gain was not documented. She further stated that the change in the resident's status, as well as all weight changes, should be documented in the nurses' notes. A review of the facility's policy on Change on a Resident's Condition or Status revised in May 2017 and Weighing and Measuring the Resident edited February 18, 2022 that was provided by the DON included the following: The Change in Resident's Condition or Status states under Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes I the resident's medical/mental condition and/or status (e.g., changes on level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): i. Specific instruction to notify the Physician of changes in the resident's condition. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The Weighing and measuring the Resident states under Purpose The purpose of the procedure is to determine the resident's weight and height, to provide a baseline and an on-going record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline to determine the ideal weight of the resident. Reporting 1. Report significant weight loss/weight gain to the nurse supervisor 4. Report other information in accordance with the facility policy and professional standards of practice. On 5/27/22 at 12:56 PM, the surveyors met with the DON. The facility did not provide additional information. NJAC 8:39-11.2(b)

Based on observations, interviews, record review, and review of facility documents, the facility failed to provide appropriate catheter care for 1 of 3 residents reviewed for catheter with Urinary Tract Infection (UTI ) (Resident #83). This deficient practice was evidenced as follows: A review of Resident #83's admission Record reflected that the resident was admitted with diagnoses which included but were not limited to: depression, chronic kidney disease, and urinary retention with an indwelling (fixed in a person's body for a long period of time) catheter. A review of Resident #83's admission Minimum Data Set (MDS), a tool to facilitate the management of care, dated 4/18/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which reflected that he/she was severely cognitively impaired. The MDS also reflected that the resident required extensive assistance of 1 to 2 staff for bed mobility, transfers, and toileting. In addition, the MDS reflected that the resident had an indwelling catheter. A review of Resident #83's Order Summary Report for May 2022 reflected a physician's order for urinary catheter care every shift for Retention/Failed voiding trial x 2, dated 4/16/22. A review of Resident #83's Care Plan initiated 04/14/22, reflected that the resident had Use of indwelling urinary catheter related to retention. The goal was for Resident #83 not to have acute complications due to urinary catheter use. The interventions included to maintain the catheter drainage bag below bladder level, secure the catheter with a securement device, and report signs of a UTI to the physician. On 5/17/22 at 11:14 AM, the surveyor observed Resident #83 in bed. The residents foley catheter drainage bag was noted to be on the left side of the bed, resting directly on the floor mat. The foley catheter was not in a privacy bag. At 12:45 PM, the surveyor observed that the resident's foley catheter drainage bag was directly touching the floor and was not in a privacy bag. On 05/18/22 at 09:15 AM, the surveyor observed the resident's foley catheter drainage bag on the left side of the bed with the bottom of the bag resting directly on the floor. The foley catheter drainage bag was not in a privacy bag. At 9:30 AM in the presence of the Unit Manager (UM), the surveyor observed the resident's foley catheter drainage bag directly on the floor. The UM stated that the Certified Nurse Aides (CNA) were responsible to ensure that the foley catheter drainage bags were in privacy bags and not on the floor. The UM attempted to run her finger underneath the drainage bad but was unable to do so. On 5/24/22 at 10:37 AM, the surveyor interviewed the UM who stated that she relayed the concern to the Assistant Director of Nursing (ADON) and spoke with the residents CNA #1. The UM stated that the CNA was supposed to know what to do. On 5/25/22 at 11:45 AM, the surveyor interviewed CNA #2. She stated that if a resident had a foley catheter drainage bag it should have been in a privacy bag and should not touch the floor to ensure appropriate infection control practices. A review of the facility policy Catheter Care, Urinary with a revised date of September 2014, indicated the following: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Under Infection Control it is stated: Use standard precautions when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor. And The policy was not being followed. NJAC 8:39-19.4 (a)5

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Consultant Pharmacist (CP) reported irregularities in the drug regiment to the physician and facility. This deficient practice occurred for 1 of 5 residents (Resident #40) that were reviewed for Unnecessary Medication. This deficient practice was evidenced by the following: On 5/17/22 at 12:10 AM, the surveyor observed Resident #40 in their bed with their eyes closed. The surveyor reviewed Resident #40's medical record. The Face Sheet (FS), an admission summary indicated that the resident was admitted to the facility with diagnoses which included Anxiety disorder (mental health condition that is a feeling of fear, dread, and uneasiness) , Persistent mood disorder, and Dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with Behavioral Disturbances. The May 2022 Order Summary Report (OSR) revealed an order dated 2/21/22 for Risperdal (is an antipsychotic medicine that is used to treat the symptoms of Schizophrenia, Bipolar disorder, and irritability) 0.25 mg (milligram) tablet give one tablet by mouth twice daily for Mood Disorder. The Significant Change Minimum Data Set (SMDS), an assessment tool used for management of care dated 3/24/22 showed a Brief Interview for Mental Status (BIMS) score of 4 of 15 which indicated that the resident's cognition was severely impaired. The SMDS revealed that the resident was on antipsychotic medication. The resident's individualized care plan that was initiated on 02/22/22 had a focus area for At risk for behavior symptoms. The care plan interventions included: Attempt psychotropic drug reduction per physician orders and observe mental status/behavioral changes when new medication started or with changes in dosage. Further review of medical records showed that there was no behavioral monitoring notes with target behaviors use of Risperdal. The Consultant Pharmacist Medication Regiment Review (CPMR) from March 2022 to May 2022 revealed that there was no recommendation for the facility to monitor target behaviors for use of Risperdal. The CPMR from March 2022 to May 2022 did not identify the irregularities with the use of Risperdal when there was no documented evidence that the behavior was being monitored with the use of Risperdal. On 5/24/22 at 10:15 AM, the surveyor interviewed a second floor, Licensed Practical Nurse (LPN) regarding behavioral monitoring notes for Resident #40. The LPN stated that all behavioral monitoring notes are in the computer under a section titled forms. The surveyor asked the LPN why there was no behavior monitoring documented for use of Risperdal. The LPN had no answer. On 5/24/22 at 1:00 PM, the surveyor met with the Director of Nursing (DON) and the License Nursing Home Administrator (LNHA) and requested copies of Resident #40's behavioral monitoring notes. On 5/25/22 at 9:15 AM, the surveyor received no behavioral monitoring notes for Resident #40. On 5/25/22 at 12:30 PM, the survey team met with the DON. The DON informed the surveyor that as per facility protocol and practice, resident on psychoactive medications including Risperdal should have a physician order to monitor for targeted behavior and documented in the eMAR. The DON further stated that Resident #40 had no physician order to monitor for target behaviors for Risperdal that was the reason why no behavior monitoring was not done. At that same date and time, the DON acknowledge that the facility did not have any documentation showing that Resident #40's behaviors were being monitored. The DON further stated that there should have a behavior monitoring for Resident #40 and this should have been identified during the CPs monthly review. A review of the facility's policy for Psychopharmacologic Medication Policy that was dated 5/2018 and was provided by the DON indicated the following: Under Policy: Residents who receive psychopharmacologic medications have been appropriately assessed and are monitored to evaluate the effectiveness of the medication (s) used, whether any side effects are present, and for reduction opportunities on an ongoing basis. Under Implementation: 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to the resident and others. NJAC 8:39-29.3 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in 3 of 7 medication carts and 1 of 2 medication refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 10:30 AM, the surveyor inspected the 2nd floor medication cart #3 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed a two opened bottle of Combigan (can help lower eye pressure in people who have glaucoma) eye drops and one bottle of Azopt (is used to treat high pressure inside the eye due to glaucoma or other eye diseases such as ocular hypertension) eye drops that had no opened date and a pharmacy label date from [DATE]. The surveyor interviewed LPN #1 who stated that once an eye drop is opened that it should have an opened date since some eye drops have a specific expiration date. On [DATE] at 10:40 AM, the surveyor inspected the 2nd floor medication refrigerator in the presence of LPN #1. The surveyor observed an opened bottle of Lorazepam (is used to treat anxiety disorders) 2 mg/ml (milligrams/milliliters) solution that contained no opened date. The surveyor interviewed LPN #1 who stated that an opened bottle of Lorazepam solution should have been dated. On [DATE] at 10:55 AM, the surveyor inspected the 1st floor medication cart #1 in the presence of a Registered Nurse (RN#1). The surveyor observed an opened bottle of Tobramycin (used in the eye to treat bacterial infections of the eye) eye drops with an opened date of [DATE] that was discontinued on [DATE]. The surveyor also observed an opened Artificial Tears eye ointment that had an opened date of [DATE] and that was expired. On that same date and time, the surveyor interviewed RN #1 who stated that a discontinued medication should have been removed from the medication cart. RN#1 also stated that the Artificial Tears (used to lubricate dry eyes and help maintain moisture on the outer surface of your eyes) eye ointment was expired and should have been removed from the medication cart. On [DATE] at 11:05 AM, the surveyor inspected the 1st floor medication cart #3 in the presence of LPN #2. The surveyor observed an opened bottle of Xalatan (used to treat high pressure inside the eye due to glaucoma or other eye diseases such as ocular hypertension) eye drops with an opened date of [DATE], that was expired. The surveyor interviewed LPN #2 who stated that an expired bottle of Xalatan eye drops should have been removed from the medication cart. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Combigan eye drops once opened have an expiration date of 30-days. 2. Azopt eye drops once opened have an expiration date of 30-days. 3. Lorazepam oral solution once opened have an expiration date of 90-days. 4. Xalatan eye drops once opened have an expiration date of 42-days. On [DATE] at 12:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Labeling of Medication Containers that was dated 4/2019 and was provided by the DON indicated the following: 3. Labels for individual resident medications include all necessary information, such as: h. The expiration date when applicable; and. A review of the facility's policy for Administration of Ophthalmic, Otic and Nasal Products that was dated 1/2015 and was provided by the DON indicated the following: c. Always check expiration date on the product before administration. If product appearance has changed (change in color, odor, etc.) do not use the product. d. Once a sterile, sealed container is opened, it is no longer sterile. These products should be discarded 30 days after opening. 8. Schedule II-V controlled medications are stored separately locked, permanently affixed compartments NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview, and record review it was determined that the facility failed to appropriately use a COVID-19 rapid antigen test in accordance with manufacturer's instructions for 1 of 3 COVID-19 rapid antigen test observations (Resident #458). This deficient practice was evidenced by the following: On 5/17/22 at 10:04 AM, two surveyors met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for an entrance conference. The DON stated that the facility was in a COVID-19 outbreak that started on 3/31/22 with 10 staff cases and 7 resident cases of COVID-19. The LNHA stated that COVID-19 positive staff members worked throughout the building and that some were direct care staff. The Resident Outbreak Line List indicated that by 5/20/22 there were 13 staff cases throughout departments and 11 facility acquired resident cases of COVID-19 on both floors of the building. On 5/20/22 at 9:05 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer a rapid antigen test for COVID-19 to Resident #458 in their room. The LPN swabbed Resident #458's nostrils for five seconds each to collect the specimen. The surveyor reviewed the electronic medical record for Resident #458. The Face Sheet (FS), an admission record summary indicated that Resident #458 had medical diagnoses that included but were not limited to Alzheimer's Disease and Major Depressive Disorder. The resident's most recent admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of care, dated 5/22/22 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating that the resident's cognition was severely impaired. On 5/20/22 at 9:26 AM, the surveyor interviewed the LPN. The surveyor asked the LPN why she swabbed Resident#458's each nostril for five seconds if the manufacturer's instruction was to swab for 15 seconds. The LPN stated that she should have swabbed for 15 seconds in each nostril to ensure the accuracy of the COVID-19 test. On 5/20/22 at 12:08 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she was the acting Unit Manager regarding the process for COVID-19 rapid antigen testing. The ADON stated that the swab should be kept in each nostril for, at least 15 seconds The surveyor asked what could happen if the person who performed the test failed to swab each nostril for 15 seconds. The ADON stated that you could get a false negative test result and that the results would not be accurate. On 5/20/22 at 12:39 PM, the surveyor expressed her concern to the LNHA and the DON. The DON stated that testing should be done in accordance with testing specifications. A review of the facility policy, Coronavirus Disease (COVID-19)-Specimen Collection, Reporting, and Documentation for COVID-19 Testing dated 9/20 reflected that a specimen should be collected according to manufacturer or laboratory instructions. The [name redacted] COVID-19 Ag Card dated 12/2020 revealed that, To collect a nasal swab sample [ .] firmly sample the nasal wall by rotating the swab in a circular path against the nasal wall 5 times or more for a total of 15 seconds, then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. NJAC 8:39-5.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 6 of 13 residents reviewed for transmission-based precautions (used for patients infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) (Resident #11, #54, #83, #105, #358, and #359). This deficient practice was evidenced by the following: 1. On 5/18/22 at 10:12 AM, the surveyor interviewed the Registered Nurse (RN) assigned to the resident who stated that Resident #11 was placed on Person Under Investigation (PUI) due to being exposed to another COVID positive resident on 5/18/22. On 5/18/22 at 10:47 AM, the surveyor observed Resident #11's room door was closed. The room was also observed to be in a PUI unit. There was a sign posted on Resident #11's door indicating, Under quarantine. Droplet/Contact Precaution. The surveyor further observed a personal protective equipment (PPE) caddy equipment hanged by the resident's room door. The surveyor reviewed Resident#11's medical records. The resident's Face Sheet (FS), an admission summary, revealed that the resident was admitted to the facility with a diagnosis that included but was not limited to Osteoarthritis (is a degenerative joint disease, in which the tissues in the joint break down over time) and Dysphagia (difficulty swallowing) following Cerebral Infarction (stroke). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 2/25/22, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. According to the individualized care plan for Resident #11 which was initiated on 11/22/21, the care plan failed to address that the resident was placed on Transmission Based Precautions (TBP), which are special measures that are put in place to prevent the spread of infection, or that they were a PUI for COVID-19. The care plan also failed to address the specific goal and intervention for Resident #11 while they were on TBP and were on PUI for COVID-19 when the resident was exposed to a positive resident on 5/18/22. On 5/26/22 at 10:17 AM, the above concern was discussed with the Director Of Nursing (DON) together with the survey team. There was no other information provided. 2. On 5/17/22 at 12:38 PM, the surveyor observed Resident #54 seated in a wheelchair in his/her room. Resident #54 was not on TBP, which are special measures that are put in place to prevent the spread of infection. During the interview of the surveyor on 5/19/22 at 10:31 AM, the Unit Secretary for the first-floor unit stated that the hall which contained rooms 117 to 136 was now considered a yellow zone and that the residents, that resided in that hall, were placed on TBP from potential exposure to COVID-19. On 5/19/22 at 10:35 AM, during the surveyor interview, the Unit Manager stated that since there were so many residents that tested positive for COVID-19 in that hall, they decided to treat all the remaining residents in that hall as being exposed to COVID-19 and placed them on TBP. On 5/19/22 at 10:38 AM, the surveyor observed a sign on Resident #54's door that indicated the resident was on TBP. The surveyor reviewed the medical record of Resident #54. The FS indicated that Resident #54 had diagnoses that included but were not limited to Atrial Fibrillation (disease of the heart characterized by irregular and often faster heartbeat), Type 2 Diabetes Mellitus (a condition that results from insufficient production of insulin, causing high blood sugar) and Systemic Lupus Erythematosus (an autoimmune disease with systemic manifestations including skin rash and erosion of joints). The resident's most recent admission Minimum Data Set (MDS) dated [DATE] indicated that the resident had a BIMS score of 12 out of 15, indicating that the resident's cognition was moderately impaired. The individualized care plan for Resident #54 was initiated on 3/29/22. The care plan did not address that the resident was placed on TBP or that they were a PUI for COVID-19. 3. On 5/17/22 at 11:14 AM, the surveyor observed Resident #83 in bed. On 5/19/22 at 9:43 AM, the surveyor observed a Droplet/Contact Precaution Stop Sign on Resident #83's door. The sign indicated that a gown, N95 respirator, eye protection, and gloves should be worn in the resident's room. On 5/20/22 at 10:40 AM, the surveyor interviewed the DON. The DON stated that Resident #83 developed symptoms including lethargy and was placed in the PUI Unit for COVID-19 on 5/18/22. The surveyor reviewed the medical record of Resident #83. The FS indicated that Resident #83 had diagnoses that included but were not limited to Type 2 Diabetes Mellitus and Dysphagia. The resident's most recent admission MDS dated [DATE] indicated that the resident had a BIMS score of 0 out of 15, indicating that the resident's cognition was severely impaired. According to the individualized care plan for Resident #83 which was initiated on 4/14/22. The care plan failed to address that the resident was placed on TBP or that they were a PUI for COVID-19. The care plan also failed to address the specific goal and intervention for Resident #83 while they were on TBP and were a PUI for COVID-19. On 5/24/22 at 8:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) working in the PUI unit. The LPN stated that she was not sure if PUI residents should have a specific care plan in place because they are PUI for COVID-19 or because they are on TBP. The LPN stated that she has never seen a specific care plan in place for any PUI residents at the facility. On 5/28/22 at 9:13 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she was the desk nurse for the PUI unit. The RN stated that no specific care plan was initiated for PUI residents. The surveyor asked the RN how the facility ensured that the care plan was person-centered, addressed the resident's needs, and drove the type of care and services that the resident received. The RN did not respond. At that same date and time, the RN stated that a TBP care plan was only initiated for residents who tested positive for COVID-19 not for PUI residents. 4. On 5/17/22 at 11:16 AM, the surveyor observed Resident #105 seated in a wheelchair in their room. Resident #105 was not on TBP. On 5/19/22 at 10:39 AM, the surveyor observed a sign on Resident #105's door that indicated the resident was on TBP. The surveyor reviewed the medical record of Resident #105. The FS indicated that Resident #105 had diagnoses that included but were not limited to Chronic Diastolic (Congestive) heart failure (A progressive heart disease that affects the pumping action of the heart muscles that causes fatigue and shortness of breath), Pulmonary edema (A condition where fluid accumulates in lung tissues) and Atrial fibrillation (an abnormal heartbeat). The resident's most recent admission MDS dated [DATE] indicated that the resident had a BIMS score of 14 of 15, indicating that the resident's cognition was intact. According to the individualized care plan for Resident #105 which was initiated on 4/26/22. The care plan did not address that the resident was placed on TBP or that they were a PUI for COVID-19. 5. On 5/17/22 at 10:26 AM, the surveyor observed Resident #358 seated in a wheelchair in his/her room. Resident #358 was not on TBP. On 5/19/22 at 10:37 AM, the surveyor observed a sign on Resident #358's door that indicated the resident was on TBP. The surveyor reviewed the medical record of Resident #358. The FS indicated that Resident #358 had diagnoses that included but were not limited to Malignant neoplasm of rectum and colon (a cancerous tumor), Atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall) and Systolic (congestive) heart failure. The resident's most recent admission MDS dated [DATE] indicated that the resident had a BIMS score of 15 of 15, indicating that the resident's cognition was intact. According to the individualized care plan for Resident #358 which was initiated on 5/5/22. The care plan did not address that the resident was placed on TBP or that they were a PUI for COVID-19. 6. On 5/17/22 at 11:08 AM, the surveyor observed Resident #359 lying in bed in his/her room. Resident #359 was not on TBP. On 5/19/22 at 10:37 AM, the surveyor observed a sign on Resident #359's door that indicated the resident was on TBP. The surveyor reviewed the medical record of Resident #359. The FS indicated that Resident #359 had diagnoses that included but were not limited to Moyamoya disease (a progressive blood vessel disorder where the carotid artery in the skull is blocked or narrowed reducing blood flow to the brain), Type 2 diabetes mellitus, and Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction (stroke). The resident's most recent admission MDS dated [DATE] indicated that the resident had a BIMS score of 14 out of 15, indicating that the resident's cognition was intact. According to the individualized care plan for Resident #359 which was initiated on 5/6/22. The care plan did not address that the resident was placed on TBP or that they were a PUI for COVID-19. On 5/24/22 at 12:50 PM, The surveyor presented the above concerns to the DON and Licensed Nursing Home Administrator (LNHA). On 5/25/22 at 12:31 PM, the surveyor interviewed the DON and the LNHA. The DON stated that the care plan should be person-centered. The surveyor asked if a care plan should be in place for residents who were identified as PUI. The DON did not respond. During the surveyor interview on 5/27/22 at 9:38 AM, the DON stated that after the facility had so many residents that tested positive for COVID-19 on 5/18/22, they decided to place the remaining residents in that hall on TBP because they could not pinpoint which residents were exposed or were not exposed to a resident or staff that tested positive. Furthermore, the DON stated that if they could not identify the direct exposures, at that point, she would consider all the residents in the area to be PUI. A review of the facility policy, Care Plans, Comprehensive Person-Centered with an edited date of 4/25/22 reflected that the care plan should incorporate identified problem areas, should describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and should be revised as information about the resident and the residents' conditions change. A review of the facility policy, [name redacted] Cohort Plan (All) with a revised date of 3/1/22 indicated that PUI residents should be placed on TBP with their doors closed, that staff should wear a gown, gloves, N95 respirator and eye protection while in the PUI resident rooms, and that PUI residents should be COVID-19 tested per protocol. A review of the facility provided policy titled, Care Plans, Comprehensive Person-Centered with an edited date of 4/25/22, included the following: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . h. Incorporate identified problem areas; i. Incorporate risk factors associated with identified problems; . l. Reflect treatment goals, timetables and objectives in measurable outcomes; m. Identify the professional services that are responsible for each element of care; n. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; p. Reflect currently recognized standards of practice for problem areas and conditions . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. N.J.A.C. 8:39-11.2(e)(2)

Based on observation and interview it was determined that the facility failed to properly dispose and maintain waste in 2 of 3 garbage dumpster areas as evidenced by the following: On 5/17/22 at 11:05 AM, the surveyor inspected the three garbage dumpster areas with the Culinary Services Director (CSD) and the Regional CSD (RCSD) in the presence of two additional surveyors. Each dumpster area was separated by high barriers. The area where the compactor dumpster was located had a strong spoiled foul odor. The CSD acknowledged the odor and stated that Environmental Services (EVS) cleaned that area and was not sure how often it was cleaned. The area that had the dumpster for the discard of cardboard top was closed however there was extensive debris on both sides of the container such as soiled disposable gloves, supplement containers, cups, food wrappers, bottle caps, wood, and plastic. The CSD could not speak to why that type of debris was there when that dumpster was only meant for cardboard. He again stated that EVS was responsible to clean that area. At 11:26 AM, the surveyor interviewed the Regional Director of Maintenance in the presence of the CSD, RCSD and two additional surveyors. He stated that maintenance was responsible for cleaning the dumpster areas as needed, which included cleaning trash off the ground. On 5/25/22 at 9:03 AM, the surveyor interviewed the Director of EVS (DEVS). He stated that housekeeping was mostly responsible for cleaning and maintaining the dumpster areas. He also stated that maintenance helped out as well. The DEVS stated that compacter got picked up once a week and if there was an odor it should get power washed. He also stated that the cardboard dumpster area should only have cardboard, no other debris. 5/25/22 at 9:15 AM, the surveyor interviewed that Director of Housekeeping (DH). He stated that both housekeeping, and maintenance were responsible for cleaning and maintaining the dumpster areas. The DH also stated that the area was cleaned daily but could not speak to a specified time. He stated that there were sometimes spills by the compacter that could cause odors and it should be cleaned with bleach and then rinsed. He further stated that there should not have been debris on the floor near the dumpster designated for cardboard and that he would not expect to see gloves or food debris in that area. The DH stated that there was no schedule or written accountability for cleaning and maintaining those areas. At 10:50 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of an additional surveyor to relay concerns regarding the dumpster areas. At that time, the surveyor requested any policies or documentation related to the cleaning and maintenance of those areas. On 5/27/22 at 9:48 AM, in the presence of the survey team the DON acknowledged that the documentation provided to the surveyor in response to the previous mentioned concerns and policy requests was all they could provide. The facility was unable to provide any policy or documentation related to the cleaning and maintenance of the dumpster areas. NJAC 8:39-19.7(a)(b)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment and in accordance with nationally recognized guidelines to prevent the development of food borne illness. This deficient practice was observed upon entering the facility, during kitchen tours and was evidenced by the following: On 5/17/22 at 9:00 AM, the survey team entered the facility and observed three stacked boxes of bread directly on the floor of the building entranceway. At 10:01 AM, the surveyor toured the kitchen with the Culinary Service Director (CSD) in the presence of two additional surveyors. The CSD had a ServSafe Certification (means a person possesses a ServSafe certificate and has proven her knowledge in food safety) with an expiration date of 6/25/2024. The entire top of a beige step on garbage near the handwashing sink was visibly soiled black substance. During an initial interview, the CSD acknowledged that the bread delivery was directly on the floor of the building entranceway and that it had been an ongoing concern that bread deliveries arrive between 4 and 5 AM, before the kitchen is open. The CSD further stated that part of the problem was that the bread company did not deliver the bread, rather the bread company hired a delivery service. There was a large white cutting board gouged and discolored on a wire rack upon entrance to the kitchen from the hallway. The CSD acknowledged the condition of the cutting board and stated it should not be used and needed to be replaced. There was also a medium sized yellow and red cutting board, each were worn and gouged. The CSD stated that they needed to be replaced. The wire rack that held the cutting boards upright had a black epoxy covering that was peeling off and the exposed metal was covered in a reddish substance. The CSD stated looks like rust to me. There were multiple metal restaurant pan covers leaning on a box of red potatoes. The CSD stated that they were clean pan covers and should not be leaning on a box of potatoes. The following observations occurred in the walk-in refrigerator: There were two fan covers covered with a gray fuzzy substance. The CSD removed a piece with his fingers and acknowledged that it was dust and should be cleaned. There was an opened package of sliced American cheese, which was labeled with an opened date of 5/16/22 and a use by date of 6/5/22. The CSD stated that the department had a labeling machine with preloaded data for best if used by information. He could not speak to the source or guidance these dates were predicated on. There was an opened bag of shredded mozzarella cheese, which was labeled with an opened date of 5/17/22 and a use by date of 6/15/22. There were two metal sheet pans with 4-ounce health shake containers, as well as one tray with 4-ounce strawberry and one tray with 4-ounce vanilla health shakes. The CSD stated that the date on the container from the manufacturer indicated the best if use by date if the shake remained frozen. He further stated that once they were defrosted the shakes were good for three days. He acknowledged that they were not dated and so he would not know when they were defrosted and thus how long they were good until. The CSD stated that the prep position usually dated the shakes and that it should have been done and could not speak to why it was not done. There were four outdated (5/16/22) 8-ounce low-fat lactose free milks. These were mixed in a milk crate with other milks dated 5/25/22. At approximately 10:15 AM, the Regional CSD (RCSD) joined the tour. There was a personal fabric lunch bag not labeled and dated in the walk-in refrigerator. The RCSD stated that there was no facility policy that allowed for personal lunches to be stored in the kitchen refrigerator and that it belonged in the employee break room. The CSD stated that it belonged to the Registered Dietitian (RD) #1. The four green epoxy covered racks in the walk-in refrigerator were observed with sticky buildup. The CSD stated that the racks were cleaned when the refrigerator emptied out and the product volume got low. He then stated that that rarely happened. At 10:33 AM, the surveyor interviewed RD #1 in the presence of the CSD, the RCSD and two additional surveyors. She stated that she put her lunch bag in the walk-in refrigerator the night before because she did not want to bring it home and did not want anyone to eat her leftover food if she left it in the breakroom refrigerator. RD #1 acknowledged that it should not have been stored in the kitchen refrigerator and could not speak to why it was not labeled or dated. At 10:37 AM, the surveyor observed a thick black smear on the tiled wall above the broom rack. The CSD was able to rub this off with his finger and stated that it's probably from the broom; it's grease. The two door reach in refrigerator had two fan covers with heavy buildup of a brownish-black debris, which the CSD acknowledged. There was a water filter attached the ice machine dated 8/26/21. The CSD did not know how often the water filter should be changed. On the bottom shelf of a stainless-steel table next to a tabletop mixer, there was a box of small disposable gloves opened that was wet and soiled. There was another large white cutting board that was gouged and soiled and appeared to have been recently used. The CSD acknowledged it was gouged and soiled and stated that it's definitely soiled and will not be used again. There were 26 gray coffee mugs that were heavily stained with a brown substance. They were stored in an upright position exposed. The CSD stated that they should have been inverted. He acknowledged that they were stained. The following observations occurred in the dry storage area at 10:46 AM, There was a 50-pound (lb.) bag of rice and two 25 lb. bags of brown rice that were opened and exposed to the environment. The CSD acknowledged this and stated that they should be sealed. There was an opened wrapped bag of lentil penne pasta dated 12/19/21. The CSD could not state if that was the opened or use by date. He further stated that was before he started in January 2022, and he had never noticed it before. There were two cases of water stored directly on floor. There was a dented large #10 can of creamed corn. He stated he had seen it this am and should have discarded it. There was no designated dented can area. The CSD stated that their process was to discard dented cans and report the losses to the vendor. The RCSD stated that an opened package of sliced American cheese had a shelf life of two days. She then stated it would be good up to 10 days. At 12:53 PM, four surveyors observed lunch on the first floor. All observed lunch trays with fruit cups not covered and open to the environment in all three hallways during tray delivery. On 5/19/22 at 9:30 AM, the surveyor conducted a second kitchen tour with the CSD. The hood baffles were observed with caked on debris. The CSD stated that the hood is cleaned quarterly, June 9th is the next scheduled cleaning. He further stated that the hood is cleaned by us as needed, I will clean it today. On 5/25/22 at 8:20 AM, the surveyor interviewed the CSD. He stated that he was often responsible for putting away deliveries and was ultimately responsible to ensure foods were rotated and removed when expired. He stated the cleaning policy was to clean as needed and that there was no actual written schedule for cleaning. At 9:03 AM, the surveyor interviewed the Director of Environmental Services. He stated he was responsible for changing the water filter for the kitchen ice machine and it should be replaced every three to six months. At 10:50 AM until 11:26 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) in the presence of another surveyor to discuss concerns. At that time the surveyor requested multiple policies which included but were not limited to: water filter usage, receiving deliveries, dented cans, labeling and dating and the guidance followed for appropriate use by dates for opened food items, food storage cold and dry, shake usage, kitchen sanitation, preventing food borne illness, preventing cross contamination, and cutting board usage. On 5/27/22 at 9:48 AM in the presence of the survey team, the DON acknowledged that the documents and the information provided in writing were the facility responses as a follow up to the meeting on 5/25/22 at 10:50 AM. At 11:10 AM, the surveyor met with RD #2. She stated that if she observed an item in the refrigerator without a label or date, she would discard it. She also stated that if she observed an opened package of sliced American cheese, she would expect it to be good for 72 hours after opening. RD #2 stated that their labeling machine was preloaded with information about best if use by dates; however, she was not sure of their source or guidance. At 1:30 PM, RD #2 provided the surveyor with a printout from the company that provided the facility with menus. It referenced best if used by dates for food items, however, she could not speak to the source or guidance this information was derived from. Review of the facility policy Food Preparation and Service with a revised date of April 2019, reflected the policy statement Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Review of the facility policy Sanitization with an edited date of 5/2/18, reflected a policy statement The food service area shall be maintained in a clean and sanitary manner. It also reflected that All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. In addition, it also reflected that All equipment . shall be washed to remove or completely loosen soils by manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. It further reflected that Kitchen . surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. And that The Food Services Manager will be responsible for scheduling staff for regular cleaning . Review of the facility policy Refrigerators and Freezers with a revised date of December 2014, reflected a policy statement This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. It also reflected that Information regarding acceptable storage periods for perishable foods will be kept in the supervisors' office. A condensed version will be posted by each refrigerator and freezer for reference. In addition, it also reflected that Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. It further reflected that Supervisors will inspect refrigerators and freezers monthly for . fan condition . And that Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of an undated facility policy Dented Can Policy reflected that All cans must be inspected, placed in the Culinary Directors office for a credit and then disposed of. We will not store any dented, bulging, or damaged cans in any other space. Review of the facility policy Food Receiving and Storage with an edited date of 12/4/18, reflected a policy statement Foods shall be received and stored in a manner that complies with safe food handling practices. It also reflected that Other opened containers must be dated and sealed or covered during storage. The DON provided the surveyor a paper with responses on 5/27/22 at 8:42 AM. Next to the question When water filters are changed and how it is tracked, indicated a response missed it and it is change with next due date to change. An addition paper was provided to the surveyor at that same date and time. It reflected that the facility's procedure for safely handling shakes was to date each shake two weeks from the date it was pulled from the freezer to ensure proper use and rotation. It also reflected that the facility's practice to replace ice machine filters was every six months and that Maintenance writes the date it should be replaced on the new filter. In addition, it reflected that the facility's procedure for care/replacement of cutting boards included once cutting boards become visibly worn, they are to be replaced. It further reflected that the facility's procedure for dating and labeling was to utilize their labeling machine whereby dates are loaded into the system with the most stringent criteria based off ServSafe guidelines which are also accepted and followed by the USDA. RD #2 provided the surveyor with a Refrigerated Storage Quick Reference Guide with a revised date of 1/9/20, on 5/27/22 at 1:30 PM. The document reflected that Cheese: Slices or Opened Packages had a recommended storage time at 35-41 degrees Fahrenheit or less for two weeks if unopened and did not reflect a recommended storage time once opened. According to guidance from ServSafe the 7th Edition based on the U.S. Food and Drug Administration Food Code 2017 and the Centers for Disease Control and Prevention, last reviewed 3/4/22, foods that are considered time/temperature control for safety (TCS) should not be kept more than seven days. According to the NJ Department of Health Chapter 24 effective date 1/3/22, a TCS food means a food that requires time and/or temperature control for safety to limit pathogenic microorganism growth or toxin formation. In addition, non-TCS foods include: Baked goods, including bread, rolls, biscuits, cakes, cupcakes, pastries, and cookies; Candy, including brittle and toffee; Chocolate-covered nuts and dried fruit; Dried fruit; Dried herbs, seasonings, and mixtures thereof; Dried pasta; Dry baking mix; Fruit jams, fruit jellies, and fruit preserves; Fruit pies, fruit empanadas, and fruit tamales (excluding pumpkin); Fudge; Granola, cereal, and trail mix; Honey and sweet sorghum syrup; Nuts and nut mixtures; Nut butters; Popcorn and caramel corn; Roasted coffee and dried tea; Vinegar and mustard; Waffle cones and pizzelles. NJAC 8:39-17.2(g), 19.7(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to: a.) ensure that staff were wearing appropriate personal protective equipment (PPE) for 12 of 29 staff observations and identified on 2 of 2 isolation units., b.) perform hand hygiene for 3 of 29 staff observations, c.) ensure that staff performed daily COVID-19 screening and monitoring for 1 of 2 staff reviewed, d.) ensure that residents received daily COVID-19 Screening and Monitoring every shift for 4 out of 4 residents reviewed (Resident #83, #96, #75, #408), and e.) disinfect personal care items prior and after being used on residents according to manufacturer's recommendations before use to check the blood sugar of 1 of 2 residents observed (Resident #47) and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policies. This deficient practice was evidenced by the following: 1. On 5/17/22 at 10:04 AM, two surveyors met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON, also the Infection Preventionist) for an entrance conference. The DON stated that the facility was in a COVID-19 outbreak which started on 3/31/22. The DON stated that the outbreak included 10 staff cases and 7 resident cases of COVID-19. The LNHA stated that COVID-19 positive staff members worked throughout the building and that some were staff who provided direct care to residents. The LNHA stated that all staff should be wearing a N95 (respirator) mask and a face shield while in the facility. The COVID ActNow Community Risk Level for [name redacted] provided by the LNHA and updated on 5/17/22 indicated that the community risk level for [name redacted], the county in which the facility was located, was high. On 5/18/22 at 10:20 AM, the surveyor observed the Unit Clerk (UC) wearing a surgical mask while sitting at the second-floor nurse's station. At this time the surveyor interviewed the UC. The surveyor asked if the UC was vaccinated against COVID-19. The UC stated that she had a religious exemption to vaccination and that she had not received any COVID-19 vaccinations. On that same date and time, the surveyor asked if the UC was fit tested (a series of steps used to determine the suitability of a respirator mask for a specific use) for a N95 mask. The UC stated that she was fit tested. The surveyor asked where the surgical mask that she was wearing came from. The UC stated that it came from the facility. The surveyor asked to see the box of surgical masks. The UC handed the surveyor the box, which was labeled, Cone Style Procedure Face Mask with Headband. On 5/18/22 at 10:53 AM, the surveyor interviewed the UC again. The surveyor asked the UC if she was wearing an N95 mask. The UC looked at the box of masks and stated, these don't say N95. The surveyor asked why the UC was wearing a surgical mask and not the N95 mask that she was fit tested for. The UC stated that she was not aware that the masks were not N95 grade and stated that she was given the box of surgical masks by a nurse who works at the facility. The facility Staff Vaccination Matrix (also known as facility vaccination record) indicated that the UC had a religious exemption to all COVID-19 vaccinations. On 5/19/22 at 11:36 AM, two surveyors observed the Dietary Aide (DA) in the hallway near the kitchen with a thick beard and a N95 respirator mask. The N95 mask was not in contact with the DA's skin to create a seal and both straps of the mask were worn around the DA's neck. The DA was observed without eye protection. At this time the surveyors interviewed the DA. The surveyor asked if the DA was vaccinated for COVID-19. The DA stated that he did not receive any vaccinations for COVID-19 because he had a medical exemption. The surveyor asked what PPE the DA should wear while in the facility. The DA stated that he needed to wear a N95 mask and an eye shield. The surveyor asked if his N95 mask was worn appropriately. The DA did not respond. The surveyor asked where the DA's eye protection was. The DA entered the kitchen and removed goggles from a shelf in the kitchen which stored kitchen supplies. The surveyor asked if it was his practice to store his goggles in this way. The DA said that this was where he usually stored his goggles. The facility Staff Vaccination Matrix indicated that the DA had a medical exemption and did not receive any COVID-19 vaccinations. On 5/20/22 at 7:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 take vital signs for and administer medications to a resident in the COVID-19 positive unit. LPN #1 removed her gloves prior to exiting the resident's room and proceeded to touch the vital signs monitor to wheel it into the hallway. Once in the hallways, LPN #1 touched the medication cart and the papers on the medication cart prior to performing hand hygiene with alcohol-based hand rub. At this time the surveyor interviewed LPN #1 and stated that she removed dirty gloves and touched equipment and papers prior to performing hand hygiene. LPN #1 did not respond. On 5/20/22 at 9:18 AM, the surveyor observed the Certified Nursing Assistant (CNA) #1 in the hallway of a 2nd floor resident care unit wearing a N95 mask with both straps worn around his neck and with goggles on top of his head. CNA #1 had no eye protection covering his eyes. At this time the surveyor interviewed CNA #1. The surveyor asked how the straps of a N95 mask should be worn. CNA #1 stated that the straps should be worn with one around the top of his head and with one around his neck. CNA #1 acknowledged that the mask was not worn properly and that it should have been. The surveyor asked how CNA #1 needed to wear his goggles. CNA #1 stated that he only needed to wear goggles in the resident rooms, not in the hallway. On 5/20/22 at 11:58 AM, the surveyor requested to speak with the Dietary [NAME] (DC) outside of the kitchen. The DC exited the kitchen, and the surveyor observed the DC wearing a surgical mask next to his skin and then a N95 mask over the surgical mask. The N95 mask was not in contact with the DC's skin to create a seal. The surveyor also observed that the DC was not wearing eye protection. On that same date and time, the surveyor asked the DC if he was vaccinated against COVID-19. The DC stated that he received two doses of a vaccination for COVID-19 but that he did not receive a booster dose yet. The surveyor asked why the DC was not wearing his masks appropriately. The DC stated that it was for, protection. The surveyor asked if the DC was supposed to be wearing eye protection. The DC stated that he did not normally wear eye protection. The [name redacted] Digital COVID Certificate indicated that the DC received 2 doses of a COVID-19 vaccination but failed to indicate the DC received a booster or additional dose of the vaccine. The surveyor reviewed the timecard for the DC which indicated the days that the DC worked at the facility. The timecard indicated that the DC worked 5/1/22, 5/2/22, 5/3/22, 5/4/22, 5/5/22, 5/6/22, 5/9/22, 5/11/22, 5/12/22, 5/13/22, 5/14/22, 5/15/22, 5/16/22, 5/17/22, and 5/20/22. A review of the COVID-19 Screening Record for when the DC screened and monitored himself for COVID-19 failed to indicate that the DC screened and monitored for COVID-19 on 5/2/22, 5/5/22, 5/11/22, 5/13/22, and 5/14/22. 2. On 5/20/22 at 9:08 AM, the surveyor observed Resident#39's name outside a transmission base precaution (TBP) room. There was a PPE box hung outside the door that included a gown and gloves. The surveyor then observed CNA#2 wearing an N95 mask and goggles did not perform hand hygiene before getting towels from a linen cart parked near the TBP room. While walking toward the TBP room, CNA#2 held the towels towards her uniform and left the towels inside the TBP room. CNA#2 did not perform hand hygiene after exiting the TBP room. During an interview with the surveyor on that same date and time, CNA#2 stated that the TBP room was on contact precaution. CNA#2 further stated that she left towels inside the room to be used later for morning care. On 5/20/22 at 9:11 AM, the surveyor observed CNA#2 went back to the TBP room with an N95 mask and goggles without performing hand hygiene, donned (applied) gown and gloves, and closed the door. On 5/20/22 at 9:16 AM, the surveyor observed the Maintenance Staff (MS) with an N95 mask did not perform hand hygiene before touching the doorknob of a TBP room while CNA#1 and Resident#39 were inside the room. Afterward, the MS went inside the bathroom of the TBP room and after 10 seconds the MS left the resident's bathroom. During an interview of the surveyor with the MS outside the TBP room, the MS stated that he was not aware of the TBP precaution and why there was a PPE box hung outside the resident's room. He further stated that he was not sure if he should be performing hand hygiene before entering and after exiting the TBP room. The surveyor then asked the MS if he was not sure, would he ask the nurse first? The MS did not reply. Later on, the MS stated, I don't need to wash my hands before and after leaving the room because I did not touch anything inside the room, I just checked the thermostat (a temperature regulator) of the resident. Then, the surveyor asked the MS if he touched the resident's room doorknob before entering the TBP room and if he should have washed his hands. The MS did not respond. During an interview of the surveyor on 5/20/22 at 9:21 AM, LPN#1 stated that Resident#39 was on contact precaution due to Bacteremia (is the presence of bacteria in the bloodstream). LPN#1 further stated that all staff must perform hand hygiene before entering the room, wear a full PPE (gown, gloves, N95 mask, and eye protection), remove PPE, and perform hand hygiene before exiting the room. On 5/20/22 at 9:28 AM, two surveyors interviewed CNA#2. The surveyor asked CNA#2 if she should perform hand hygiene before getting clean towels and before donning and doffing (putting off) PPE. CNA#2 stated, they (facility management) did not tell me that I have to do that. On 5/20/22 at 9:28 AM, the surveyors interviewed the Assistant Director of Nursing (ADON). The ADON informed the surveyors that all staff was aware that as a standard of practice in the facility, staff must perform hand hygiene before and after exiting the resident's room. On 5/20/22 at 9:47 AM, the surveyor in the presence of the survey team informed the LNHA and the DON about the above concerns. Both the LNHA and the DON acknowledge that both CNA#1 and MS should have performed hand hygiene. 3. On 5/23/22 at 9:49 AM, the surveyor entered the second floor and approached closed doors with signage indicating Yellow Zone. The signs further indicated PPE reminders such as gown prior to entering the room for any purpose, gloves, fit tested N95 (respirator mask) or KN95 respirator, and eye protection. On 5/23/22 at 9:58 AM, the surveyor observed a nurse with a thick, long beard, an N95 mask, and eye protection. The nurse's beard covered his cheeks, chin, and neck. The surveyor observed that the N95 mask only covered a small portion of the nurse's mouth area. The N95 mask was not able to be worn down below the chin area and was not in contact with the nurse's face to create a seal. On 5/23/22 at 9:59 AM, the nurse was identified as an agency LPN #2. LPN #2 stated he floats to units in the facility. LPN #2 stated all the residents in the Yellow Zone have had exposure to COVID-19 and were being monitored. LPN #2 stated staff limits contact with the residents, would wear PPE gowns into the resident room, remove the PPE gown when leaving the room, and change to a new N95 mask. On 5/23/22 at 10:04 AM, the surveyor observed a CNA #2 wearing an N95 mask, eye protection, and no PPE gown. CNA #2 was carrying clean linens, did not don a PPE gown, and entered a two-resident room in the Yellow Zone. On 5/23/22 at 10:08 AM, during an interview with the surveyor, CNA #2 stated she had worked at the facility for 3 months but not usually in the Yellow Zone. CNA #2 stated the process would be to wear a PPE gown into the resident room but that it was confusing on how to carry linen and put a gown on. CNA #2 stated she would bring the linen into the room, and squeeze the linen between her knees while she donned the PPE gown. CNA #2 acknowledged she should have donned the PPE gown prior to entering the resident room for infection control purposes. CNA #2 stated she had education on PPE and thinks she was fit tested for the N95. On 5/23/22 at 10:16 AM, during an interview with the surveyor, the LPN acting Unit Manager#1 (LPN/UM#1) on the second floor stated all staff even agency staff would have received PPE and Infection Control education at facility. The LPN/UM#1 stated all education, and N95 respirator mask fit testing would be done at the facility. She further stated that all staff were expected to wear PPE into TBP rooms and that PPE was to be donned prior to entering the room for infection control purposes. On 5/23/22 at 10:35 AM, during an interview with the surveyor, the DON stated she had worked at the facility about three months. She stated the facility had a [NAME] Zone which was a non-ill unit, a Yellow Zone for Person Under Investigation (PUI) residents who were new admissions or had been exposed to COVID-19, and a Red Zone for the COVID-19 positive residents. The DON stated agency staff were fit tested to wear the N95 mask. She stated that all staff working on the Yellow Zone would be required to perform hand hygiene, wear an N95 respirator mask and full PPE prior to entering a resident room to prevent the spread of infection. The DON stated staff who needed to bring linens into the TBP room, should have PPE on prior to entering the room. On 5/23/22 at 11:46 AM, during a follow up interview with the surveyor, LPN #2 stated he had been fit tested for the N95 mask at the facility twice with his beard. LPN #2 further stated it (the beard) wasn't this big and it was tough, but they finally got a seal. On 5/23/22 at 11:50 AM, the surveyor observed a housekeeper in the non-ill hall on the second floor. The surveyor observed the housekeeper was wearing an N95 mask with one strap around the back of her head and the second strap in front of her face resting on the nose area of the N95 mask. The surveyor further observed the housekeepers face shield had been pushed up on the top of her head and not providing protection to the eye area. During an interview with the surveyor at that time, the housekeeper stated she was in a [NAME] Zone, and would change her mask in and out of rooms when she was in the PUI (Yellow Zone) unit. The housekeeper further stated she was required to wear an N95 mask and a face shield in all areas of the facility. The surveyor inquired if there was a reason the housekeep was not wearing her PPE as educated. The housekeeper could not provide a reason. The housekeeper acknowledged her N95 mask and face shield should have been worn properly to offer protection. The housekeeper further stated she had been educated on PPE. On 5/23/22 at 12:06 PM, during a follow up interview with the surveyor, the DON stated CNA #2 absolutely should have had a (N95 respirator mask) fit test prior to working on the PUI unit. On 5/24/22 at 10:38 AM, the DON provided the surveyor with an Occupational Safety and Health Administration (OSHA) Respirator Medical Evaluation Questionnaire Modified Form for Use with N95 Respirator Only, for CNA #1 dated 5/23/22. The DON acknowledged that CNA #1 had not had the medically cleared, N95 respirator fit test prior to working on the PUI Yellow Zone. On 5/24/22 at 11:18 AM, during an interview with the surveyor, the facility Registered Nurse Educator (RNE) who administered the N95 respirator fit tests for the facility, stated a staff member would have to have a seal against their face where no air can get in. The RNE stated one staff was able to do a seal with his beard in a rubber band and the N95 respirator mask bottom flap tucked. The RNE further stated that on 5/23/22, she had the LPN#4 manipulate his beard the same way and the LPN#2 was annoyed. The RNE further stated the facility policy was to follow OSHA guidelines but could not speak to what the guideline referenced about beards. Furthermore, the RNE stated a company trained her on 4/13/22 to do the N95 respirator mask fit testing. In the presence of the surveyor, the RNE reviewed the OSHA guideline and acknowledged a beard was contrary to passing a FIT test seal. The RNE stated that she became aware of the OSHA guideline and facility policy after administering the N95 fit test for LPN #2 on 5/23/22 and that had she been aware of the policy, LPN #2 would not have passed the fit test. On 5/25/22 at 9:10 AM, while on the second floor Yellow Zone, the surveyor observed CNA #2 gather linens from a covered cart. CNA #2 was observed holding linens in her left hand while donning a PPE gown on her right arm. Next the surveyor observed CNA #2 move the lines to her right hand to don the PPE gown on her left arm. The surveyor observed that CNA #2's PPE gown was not secured around the neck or waist in the back. CNA #2 entered the room of a resident on TBP. On 5/25/22 at 9:12 AM, LPN #1 was present on the PUI Yellow Zone and stated the back of the PPE gown should be secured. LPN #1 knocked on the resident door and CNA #2 opened the door with the PPE gown visibly untied and loose around her body exposing her clothing. LPN #1 educated CNA #2 and CNA #2 secured her PPE gown. On 5/25/22 at 9:15 AM, the surveyor observed the first floor Red Zone with signage to Stop, Quarantine, Droplet/Contact Precautions, only essential personnel should enter this room, everyone must clean hands, gown prior to entering the room for any purpose, N95 or KN95 respirator fit tested, eye protection, and gloves. The surveyor observed PPE bins with PPE gowns, N95 masks, surgical masks, eye protection, gloves, and alcohol-based hand rub throughout the unit. On 5/25/22 at 9:17 AM, the surveyor observed CNA #3 wearing eye protection, and an N95 mask. CNA #3 was observed inside a TBP isolation room of a COVID-19 positive resident (Resident #49). CNA #3 was within six feet of Resident #49, was touching the resident's television set with his bare hands and was speaking to the resident. CNA #3 exited to the door of the room and the surveyor stopped to speak to him. CNA #3 stated he had worked at the facility for eight years and that residents in the Red Zone were there because they had COVID-19. CNA #3 further stated he had been educated on properly wearing PPE. CNA #3 could not offer any explanation as to why he had no PPE gown or gloves on while inside the room of COVID-19 positive resident. On 5/25/22 at 9:22 AM, the DON was present on the Red Zone and escorted CNA #3 off the unit. The DON stated no staff should be in a COVID-19 positive resident room for any reason with PPE on. A review of the facility provided, Disclosure Statement, dated 01/04/21 revealed that LPN #2 was contract or agency staff and had received education on topics which included but were not limited to respiratory protection program and 95 masks, and Infection Control. A review of the facility provided education transcript revealed that CNA #3 had completed on-line education which included but was not limited to infection control prevention dated 03/29/22; introduction to Coronavirus 2019 dated 04/20/22, Keep COVID Out was dated 02/25/21, and using PPE correctly for COVID 19 dated 02/25/21. A review of the facility provided email dated 05/24/22 at 3:10 PM, revealed the company who trained the facility RNE indicated part of that training included that fit testing can't be done/is not reliable when individuals have beards. 4. On 5/17/22 at 11:14 AM, the surveyor observed Resident #83 in bed. On 5/20/22 at 10:40 AM, the surveyor interviewed the DON. The DON stated that Resident #83 developed symptoms including lethargy and was placed on the PUI Unit for COVID-19 on 5/18/22. The surveyor reviewed the electronic medical record for Resident #83. The Face Sheet (FS), an admission record indicated that Resident #83 had diagnoses that included but were not limited to Type 2 Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), acute kidney failure, and dysphagia (difficulty swallowing). The resident's most recent admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/18/22 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating that the resident's cognition was severely impaired. On 5/20/22 at 12:20 PM, the surveyor reviewed all the COVID-19 Patient Screening & Monitoring Tools for Resident #83 for April and May 2022. Resident #83 was screened and monitored for COVID-19 on 4/13/22 at 22:35, on 5/2/22 at 21:54, 5/4/22 at 22:02, 5/9/22 at 15:59, 5/10/22 at 12:57, 5/11/22 at 22:48, 5/13/22 at 15:23, 5/14/22 at 14:27, 5/15/22 at 14:34, and at 5/16/22 at 14:31. The review of COVID-19 Patient Screening & Monitoring Tools failed to indicate that Resident #83 was screened and monitored for COVID-19 daily every shift. On 5/17/22 at 10:58 AM, the surveyor observed Resident #96 sitting in a wheelchair in their room. The surveyor reviewed the electronic medical record for Resident #96. The FS indicated that Resident #96 had diagnoses that included but were not limited to heart failure, end stage renal disease, Parkinson's Disease, and Dementia. The resident's most recent admission MDS, dated [DATE] indicated that Resident #96 had a BIMS score of 13 out of 15 indicating that the resident's cognition was intact. The 5/18/22 Nursing/Clinical Progress Note Indicated that Resident #96's family and physician were made aware of their positive COVID-19 result on this date. On 5/20/22 at 12:25 PM, the surveyor reviewed all the COVID-19 Patient Screening & Monitoring Tools completed for Resident #96 for April and May 2022. Resident #96 was screened and monitored for COVID-19 on 4/23/22 at 15:05, on 4/30/22 at 15:18, on 5/2/22 at 16:03, on 5/4/22 at 00:08, on 5/5/22 at 16:53, on 5/6/22 at 15:05, on 5/9/22 at 16:31, on 5/10/22 at 13:17, on 5/11/22 at 23:05, on 5/13/22 at 15:39, on 5/14/22 at 14:19, on 5/15/22 at 14:10, and 5/19/22 at 18:47. The review of COVID-19 Patient Screening & Monitoring Tools failed to indicate that Resident #96 was screened and monitored for COVID-19 daily every shift. On 5/19/22 at 11:04 AM, the surveyor observed the Resident #75's room with a Contact/ Droplet Precaution Stop Sign on the door. The surveyor observed Resident #75 sitting in their wheelchair, awake and responsive to surveyor's questions. The surveyor reviewed the electronic medical record for Resident #75. The FS indicated that Resident #75 had diagnoses that included but were not limited to end stage renal disease, malignant neoplasms (new and abnormal growth especially as a characteristic of cancer) of the left kidney, colon, and bladder, and dysphagia (difficulty swallowing). The resident's most recent admission MDS, dated [DATE] indicated that the resident had a BIMS score of 13 out of 15, indicating that the resident's cognition was intact. The List of Residents in Yellow Zone provided by the DON on 5/31/22 revealed that Resident #75 was designated a PUI for COVID-19 on 5/18/22. On 5/20/22 at 12:26 PM, the surveyor reviewed all the COVID-19 Patient Screening & Monitoring Tools completed for Resident #75 for May 2022. Resident #75 was screened and monitored on 5/3/22 at 1:17, on 5/3/22 at 14:27, on 5/4/22 at 22:59, on 5/6/22 at 14:27, on 5/9/22 at 19:26, on 5/10/22 at 11:23, on 5/11/22 at 13:00, on 5/12/22 at 14:00, on 5/12/22 at 22:14, on 5/13/22 at 19:10, on 5/16/22 at 14:19, on 5/17/22 at 13:31, on 5/17/22 at 20:42, on 5/18/22 at 19:28. The review of COVID-19 Patient Screening & Monitoring Tools failed to indicate that Resident #75 was screened and monitored for COVID-19 daily every shift. On 5/23/22 at 10:03 AM, the surveyor observed Resident #408's door with a Contact/ Droplet Precaution Stop Sign on the door. The surveyor reviewed the electronic medical record for Resident #408. The FS indicated that Resident #408 had medical diagnoses that included but were not limited to fracture of unspecified part of neck of left femur, subsequent encounter, Type 2 Diabetes Mellitus, and Dementia. The resident's most recent quarterly MDS, dated [DATE] indicated that the resident had a BIMS score of 0 out of 15, indicating that the resident's cognition was severely impaired. The List of Residents in Yellow Zone provided by the DON on 5/31/22 indicated that Resident #408 was identified as a PUI for COVID-19 on 5/18/22. On 5/23/22 at 12:40 PM, the surveyor reviewed all of Resident #408's COVID-19 Patient Screening & Monitoring Tools for April and May 2022. Resident #408 was screened and monitored for COVID-19 on 4/6/22 at 14:22, on 4/29/22 at 15:01, on 5/1/22 at 18:20, on 5/2/22 at 23:13, on 5/3/22 at 13:59, on 5/4/22 at 22:40, on 5/6/22 at 14:54, on 5/9/22 at 22:27, on 5/10/22 at 11:37, on 5/11/22 at 13:36, on 5/12/22 at 14:37, on 5/12/22 at 22:28, on 5/13/22 at 19:57, on 5/16/22 at 21:47, on 5/18/22 at 22:37, on 5/19/22 at 15:50, on 5/21/22 at 12:39, and on 5/21/22 at 22:44. The review of COVID-19 Patient Screening & Monitoring Tools failed to indicate that Resident #408 was screened and monitored for COVID-19 daily every shift. On 5/23/22 at 12:42 PM, the surveyor interviewed the DON. The surveyor asked the DON what her expectation was of COVID-19 screening and monitoring for residents in the facility. The DON stated that her expectation was that residents were screened and monitored daily and every shift. On 5/24/22 at 8:57 AM, the surveyor interviewed LPN #5 about the expectation for COVID-19 screening and monitoring of residents. LPN #5 stated that at the end of every shift that she fills out the COVID-19 Screening & Monitoring Tool on an odds and evens basis according to an alternating, skilled nursing schedule. LPN #5 stated that COVID-19 screening and monitoring is not done every shift on every resident. On 5/24/22 at 9:13 AM, the surveyor interviewed the registered nurse (RN) who stated that she was the desk nurse for the first floor about the expectation for COVID-19 screening and monitoring. The RN stated that the expectation was that COVID-19 screening and monitoring would be completed daily and every shift for all unexposed and PUI residents. 5. On 5/24/22 at 10:30 AM, two surveyors entered the clean laundry folding area. The surveyors observed the [NAME] folding linens. The surveyors also observed goggles and a N95 mask on a table near the clean folded linens and a clear plastic bag with an empty plastic water bottle inside hanging and touching the clean folded linen. At this time the surveyors interviewed the Porter. The [NAME] stated that the linens that he is folding are clean, that the table is clean and that the linens are folded on the table. The [NAME] also stated that the goggles and N95 were his PPE and that he usually stored them on the table while he was folding linens. The [NAME] stated that the person who worked yesterday on the afternoon shift put up the plastic bag. Furthermore, while the surveyors interviewing the Porter, part of the clean linen that he was folding touched the floor. The surveyor pointed to the [NAME] that part of the linen touched the floor. The [NAME] put the linen that he was folding back in the cart with the rest of the clean linen. The surveyor asked the [NAME] what should happen if clean linen touches or falls on the floor. The [NAME] stated that it needed to be washed again. The [NAME] did not remove the linen that touched the floor from the clean folded laundry. On 5/24/22 at 10:40 AM, two surveyors entered the dryer room. The surveyors observed a desk with linens stacked upon it which also had a paper on it. The surveyors observed that above the desk that there were personal effects affixed to the wall and that a necklace hung down and touched the linens. At this time, the surveyors interviewed Housekeeper #1 and the Laundry Aide (LA) who were in the dryer room. The LA stated that the papers were a resident census. The LA stated that the papers should be inside the desk and not on top of it with the clean linen. On 5/24/22 at 10:50 AM, the surveyors and the LA entered the washing machine room. The surveyor asked about the LA's process for cleaning the washing machines and dryers between loads of laundry. The LA stated that for the COVID-19 and PUI resident's laundry that she washes the inside of the washing machine and the dryer with soap and water. She further stated that she washes the washing machine and dryer for non-COVID-19 resident's laundry with soap and water, sometimes but not between every load. The surveyor asked if there was a log to ensure accountability for the cleaning of the washing machines and dryers. The LA stated that there was not. At that time, the surveyor asked how the LA disinfected her PPE including goggles and face shield. The LA stated that she washed her goggles with water. The surveyors asked where the LA stored her goggles. The LA stated that she stored her goggles inside of the desk in the room. The LA opened the desk drawer. Inside the drawer the surveyors observed goggles, pens, a marker, and lotion. The surveyors asked what the other items in the drawer were. The LA stated that these were her personal items. On 5/24/22 at 11:08 AM, two surveyors interviewed the Director of Housekeeping and the Regional Director of Environmental Services. The Director of Housekeeping stated that PPE should not be stored on the clean table, that a plastic bag should not be hanging near and coming into contact with the clean linen, that clean linens should be rewashed if they come into contact with the floor, that PPE should not be stored in a desk drawer with personal items, that garbage should be covered, that staff's personal belongings should not be hanging down and coming into contact with resident clean linen, and that bleach sanitizer should be used to disinfect the washing machines and dryers after every load of laundry and should also be used to disinfect PPE including goggles, and that soap and water should not be used. On 5/24/22 at 12:50 PM, The surveyor presented her concerns to the DON and LNHA. On 5/25/22 at 12:31 PM, the DON and LNHA met with the survey team to present responses to their concerns. The DON stated that PPE such as a N95 and eye protection such as face shields or goggles needed to be worn by staff at all times while in the facility. The DON also stated that during outbreak it was her expectation that all residents be screened and monitored for COVID-19 every day and every shift. The DON continued to state that LPN #1 should have performed hand hygiene after removing gloves prior to touching anything else. The LNHA stated that all employees should be screened and monitored for COVID-19 every day. On 5/27/22 at 11:42 AM, two surveyors observed CNA #4 on the 2nd floor resident care area wearing an eye shield on top of her head and not covering her eyes. The surveyors interviewed CNA #4. CNA #4 stated that she works on the PUI unit. The surveyors asked about the way that she was wearing her face shield. CNA #4 stated that she sanitized her eye shield after leaving the PUI unit and this is why it was worn on top of her head, because it was drying. On 5/27/22 at 1:06 PM, the surveyor expressed her concern about CNA #4 to the DON. The DON stated that the eye shield should have been covering the CNA's eyes. 6. During