Every finding on record at Clover Rest Home

Based on observation, interview, and record review, it was determined that the facility failed to ensure that oxygen tubing was stored in accordance with infection control measures. This was found with 1 of 2 residents who received oxygen therapy, Resident #180. The deficient practice was evidenced by the following: On 5/1/25 at 11:25 AM, the surveyor observed Resident #180 in the day room participating in the activities. The surveyor observed a portable oxygen tank on the back of the wheel chair with oxygen tubing including the nasal cannula (NC) portion of tubing hanging off the tank, touching the floor and was not in use and not stored in a bag. The surveyor interviewed the Certified Nursing Assistant (CNA), who stated that the tubing should not have been on the floor. The CNA picked the tubing up off of the floor and put it into the small plastic baggie. The surveyor asked the CNA if she should have put the tubing from the floor into the bag or should have discarded it. The CNA did not respond. A review of the admission Record reflected that Resident #180 was admitted to the facility with diagnoses that included but were not limited to; Chronic Respiratory Failure with hypoxia and shortness of breath. A review of the Clinical Physician's orders reflected a Physician's Order (PO) dated 5/1/25, for oxygen at 2L/min (liters per minute) via NC as needed every shift for Oxygen saturation less than 90%. On 5/5/25 at 1:07 PM, the survey team met with the Administrator, Director of Nursing (DON), and the Assistant Administrator to discuss the above observations and concerns. The DON stated that the tubing which was found on the floor should not have been placed into a bag and should have been discarded and replaced with a new one. NJAC 8:39-27.1 (a)

Based on observations and interview on 01/25/2024 and 01/26/2024, it was determined that the facility failed to provide at least 80-square feet per Resident bed in multi-bedded rooms or 100-square feet in a single bedded room as evidenced by the following: On 01/25/2024 during the survey entrance at approximately 10:01 AM, a request was made to the Administrator and Director of Maintenance (DOM) to provide a copy of the facility lay-out which identifies the various rooms and smoke compartments in the facility. A review of the facility provided lay-out identified the facility is a three-story (3) building with a basement. There are eighteen (18) Resident sleeping rooms and common areas on the first floor. Starting on 01/25/2024 at approximately 10:40 AM, in the presence of the facility's DOM, the surveyor observed, measured and recorded the following Resident rooms: A-Wing Resident rooms: A-1 measured 61 square feet per resident bed A-2 measured 91.54 square feet per single bedded room A-3 measured 63.5 square feet per resident bed A-4 measured 47.5 square feet per resident bed B-Wing Resident rooms B-1 measured 75.7 square feet per resident bed B-2 measured 74.57 square feet per resident bed B-3 measured 73.2 square feet per resident bed B-4 measured 72.7 square feet per resident bed B-5 measured 63.85 square feet per resident bed B-6 measured 58.23 square feet per resident bed B-7 measured 58.35 square feet per resident bed B-8 measured 58.6 square feet per resident bed The facility's DOM confirmed the findings at the times of inspection. The Administrator (via telephone) and DOM was informed of the deficiency during the Life Safety Code survey exit on 01/26/2024 at approximately 12:05 PM. NJAC 8:39 -31.2

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with Federal guidelines for 1 of 15 residents, Resident #8 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 1/22/24 at 11:41 AM, the surveyor observed Resident #8 sitting in a wheelchair with other residents in the day room for recreational activity. The resident was resting in the wheelchair with there eyes closed. There was no urinary catheter observed. On 1/24/24 at 9:40 AM, the surveyor reviewed the electronic and paper medical record for Resident #8. An Admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, right sided weakness following cerebral infarction (stroke), vascular dementia, anxiety disorder, urinary tract infections, hydronephrosis with renal and ureteral calculous obstruction, and overactive bladder. A review of a Quarterly MDS assessment, dated 11/27/23, Resident #8 was documented as rarely/never understood and the resident was unable to complete a Brief Interview for Mental Status (BIMS). In Section H (Bladder and Bowel) of the MDS, under H0100. Appliances, Resident #8 was coded as having an indwelling catheter (including suprapubic catheter and nephrostomy tube). A review of the Order Summary Report for Resident #8 revealed there were no physcian orders for indwelling catheters. On 1/24/24 at 12:40 PM, the surveyor interviewed a Registered Nurse (RN) who cared for Resident #8 about the resident having a catheter. The RN stated the resident previously had a nephrostomy (small tube that helps drain urine) from your kidney. The RN reviewed Resident #8's medical record and explained the resident last had a nephrostomy in March 2022 which was removed in May 2022. The RN stated the resident did not have a nephrostomy tube or other indwelling catheter since that time. On 1/24/24 at 12:56 PM, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON confirmed that Resident #8 previously had a nephrostomy and did not have an indwelling catheter at the time of the MDS assessment. The DON stated she would review the resident's medical records and follow up with the MDS coordinator who was currently not on-site at the facility. On 1/24/24 at 1:21 PM, the DON informed the surveyor that she spoke to the MDS coordinator and acknowledged that the resident should not have been coded for an indwelling catheter. The DON further stated it was a data entry error by the MDS coordinator and the MDS assessment would be modified. On 1/24/24 at 2:30 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and DON about the above concerns. The DON and LNHA acknowledged MDS assessments should be coded accurately. No further information was provided. NJAC 8:39-33.2 (d)

Based on observation, interview, and review of medical records, it was determined that the facility failed to follow professional standards of practice by a.) not acquiring physician's order (PO) for the administration of Oxygen, b.) not administering the medication as ordered by the Physician and c.) by not following the facility's policy for (Peripherally Inserted Central Catheter) PICC line medication administration. This deficient practice was observed for 1 of 15 residents reviewed, Resident #19, Resident #5 and Resident #127 as 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 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. 1. On 1/22/24 at 11:35 AM, the surveyor observed Resident #19 lying on the bed in the resident's room. The surveyor inspected the Oxygen tubing dated 1/21/24 and the Oxygen concentrator which was set at 2 liter(L)/minute (min.) On 1/23/24 at 8:40 AM, the surveyor observed Resident #19 awake, lying on bed. The surveyor inspected the Oxygen concentrator which was set at 2L/min. The oxygen was delivered continuously via nasal canula. The surveyor reviewed Resident #19's hybrid medical records. The admission record (AR) reflected that Resident #19 was admitted to the facility with medical diagnoses which included but was not limited to Fracture of Upper End of right tibia; Hyperlipidemia; Chronic Obstructive Pulmonary Disease; and Hypertension. A review of the Admission Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 12/3/2023 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating that the resident was cognitively intact. On 1/24/24 at 10:50 AM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1) assigned to Resident #19 who stated that for any resident who was on oxygen, it must be documented in the electronic treatment administration record. The surveyor interviewed the facility's Director of Nursing (DON) who stated that there was no Physician's Order (PO) for Resident #19's continuous use of oxygen. A review of the facility's Policy and Procedure titled, Oxygen Administration reflected under preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. On 1/24/24 at 2:50 PM, the surveyor met with the facility's Licensed Nursing Home Administrator and DON. The DON acknowledged that there was no PO for Resident #19 who was on continuous oxygen. 2. On 1/23/24 at 8:40 AM, the surveyor observed LPN #2 administer medication to Resident #5. The surveyor observed LPN #2 dispensed 2 tablets from a bottle labeled, Cranberry 500 mg + Vitamin C 200mg. The surveyor reviewed Resident #5's hybrid medical records. The AR reflected that Resident #5 was admitted to the facility with medical diagnoses which included but was not limited to XXXXXXXXXXXXXXXXXX. The resident had a current PO which reflected in the January 2024 electronic Medication Administration Record for Cranberry Oral Tablet 500 milligrams (mg) give 2 tablet by mouth one time a day for UTI prevention with an order date of 1/2/24. The surveyor observed LPN #2 dispensed 2 tablets from a bottle with a label indicating, Cranberry 500 mg + Vitamin C 200mg. On 1/23/24 at 10:05 AM, the surveyor interviewed LPN #2 who acknowledged that the medication she administered did not match the current PO for Resident #5. No further information was provided. 3. On 1/22/24 at 11:50 AM, the surveyor observed Resident #127 lying on the bed in the resident's room. The surveyor reviewed Resident #127's hybrid medical records. The AR reflected that Resident #127 was admitted to the facility with medical diagnoses which included but were not limited to Acute Osteomyelitis, Pressure Ulcer of left heel; Type 2 Diabetes Mellitus and Hyperlipidemia. A review of the A/MDS, an assessment tool used to facilitate the management of care, dated 1/25/24 reflected that the resident had BIMS score of 14 out of 15 indicating that the resident was cognitively intact. A review of the progress notes dated 1/18/2024 which documented that Resident #127 had an intact left arm PICC line patent for intravenous (IV) antibiotics. A review of the electronic Medication Administration Record (eMAR) reflected a PO dated 1/18/2024 for Ceftriaxone Sodium Injection Solution Reconstituted 1 gram (GM). Use 1 GM intravenously one time a day for wound care for 4 days. The medication was administered by LPN #2 as reflected in the eMAR. Further review of the eMAR reflected a PO dated 1/18/24 to, Flush IV with 10 milliliter (ml) and 5 ml heparin every night shift for 8 days. The medication was administered from January 18, 2024 through January 23, 2024 by a LPN. The surveyor reviewed the facility's policy and procedure titled, PICC Medication Administration Policy with a review date of 7/7/23 which reflected under Policy, The catheter must be flushed after each use by an Registered Nurse (RN) only. Further review of the policy indicated, Note: Only RN's with IV certification can access a PICC line, infuse medications, care for and maintain it. However, an LPN can prepare IV medication, spike and hang the medication on the pole, but will not connect it to PICC. The surveyor interviewed the facility's DON who confirmed that the LPNs who administered the IV medication through the PICC line were not IV certified. On 1/24/24 at 2:50 PM, the surveyor met with the facility's Licensed Nursing Home Administrator and DON. The DON agreed that the medication should not have been administered by a non IV certified LPN. NJAC 8:39- 29.2 (d)

Complaint NJ #: 163054 Based on interview and review of the Nurse Staffing Report it was determined that the facility failed to ensure that a required Registered Nurse (RN) was present at the facility 7 days a week for at least 8 consecutive hours a day for 4 of 14 days reviewed. This deficient practice was evidenced by the following: Per the Interpretive Guidance S483.35(b) Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week. However, per Facility Assessment requirements at F838, S483.70(e), facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. If it is determined the services of an RN are required for more than 8 hours a day. Facilities may choose to have differing tours of duty (e.g. 8 hour- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. Review of the Nurse Staffing Report completed by the facility for the week of 3/12/23 to 3/25/23 revealed the facility had no RN coverage on any shift for the following days: 3/12/23, 3/18/23, and 3/19/23. Review of the Nurse Staffing Report completed by the facility for the week of 1/14/24 to 1/20/24 revealed the facility had no RN coverage on any shift for 1/15/24. On 1/24/24 at 2:15 PM, during an interview with the surveyors, the Director of Nursing (DON) agreed that there should be a RN in the facility daily for 8 consecutive hours. The DON stated that she was previously the only RN employed by the facility. No further information was provided. NJAC 8:39-25.2(h)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/22/24 at 9:10 AM, the surveyor in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the food preparation area, the surveyor observed the microwave with a white and yellowish debris throughout the microwave. 2. Next to the refrigerator/freezer the surveyor observed an Air Condition (AC #1) unit with a heavy buildup of a brown colored dust-like debris on the air outlet grill of the AC. 3. Above the 3 compartment sink, the surveyor observed AC #2 with a heavy buildup of a brown colored dust-like debris on the air outlet grill of the AC. The FSD explained that the debris in the microwave was from the weekend staff, unable to state why nobody had cleaned the microwave. The FSD revealed that the microwave should be cleaned after each meal and/or when visibly soiled. The FSD verified that the maintenance department is responsible for maintaining and cleaning the AC units. On 1/22/24 at 10:30 AM, the surveyor interviewed the Maintenance Director (MD) who stated that cleaning should be performed monthly but did not have a documented schedule. The MD revealed that the ACs where cleaned last month but could not provide any documented proof that this occurred. On 1/24/24 at 9:55 AM, the FSD provided the surveyor with a facility policy titled, Clover Rest Home Sanitation of Small Equipment, no created or revised date noted. Under the policy section it states, Small equipment will be cleaned and sanitized as needed to maintain good sanitation and prevent foodborne illness. Under the procedure section of the policy it states, Nonfood contact surfaces will be cleaned & wiped with a sanitizing solution .Microwave will be cleaned as needed, a minimum of once daily. Inside and outside will be cleaned & wiped with a sanitizing solution. On 1/24/24 at 2:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA acknowledged that all equipment in the kitchen should be cleaned and sanitized when visibly soiled. No further information was provided. NJAC 8:39-17.2(g)

Based on interview, review of medical records (MR) and pertinent facility documents on 1/19/23 and 1/25/23, it was determined that the facility failed to reassess and provide care for pressure ulcers in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed for pressure ulcer care. The deficient practice is evidenced by the following: 1. According to the Admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Pneumonia and Anemia. The Minimum Data Set (MDS), an assessment tool, dated 2/13/22, revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognitive status and required extensive assistance with Activities of Daily Living (ADL). The Nursing Evaluation Collection (NEC), an admission nursing assessment form, revealed that Resident #3 had a reddened sacrum/buttock and an unstageable left foot wound covered with eschar. The Order Summary Report (OSR), a physician order record, revealed the following: Apply skin prep to wound in left foot every day and evening shift for unstageable wound which started on 2/16/22. Apply Silvadene cream 1% to sacral ulcer topically every shift which started on 2/24/22. The care plan (CP) for the risk for skin breakdown and left foot ulcer was initiated on 2/16/22. Goals and interventions included but were not limited to: Administer treatment to left foot, monitor effectiveness; pressure reducing cushion to the wheelchair; notify MD of any skin concerns and initiate treatment promptly. The Progress Note (PN) revealed the following: on 2/11/22, the Director of Nursing (DON) documented an unstageable wound to the top of the left foot with eschar, and reddened buttocks. On 2/24/22, the attending Nurse Practitioner (NP) documented multiple minimal stage 2 pressure sacral ulcers, measurement as per nursing notes. There was no documentation in the PN to indicate that the wounds were reassessed and measured after they were initially noted on 2/11/22 for the left foot wound and on 2/24/22 for the sacral wound. The February 2022 Electronic Medical Record (ETAR) revealed that the treatment for the left foot wound started on 2/16/22. The ETAR reflected to apply skin prep to left foot ulcer every day and evening. There was no documentation that the treatment was performed on 2/17/22 day and evening, 2/20/22 day, 2/24/22, and 2/26/22 evenings. The treatment for the sacral ulcer was started on 2/24/22 every shift, and there was no documentation on 2/24/22 and 2/26/22 evening, and 2/28/22 night. Additionally, there was no documentation in the ETAR for weekly skin assessments or wound measurement. During an interview with the License Practical Nurse (LPN) on 1/19/23 at 1:13PM, she stated that the nurse who assessed the wound on admission is responsible for calling the primary physician (PP) for wound treatment orders and entering the orders in Electronic MR (EMR). She explained that wound treatments performed by the nurses is documented in the ETAR, and if not documented, it means it was not done. Additionally, resident who requires an air mattress needs a physician's order with setting instructions. The order is entered into the EMR and nurses document every shift in the TAR to show that air mattress was checked. She further explained that the former Assistant DON used to complete the weekly wound assessment/measurement (WWAM) until the end of 2021. After that, the staff nurses or the DON began doing it. However, the LPN could not explain why there was no wound treatment ordered for the left foot wound until 2/16/22 and no weekly wound assessment. During an interview with the NP post survey on 2/15/23 at 12:18 PM, she stated that she expects nurses to call her or the PP for treatment orders for new or existing pressure wounds. She could not recall the Resident but stated that there should have been an order for the left foot wound if she was notified. During an interview with the DON on 1/19/23 at 1:35 PM, she stated that the attending nurse must call the PP for wound treatment orders. WWAM must be documented in the EMR by the nurses, and if not documented, it was not performed. Weekly wound assessment does not require a doctor's order. The DON could not explain why Resident #1 was not provided treatment for left foot wound until 2/16/22, and WWAM was not documented in the EMR or PN. However, she acknowledged that the treatment should have been initiated and weekly wound measurement should have been done. A review of the facility policy on Pressure Ulcers/Skin Breakdown- Clinical Protocol revised 4/2018 indicated that the nurse shall describe and document/report full assessment of the pressure sore .the physician will order pertinent wound treatments and help identify medical interventions related to the wound management. NJAC 8:39-27.1(e)

Based on interviews, record review, and facility policy review, it was determined that the facility failed to develop a comprehensive care plan with interventions for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice had the potential to affect all residents. Findings included: 1. The facility admitted Resident #27 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #27's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A further review indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #27's care plan, dated 09/22/2021, revealed no focus care area for DM, insulin use, or any other interventions of care for DM. A review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The sliding scale indicated the following: if BS (blood sugar) of 0-150, give zero units; if BS of 151-200, give two units; if BS of 201-250, give three units; if BS of 251-300, give four units; if BS of 301-350, give five units; if BS of 351-400, give six units; and if BS was greater than 400, contact the physician. The order indicated to inject subcutaneously four times a day (QID) for DM. During an interview on 10/20/2021 at 10:20 AM, the MDS Coordinator stated a resident's care plan was developed based on the care areas triggered by the admission MDS assessment. The MDS Coordinator further stated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator acknowledged that Resident #27 admitted on [DATE] and did not have a care plan for DM and did not know why. The MDS Coordinator then stated she would create one at that time. The MDS Coordinator stated it was important to have a care plan for DM so all staff would know the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/20/2021 at 2:55 PM, the Director of Nursing (DON) stated Resident #27 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated it was important to include DM and the interventions in place in the care plan, so staff knew what to look for in signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. Also, staff needed to know when to call the physician if a resident's blood glucose was greater than 400. The DON then stated the MDS Coordinator had been in that position for over a year, and the MDS Coordinator was expected to initiate a care plan for DM and insulin administration. During an interview on 10/21/2021 at 9:15 AM, the Administrator stated he expected a complete and accurate comprehensive care plan for all residents, so staff knew how to care for each resident. A review of the facility's policy titled, Care Planning - Interdisciplinary Team Policy, dated 09/2013, revealed, the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident .comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. New Jersey Administrative Code S 8:39-11.2 (e) 1

Based on record review, staff interviews, and facility policy review, it was determined the facility failed to revise and update a care plan related to a nephrostomy tube for one (Resident #10) of 12 residents reviewed for care planning. Findings included: 1. The facility admitted Resident #10 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/25/2021, indicated Resident #10 was rarely/never understood. The resident had both long-term and short-term memory impairment and was severely cognitively impaired. Resident #10 had a nephrostomy tube. A review of the care plan, dated 02/24/2021, indicated Resident #10 had a nephrostomy tube inserted due to poor kidney function, urosepsis, and stones. There were goals of being and remaining free from catheter-related trauma through the next review date of 08/23/2021 and showing no signs or symptoms of urinary infection through the next review date of 08/23/2021. Interventions on 02/24/2021 included flushing the drainage tube two times per week with 10cc (cubic centimeters) of saline. A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 03/26/2021. A review of the record revealed there was no updated care plan reflecting the flushing of the nephrostomy catheter every day. During an interview with the MDS Coordinator on 10/20/2021 at 10:20 AM, she stated care plans should be completed timely. During an interview with the Director of Nursing (DON) on 10/20/2021 at 2:50 PM, she stated she would expect the care plan would be updated to reflect how the resident's nephrostomy tube was to be cared for. During an interview with the Administrator on 10/21/2021 at 9:20 AM, he stated the MDS Coordinator updated all care plans, and he would expect the care plan would be updated timely and be accurate. A review of the facility's policy titled, Nephrostomy and Cystostomy Tube Care and Maintenance, dated 2020-2021, indicated, residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. New Jersey Administrative Code S 8:39-11.2 (i)

Based on observations and staff interviews, it was determined that the facility failed to provide at least 80 square feet per resident bed, in multi-bedded rooms. Findings included: 1. During a tour of the facility on 10/21/2021 from 8:16 AM to 8:24 AM in the presence of the facility's Maintenance Director, the surveyor observed that resident rooms located on the A-Wing, Rooms 1, 2, 3, and 4 did not have 80 square feet per resident bed. The resident rooms on the A-Wing measured 59.37 square feet per resident bed. The surveyor also observed that resident rooms located on the B Wing, Rooms 1, 2, 3, 4, 5, 6, 7, and 8 did not have 80 square feet per resident bed. The resident rooms on the B Wing measured 77 square feet per resident bed for Rooms 1, 2, 3, and 4, and 66 square feet per resident bed for resident Rooms 5, 6, 7, and 8. The facility's Maintenance Director confirmed these findings during the tour and acknowledged that the above-mentioned rooms were not 80 square feet per resident bed. He further stated he was present during the 2019 Fire Safety Evaluation System (FSES) survey when measurements were taken with a laser and the measurements were accurate. The surveyor verbally informed the facility's Administrator of the above findings during the exit conference. New Jersey Administrative Code S 8:39-31.2(e)

C#: NJ 3 Based on observations, interviews, review of medical records, and other pertinent facility documentation on 3/5/2021, it was determined that the facility failed to ensure that appropriate Transmission Based Precautions ( TBP) were practiced by healthcare staff while caring for a resident ( Resident #2) who had been placed on Persons Under Investigation ( PUI) and isolation droplet precautions for possible exposure to COVID-19. The staff were not using appropriate Personal Protective Equipment ( PPE) according to the Centers for Disease Control ( CDC) guidelines, New Jersey Department of Health Executive Directive Number ( NO) 20-026 and facility polices and procedures for infection control when entering a PUI resident room and leaving to enter 2 non-PUI residents rooms ( Resident #5 and Resident #6) . The facility also failed to implement mitigation strategies to prevent the transmission of COVID-19 by not appropriately identifying a resident ( Resident #5) who had been positive and symptomatic for COVID -19 during a acute care hospital in-patient admission from 2/6/2021 to 2/24/2021. Resident #5 was readmitted back the facility on 2/24/2021 as a non-PUI, but the resident was still having residual effects of the virus according to the documentation noted in the resident's Care Plan on 2/27/2021. On 2/24/2021, Resident #5 was placed in a room with another resident ( Resident #4) who was non-PUI. Resident #4 was discharged from the facility on 3/4/2021. The facility's failure to adequately monitor staff not using PPE appropriately and co-[NAME] residents properly posed a serious and immediate threat to the safety and well-being of all non-PUI residents residing in the facility. On 3/5/2021 an Immediate Jeopardy ( IJ) situation was identified at 3:10 p.m. and reported to the Administrator and the Director of Nursing. The facility was presented with the IJ template that described the deficient practices. On 3/5/2021, the facility provided an acceptable IJ Removal Plan at 4:37 p.m. On 3/9/21, the surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating all facility staff on quarantining, PUI contact, droplet precautions, donning (putting on) and doffing (removing) of the appropriate PPE in PUI/droplet isolation rooms with return demonstrations done with the Infection Preventionist. This deficient practice was identified for 4 of 4 staff members, who provided care to residents on the B hallway, who were designated PUI or non-PUI for 3 of 7 sampled residents ( #2,#5, and #6) reviewed for infection control practices. Also, the facility failed to follow its policies titled Admission/Re-Admission Policy and Procedure for COVID-19, Coronavirus Disease (COVID-19) Infection Prevention and Control Measures, and Outbreak Response Plan. the deficient practices were evidenced by the following: During a B hallway tour on 3/5/2021 at 9:56 a.m., a member of the survey team observed the Certified Nursing Assistant (CNA) in a PUI/isolation droplet precaution room occupied by Resident #2. The CNA was at the resident's bedside without wearing any PPE. The CNA only wore a surgical mask. The CNA then left the room, walked to the end of the hallway, and then into the main activity area where non-PUI residents were present. The surveyor at this time, had observed a plastic bin located outside Resident #2's PUI/isolation droplet precaution room. The PPE that was in the plastic bin were disposable gowns, goggles, surgical masks, gloves, plastic bags with a hand sanitizer bottle, and disinfecting wipes. The signage located outside of the room on the left side of the doorway indicated to Stop and isolation/droplet precautions. During a second tour of the B hallway on 3/5/2021 at 10:15 a.m., the surveyor observed the Occupational Therapist (OT) in Resident #2 's PUI/ isolation droplet precaution room. The OT was at the resident's bedside, leaning over the bed and speaking with the resident. The OT wore a surgical mask and gloves only. The OT came out of the room and placed the gloves in the trash by the door and went to the end of the hallway towards a nursing station that is used for charting purposes only. No residents were present at that time in the area. According to the facility Admission Record (AR), Resident #2 was readmitted to the facility on [DATE] from a acute care hospital; with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission to the facility resident had a rapid Covid-19 test that was negative. According to the Minimum Data Set (MDS), an assessment tool dated 2/24/2021, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 2/15, which indicated the resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with Activities of Daily Living (ADLs). A review of the Progress Notes (PN) dated 3/4/2021 at 4:29 a.m., showed Resident will be placed on 14-day isolation droplet precaution per facility protocol . Review of a second PN dated 3/4/2021 at 10:07 a.m. written by the Director of Nursing (DON), revealed that Resident (#2) is quarantined in room for 14 days per (NJDOH) New Jersey Department of Health policy. During an interview on 3/5/2021 at 10:42 a.m., the OT stated when a resident is on PUI/ droplet isolation, I wear the full PPE. The OT explained she wears gown, face shield or goggles, N95 mask with surgical mask and gloves. The OT also stated she forgot to put on the PPE and said, I should have worn the PPE. During an interview on 3/5/2021 at 11:20 a.m., the Certified Nursing Assistant ( CNA) stated to the surveyors, that before entering a PUI/droplet isolation precaution room, the staff has to wear PPE, including gown, gloves, goggles, or face shield, and an N95 mask. According to the CNA, before entering the PUI/droplet isolation room, she did apply the full PPE when she was in the resident's room. She also indicated for the surveyors to review the facility's camera. The surveyors reviewed the facility's video recording camera of the B hallway on 3/5/2021 at 11:30 a.m., in the presence of the Administrator and the Director of Nursing (DON). The camera revealed the following: On 3/5/2021 at 9:42 a.m., the LPN went into the PUI/ isolation droplet precaution room occupied by Resident #2 wearing only a surgical mask. The LPN did not apply the required PPE per facility policy and NJDOH guidelines into the PUI/ droplet isolation precaution room. The LPN then came out of the room at 9:45 a.m. and into the hallway, spoke with other staff members, and then proceeded out of the area. On 3/5/2021 at 9:43 a.m., the Director of Rehabilitation (DOR) went into Resident #2 PUI/ isolation droplet precaution room without applying any required PPE and came out of the room at 9:47 a.m. The DOR then went into Resident #5 room, who was noted as non-PUI. Then DOR left that room went into a second non-PUI resident room , Resident #6 at 9:49 a.m. On 3/5/2021 at 9:57 a.m., the CNA went into the PUI/ droplet isolation precaution room wearing only a surgical mask without any N95 mask, gown, a face shield or goggles, or gloves. The CNA then came out of the room and walked down the hallway. During an interview on 3/5/2021 at 11:20 a.m., the CNA stated, I am confused about what residents are considered as quarantine and the number of days for the quarantine for COVID prevention. The CNA explained when a resident was a new admission or readmitted from the hospital; the residents were placed in rooms with current residents who were not on quarantine. During an interview on 3/5/2021 at 12:05 p.m., the DOR stated she did not wear the appropriate PPE into the PUI/ isolation droplet precaution room because she was in the room for less than a minute to fix Resident #2's leg rest for the wheelchair, so the full PPE was not needed. The DOR also stated she didn't have any contact with the resident. During an interview on 3/5/2021 at 12:25 p.m., the LPN stated if a resident was on PUI/ droplet isolation, I wear a disposable gown, N95 mask with a surgical mask over it, goggles and gloves. The LPN also stated a Stop sign and isolation /droplet precaution signs were outside of Resident 2's door. The LPN further explained she did not wear PPE into the PUI/ isolation droplet precaution room because she did not have any patient contact, so PPE was not needed. During an interview on 3/5/2021 at 2:15 p.m., the DON stated the purpose of wearing the appropriate full PPE into a PUI/droplet isolation precaution room was to prevent the spread of COVID-19 infection between staff and residents. The DON also stated that residents are on isolation droplet precautions for investigative purposes, quarantined for 14 days for COVID-19 infection, even if there are no signs or symptoms. During an interview on 3/9/2021 at 1:00 p.m., the DON stated to the surveyors, I saw exactly what you all saw on the camera; the CNA, OT, DOR, and LPN all entered Resident #2's room without wearing any PPE. The DON explained before going into a PUI/ droplet isolation room, staff should wear an N95 mask with a surgical mask over it, a gown, goggles, or face shield, and gloves. The disposable gown, gloves, surgical mask, and goggles/face shield are removed upon exiting the room Resident #5 was not observed being on PUI/ isolation droplet precaution during the B hallway tour on 3/5/2021 and 3/9/2021. According to the AR, Resident #5 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS, an assessment tool dated 3/3/2021, Resident #5 had a BIMS of 6/15, which indicated the resident was severely cognitively impaired. The MDS also indicated that Resident #5 needed extensive assistance with ADLs. Review of Resident #5' Care Plan dated 2/24/2021 revealed under Focus: COVID RECOVERY: Resident #5 previously tested positive for COVID-19-hospitalized [DATE] through 2/24/2021 for COVID pneumonia was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record progress note dated 2/24/2021 at 3:10 p.m. by the DON, noted that the resident had COVID -19 and pneumonia causing metabolic brain disorder. The resident was incontinent of bowel and bladder. Vital signs were documented as : temperature was 97.9, heart rate 110, blood pressure 91/70 and oxygen saturation level 94 percent on room air. Resident was sleeping. A progress noted dated 2/25/2021 at 6:35 am by a Licensed Practical Nurse ( LPN) noted the resident was very lethargic and had slept the entire shift. On 2/25/2021, at 1:41 p.m., the progress noted that the resident expressed feeling weak to the LPN. Also noted in the Resident #5 MR,on the day of admission back into the facility on [DATE], the resident was placed in to the room with Resident #4. A review of Resident #4 MR, according to the AR, this resident was admitted to the facility from an acute care hospital in-patient stay on 2/9/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 had been placed on a PUI/ droplet isolation precaution from 2/9/2021 through 2/23/2021. The resident discharged from the facility on 3/4/021 and was given a rapid COVID-19 test, which was negative. The MR showed no evidence that Resident #5 was placed on PUI/ isolation droplet precaution on the day of admission to the facility on [DATE] through 3/9/2021 per the facility's policy and DOH guidelines. During a post-survey telephone interview on 3/10/2021 at 10:45 a.m., the surveyor asked the DON why Resident #5 was not on PUI/ isolation droplet precaution upon admission and placed with a roommate. The DON stated that Resident #5 was Covid-19 recovered in the hospital before coming back to the facility. During a telephone interview on 3/9/2021 at 11:22 a.m., the Medical Director (MD) stated staff did not need a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD explained it is the facility's policy for the residents to be placed on quarantine for 14 days to prevent the spread of the COVID-19 infection, so staff should follow the policy. During an interview on 3/9/2021 at 1:00 p.m., the DON stated she obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the COVID-19 Vaccine Clinic / Patient Information Log with clinic dates 1/18/2021 and 2/8/2021 provided on 3/9/2021 from the Director of Nursing ( DON) indicated Residents #2, Resident #4 and Resident #5 were not vaccinated. Resident #6 had completed the 2 vaccination shots. Also, the staff who are employed at this facility at the time of the survey had not been vaccinated according to the DON. Review of facility policy titled Admission/Re-Admission Policy & Procedure for COVID-19 revised May 18, 2020 revealed under Objective: revealed To implement proper infection control prevention and practices to prevent the development and transmission of COVID-19 and other communicable disease and infections. Under Procedures: B. Resident will be assessed for symptoms such as cough, body aches, sore throat, shortness of breath, and other flu-like symptoms, the resident will immediately be placed on isolation precautions for 14 days .E. Protective personal equipment (PPE) must be worn before entering room. Review of facility policy titled Coronavirus Disease (COVID-19) Infection Prevention and Control Measures revised April 2020 revealed, under Policy Statement This facility recommended standard and transmission-based precautions .to prevent the transmission of COVID-19 within the facility. Under Policy Interpretation and Implementation .12. For a resident with known or suspected COVID-19: a. Staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available . Review of the facility's Outbreak Response Plan revised November 2020 indicated that the facility would implement Transmission Based Precautions in accordance with Centers for Disease Control guidance. N.J.A.C. 8:39-19.4 (a) (b)

C #: NJ 302 Based on observation, interviews and record review, as well as review of pertinent facility documents on 1/13/21, it was determined that the facility failed to establish and implement an acceptable standards of infection prevention and control to prevent the spread of infection control for 9 of 21 residents (Residents: #1, and unsampled Residents #A, #B, #C, #D, #E, #F, #G, #H) observed not wearing a face mask. This deficient practice is evidenced by the following: Reference: EXECUTIVE DIRECTIVE NO. 20-026, dated October 20, 2020.III Required standards for visitation .3. Cohorting, PPE and Training Requirements in Every Phase: .ii. Facilities shall implement universal source control for everyone in the facility. All residents, whether they have COVID-19 symptoms or not, must practice source control when around others (surgical mask if supply is available) in accordance with CDC guidance . Reference: New Jersey Department of Health, COVID-19 also known as Severe Acute Respiratory Syndrome Coronavirus 2 or [DIAGNOSES REDACTED]-CoV-2, dated November 23, 2020, COVID 19 .7 CONTROLLING FURTHER SPREAD .C. Managing Special Situations .Long-Term Care Facilities .Use of standard and transmission-based precautions which includes appropriate use of personal protective equipment; Implement universal source control (i.e., use of barrier to cover the nose and mouth) .All patients/residents, whether they have COVID-19 symptoms or not, should cover their nose and mouth (i.e., source control) when around others, as tolerated. Source control may be provided with tissue, facemasks, or cloth face coverings . Reference: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES, dated 11/2020 .Infection Prevention, Control & immunizations .Source Control for COVID-19: Ensure residents (when receiving visitors or while outside of their room), visitors, and others at the facility are donning a cloth face covering or facemask while in the facility or while around others outside . Reference: New Jersey Hospital Association (NJHA), COVID-19 TOOLKIT OF RESOURCES FOR LONG TERM CARE FACILITIES, Version 2, dated April 10, 2020, under PROTECTING RESIDENTS, VISITORS, AND HCP .Restrict the movement of residents throughout the facility .Restrict residents (to the extent possible) to their rooms except for medically necessary purposes. IF they leave their room, residents should practice source control measures (e.g., use of barrier to cover their nose and mouth) .All residents, whether they have COVID-19 symptoms or not, should cover their nose and mouth .when around others . During the tour with the Director of Nursing (DON) on 1/13/2021 the surveyor observed following: At 9:22 am to 10:07 am, the surveyor observed 7 unsampled residents (Resident A, B, C, D, E, F, and G) watching Television (TV) in the facility's activity room without a facemask on. At 10:05 am, surveyor observed unsampled Resident H walking in the hallway without a face mask on. At 10:08 am, the surveyor observed Resident #1, enter the dining room without a face mask on. The surveyor observed Res #1 observed touched his/her mouth and nose then touched the table and the chair. At 10:29 am, Resident #1 left the dining room, continued to walk without a face mask on and opened the closets in the hallway. Then without a face mask on, Resident #1 walk past other residents towards the activity room. The surveyor conducted an interview with multiple Certified Nursing Assistants (CNAs) on 1/13/21 at 10:44 am. The CNAs stated residents were allowed to walk outside their rooms without a face mask on. The surveyor conducted an interview with Resident #1 who was cognitively intact on 1/13/21 at 11:09 pm. The Resident stated that he/she was told by the staff that residents were allowed to walk outside their rooms without a face mask on. Resident #1 revealed that he/she had been coughing and had a runny nose. The surveyor conducted an interview with License Practical Nurse (LPN #1) on 1/13/21 at 11:39 am. The LPN stated that residents did not have to wear a face mask outside their rooms. The surveyor conducted an interview with the Director of Nursing (DON) on 1/13/21 at 12:14 pm. The DON stated that she was not aware that residents could not walk outside their rooms without a facemask on. NJAC 8:39-27.1(a)

Based on observation, interview, and review of records, it was determined that the facility failed to: a) screen everyone upon entering the facility for symptoms of Covid-19 virus, and failed to disinfectant and sanitize the equipment used in the COVID-19 screening process; and, b) ensure that workers were knowledgeable regarding the cleaning chemicals used in the workplace for 3 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: A review of the U.S. CDC's Cleaning and Disinfecting Your Facility, updated on 7/28/2020, included, Practice routine cleaning of frequently touched surfaces. High touch surfaces include tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, sinks, etc. Disinfect with a List N: disinfectants for use against [DIAGNOSES REDACTED]-CoV, [MEDICAL CONDITION] that causes COVID 19. For electronics, such as tablets, touch screens, keyboards, remote controls, and ATMs, consider putting a wipeable cover on electronics. Follow the manufacturer's instructions for cleaning and disinfecting. If no guidance, use alcohol-based wipes or sprays containing at least 70% alcohol. Dry surface thoroughly and wear appropriate PPE when cleaning or disinfecting frequently touched surfaces and electronics. Additional considerations for employers: Educate workers performing cleaning, laundry, and trash pick-up to recognize the symptoms of COVID-19. Develop policies for worker protection and provide training to all cleaning staff on-site prior to providing cleaning tasks. Ensure workers are trained on the hazards of the cleaning chemicals used in the workplace in accordance with OSHA's Hazard Communication Standard. 1. On 12/3/20 at 8:59 AM, the Registered Nurse, allowed surveyors access into the facility and guided the surveyors through a hallway, past resident rooms to the nurses' station on A Unit. The RN did not screen the surveyors upon entrance. The Director of Nursing (DON) met the surveyors at the nurses' station on A unit and used the thermometer that had been sitting directly on the desk, not on a clean barrier, to take the surveyor's temperatures. The DON then placed the thermometer back on the desk without disinfecting it. The surveyors asked the DON what the facility's screening policy and the procedure was. The DON replied, we take the temperatures and then have you sign the book. The surveyors asked the DON why she didn't disinfect the thermometer and why she didn't ask the screening questions for symptoms or contact. The DON did not respond. The surveyors asked the RN why she did not screen them upon entry into the facility. The RN did not respond. The surveyor reviewed the facility policy entitled, Infection Control-Outbreak Plan, dated March 2020 and revised November 2020, which indicated that the facility shall screen and log everyone entering the facility for symptoms of the infectious disease. Screening will include: Temperature checks, including subjective or objective fever equal to or greater than 100.4 degrees Fahrenheit or as further restricted by the facility. Completion of questionnaire about symptoms and potential exposure, which shall include a minimum: a. Exhibit signs and symptoms of infectious disease, including Covid-19, such as fever, chills, cough, shortness of breath or difficulty breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion, or runny nose, nausea or vomiting, or diarrhea. b. Has had contact with someone with a confirmed [DIAGNOSES REDACTED]. c. In the last 14 days, has returned from a designated state under the 14-day quarantine travel advisory. 2. On 12/3/2020 at 9:40 AM, the Housekeeping Director (HD), in the presence of the DON, informed the surveyor that he was also the director of maintenance and had been working in the facility for over [AGE] years. The HD stated that housekeeping staff use bleach germicidal wipes and liquids as disinfecting chemicals for frequently touched surfaces. The surveyor asked the HD what the bleach wipes' contact time was, and the HD replied, I'm not sure. The surveyor then asked the HD if the housekeeping staff were educated about the disinfecting chemicals used in the facility. The HD did not respond. The surveyor asked the HD for any documentation of in-services that the staff had been educated on the proper use of the chemicals. On that same day at 10:00 AM, during an interview, the surveyor asked the housekeeper what chemicals were used to clean the high touch areas in resident rooms. The housekeeper replied that she used disinfectant 30-17 and Clorox bleach wipes. The surveyor asked the housekeeper what the contact time was for each of the cleaning agents. The housekeeper replied, I don't know. The housekeeper stated that she had not received an in-service on contact times for the chemicals. On that same At 10:15 AM, the HD told the surveyor that he was not able to provide any documentation that the staff received in-services about the chemicals used in the facility. On that same day, at 10:30 AM, during an interview, the Registered Nurse (RN) stated that she used Sani wipes for disinfecting multiuse equipment and Chlorox bleach wipes to disinfect the medication cart. The surveyor asked the RN what the contact time was for the Sani wipes and the Bleach wipes. The RN replied, I have no idea. The surveyor asked the RN if she received in-services regarding the contact time for the disinfectant chemicals. The RN did not respond. A review of the facility's Infection Control-Outbreak Plan Policy with a revised date of November 2020 included: 1. The facility shall screen and log everyone entering the facility for symptoms of the infectious disease. Screening will include: a. Temperature checks, including subjective and /or objective fever equal to or greater than 100.4 degrees Fahrenheit or as further restricted by the facility. b. Completion of questionnaire about symptoms and potential exposure, which shall include a minimum: c. Exhibit signs and symptoms of infectious disease, including Covid-19, such as fever, chills, cough, shortness of breath or difficulty breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion, or runny nose, nausea or vomiting, or diarrhea. d. Has had contact with someone with a confirmed [DIAGNOSES REDACTED]. e. In the last 14 days, has returned from a designated state under the 14-day travel advisory. 2. Environmental cleaning the facility will follow current CDC guidelines for environmental cleaning specific to the ID in addition to routine cleaning for the duration of the threat. Also, Environmental Cleaning and Disinfection included, Housekeeping Department will increase the frequency of routine cleaning and disinfection of frequently touched surfaces and shared medical equipment using frequently using products that have EPA-approving emerging [MEDICAL CONDITION] pathogens claims that have demonstrated effectiveness [MEDICAL CONDITION] similar to COVID-19 on hard non-porous surfaces. Adhere to internal environmental cleaning protocols to ensure appropriate measures are being taken to clean and disinfect throughout the facility. At 11:11 AM, the surveyors met with the DON and discussed the above concerns. The facility provided no additional information. NJAC 8:39-19.4 (a) NJAC 8:39-27.1

Based on observation and interview on 11/24/19, it was determined that the facility failed to provide at least 80-square feet per resident bed, in multi-bedded rooms as evidenced by the following: During a tour of the building from 10:15 AM to 12:15 PM, in the presence of the facility's Maintenance Director, the surveyor observed that resident rooms located on the A-Wing; 1,2,3 and 4 did not have 80 square feet per resident bed. The surveyor also observed that resident rooms located on the B Wing; 1,2,3,4,5,6,7, and 8 did not have 80 square feet per resident bed. The resident rooms on the A-Wing measured 59.37 square feet per resident bed. The resident rooms on the B Wing measured 77 square feet for rooms 1,2,3 and 4 and, 66 square feet for resident rooms 5,6,7 and 8. The facility's Maintenance Director confirmed these findings during the tour and acknowledged that the above mentioned rooms were not 80 square feet per resident bed. The surveyor verbally informed the facility's Administrator of the above findings during the Life Safety Code exit conference at 1:00 PM. NJAC 8:39-31.2(e)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan for a resident on contact precaution due to an infection. This deficient practice was identified for 1 of 12 residents (Resident #27) reviewed for comprehensive care plans and was evidenced by the following: On 1/22/19 at 10:15 AM, the surveyor observed Resident #27 seated in a regular chair watching TV in the resident's own room. The surveyor observed PPE (Personal Protective Equipment) placed outside of the resident's room door. The surveyor reviewed Resident # 27's medical record. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The surveyor interviewed the Certified Nurses Assistant assigned to the resident who stated that the resident was currently on contact precautions. The surveyor reviewed the current resident's care plan which revealed that the facility did not develop a care plan reflecting the resident's infection. On 1/23/19 at 1:30 PM, the surveyor spoke to the Administrator and the Director of Nursing who did not provide further information. NJAC 8:39-11.2(e)

Based on observation and interview on 01/22/19, it was determined that the facility failed to provide at least 80-square feet per resident bed in multi-bedded rooms as evidenced by the following: During a tour of the building in the presence of the facility's Maintenance Director, the surveyor observed that resident rooms 1,2,3 and 4 located on the A Wing did not have 80 square feet per resident bed. These rooms measured 59.37 square feet per resident bed. Also, the surveyor observed resident rooms 1,2,3,4,5,6,7 and 8 did not have 80 square feet per resident bed. The resident rooms on the A Wing measured 59.37 square feet per resident bed. B Wing resident room [ROOM NUMBER] measured 77 square feet per resident bed. Resident rooms #5, 6, 7, and 8 on the B Wing measured 77 square feet per resident bed. The facility's Administrator acknowledged in an interview at 1:15 p.m. that these rooms were not 80 square feet per resident bed. All of the above noted rooms currently house 2 residents. The exceptions are room [ROOM NUMBER] and 8 (Private Room) on A wing and rooms [ROOM NUMBERS] on B wing NJAC 8:39-31.2(e)

Based on observation at 10:30 a.m. on 12/1/17, it was determined that the facility failed to provide at least 80-square feet per resident bed in multi-bedded rooms as evidenced by the following: Resident rooms #1, #2, #3 and #4 on A wing and #4, #5, #6 and #7 on B wing, did not have 80 square feet per resident. The resident rooms on A wing measured only 59.37 square feet per resident. On B wing resident room [ROOM NUMBER] measured only 77 square feet per resident, and resident rooms #5 through #7 measured 66 square feet per resident. NJAC 8:39-31.2(e)

Based on observation at 10:30 a.m. on 11/4/16, it was determined that the facility failed to provide at least 80-square feet per resident bed in multi-bedded rooms as evidenced by the following: Resident rooms #1, #2, #3 and #4 on A wing and #4, #5, #6 and #7 on B wing, did not have 80 square feet per resident. The resident rooms on A wing measured only 59.37 square feet per resident. On B wing resident room #4 measured only 77 square feet per resident, and resident rooms #5 through #7 measured 66 square feet per resident. NJAC 8:39-31.2(e)

Based on observation at 10:30 a.m. on 10/1/15, it was determined that the facility failed to provide at least 80-square feet per resident bed in multi-bedded rooms as evidenced by the following: Resident rooms #1, #2, #3 and #4 on A wing and #4, #5, #6 and #7 on B wing, did not have 80 square feet per resident. The resident rooms on A wing measured only 59.37 square feet per resident. On B wing resident room #4 measured only 77 square feet per resident, and resident rooms #5 through #7 measured 66 square feet per resident. NJAC 8:39-31.2(e)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices; observe proper food storage protocols; maintain fresh and frozen dairy foods in a safe and consistent manner; and maintain food equipment services to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 10/23/14 at 8:15 a.m. during the initial tour of the kitchen, in the presence of the cook, the surveyor observed the following: 1. The dispenser holding cup for the juice machine had a large buildup of concentrated syrup. 2. The air inside the white, 2 door, and side by side residential refrigerator felt warm when the door was opened and the internal temperature registered +50 degrees Fahrenheit (F) and the half gallon containers of milk felt warm. At 8:25 a.m. the surveyor placed a calibrated thermometer inside the unit and after 5 minutes it registered +44 degrees F. 3. The air inside the freezer section of the above unit felt warm when opened and six 4 ounce (oz.) portion controlled (pc) nutrition supplement shakes on a shelf in the door were soft to touch. At 8:31 a.m. the surveyor placed a calibrated thermometer inside the unit and after 5 minutes it registered +13.9 degrees F. At 8:45 a.m. the surveyor rechecked the freezer and placed a calibrated thermometer inside the freezer of the above mentioned unite and after 5 minutes the thermometer registered +14.9 degrees F. Review of the manufacturer's label for the nutrition supplement stated the product was stored frozen until ready for use. The product should be thawed at or below +40 degrees F, kept in the refrigerator and discarded after 14 days. Compliance with the manufacturer's instructions was not observed by the surveyor. 4. A shelf inside the 2 door reach-in commercial refrigerator had 4 filled 36-count cardboard egg cartons. The top carton had both raw shelled eggs and used egg shells mixed together. 5. The air inside the filled, white residential reach-in freezer located inside an out-of-service, walk-in refrigerator, felt warm and the bread, rolls and croissants inside were soft to touch. At 8:47 a.m. the surveyor placed a calibrated thermometer inside the freezer section of the above mentioned unit and after 5 minutes the temperature registered +16.2 degrees F. When the Director of Maintenance was interviewed he stated that he was not informed of any problems with the kitchen equipment for the past few months. 6. A wall-mounted open storage shelf located to the right of the dish machine contained multiple wet-nested service ware that included 8 oz. clear plastic cups, green coffee mugs, 4 oz. green bowls and 4 oz. clear plastic dessert cups. 7. The manual can opener blade was soiled with food debris. 8. The dry storage room located on the lower level contained multiple dented cans that were not removed or set aside in a designated area for return or disposal. 9. The floor in the dry storage room was soiled with dust and debris. 10. Five cases of canned food product for the 3 day emergency menu were expired and many of the emergency menu items were missing from the inventory and the floor inside the storage room was soiled with debris. At 9:10 a.m. during an interview with the administrative staff they stated that the designated food for the emergency menu was rotated annually, usually around Christmas. On 10/27/14 at 8:35 a.m. the surveyor re-entered the kitchen to re-check the equipment temperatures with a calibrated thermometer which confirmed the previous day's observations. The surveyor reviewed the temperature logs for the residential refrigerator and freezers from January 1, 2014 through October 22, 2014. The temperatures recorded from 10/8/14 through 10/21/14 the refrigerator section of the side by side unit were above +40 degrees F. The freezer temperatures for both units were above 0 degrees F from August 18, 2014 through October 22, 2014. On 10/27/14 at 12:30 p.m. the Administrator and the Director of Nurses were informed of the surveyor's findings. On 10/23/14 at 12:35 p.m. the surveyor reviewed the facility's policy and procedure (P&P) for "Resident Food Supplies", "Storage Safety" "Food Service Temperatures", "Kitchen Infection Control Procedures" and "Emergency Food Supply." The "Emergency Food Supply" P&P stated "food inventory will be periodically used/disposed of according to a defined schedule that ensures all products are within the manufacturers recommended use by date." The "defined schedule" was not provided for surveyor review. The P&P's reviewed by the surveyor were not dated with a date they were initiated or a revised date and many of them failed to reflect current local, state or federal guidelines as stated below. The P&P for "Resident Food Supplies" stated rotation of stock will be performed daily as new supplies are delivered. The P&P failed to include refrigerator or freezer temperature guidelines. The "Storage Safety" P&P failed to include guidelines for a well-ventilated room, and storage heights. The "Kitchen Infection Control" P&P stated "clean pots, pans, pitchers etc., should be stored upside down" but did not included any information that related to air-dried items to prevent contamination from wet-nested service ware. NJAC 8:39-17.2(g)