**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of misappropriation for one (Resident (R) 93) of two residents reviewed for abuse out of 40 sampled residents. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from misappropriation. Findings include: Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 09/22 indicated . All allegations are thoroughly investigated. The administrator initiates investigations. interviews the resident (as medically appropriate) or the resident's representative. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. interviews the resident's roommate, family members. documents the investigation completely and thoroughly. Review of R93's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled Reportable Event Record/Report, dated 07/19/24, indicated a family member (F) 1 reported that Certified Nurse Aide (CNA) 1 received $100 from R93's cash app on 06/11/24. The facility investigation failed to show that a statement was collected from the resident. There were no other interviews, such as other residents and staff, other than from CNA1 who admitted R93 sent her $100 via a cash app as a gift. During an interview on 07/30/25 at 3:32 PM the Director of Nursing (DON) stated she investigates an allegation of abuse/neglect or misappropriation she would attempt to obtain a statement from the resident involved, other residents, and staff who were on the same shift. The DON confirmed she read the facility investigation which involved R93 and CNA1 and confirmed the investigation was not complete. During an interview on 07/30/25 at 3:56 PM, the Social Services Director (SSD) stated that when she completes an abuse/neglect or misappropriation investigation, she would interview the resident, the person accused, and any other residents and staff who worked at the time of the allegation. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that food preferences were honored for one out of two sampled residents (Resident (R) 26). The facility failed to ensure the resident was given dinner that she had ordered and strawberry ice cream. Findings include: Review of a facility policy titled Menu, dated 10/2017 indicated . Menus are developed and prepared to meet resident choices. Review of R26's electronic medical records (EMR) titled admission Record dated 04/22/25 initially and was readmitted to the facility on [DATE]. During an observation conducted on 07/28/25 at 11:32 AM, R26 pointed to a tray and gave permission to lift the lid to her meal. Observed a beef and Asian noodle dish. R26 explained that she had saved her dinner meal from the night before since it was not what she had ordered. The resident stated she ordered a grilled steak. During this interview the resident presented a menu titled Selection Sheet, dated 07/27/25, for the dinner meal. The resident stated she selected the grilled steak on the menu. During an observation on 07/29/25 at 12:27 PM, Certified Nurse Aide (CNA) 3 brought in R26's noon meal. On the tray was chocolate ice cream. The resident stated she had ordered strawberry ice cream and presented her menu. The resident had handwritten two strawberry ice creams. CNA3 verified the chocolate ice cream on the resident's tray. During an interview on 07/31/25 at 8:39 AM, the Dietary Manager (DM) stated there were two choices for residents on the menu. The DM stated in addition, the resident could write items that they might want, and the kitchen would attempt to accommodate them. The DM stated it may have been a mistake if R26 was sent chocolate ice cream instead of strawberry. The DM stated he was here on 07/27/25 and thought that he was accommodating the resident with beef lo Mein instead of the grilled steak since it was the same meat. The DM stated R26 required small bites of food, and this was why he sent the beef lo Mein to the resident instead of the grilled steak. During an interview on 07/31/25 at 12:00 PM, the Director of Nursing (DON) stated residents were provided with an alternate meal so they can select, and we can accommodate what they want. NJAC 8:39-17.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure one of one resident (Resident (R) 26) reviewed for assistive devices during dining out of a total sample of 40. This had the potential to cause a decrease in the resident's dietary intake. Findings include: Review of a facility policy titled, Assistance with Meals dated 03/22, indicated .Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles. Review of R26's electronic medical records (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. Review of R26's EMR titled admission Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date of 06/10/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which revealed the resident was cognitively intact. Review of a document provided by R26 titled Selection Sheet, dated 07/27/25, indicated the resident used specialized handled utensils. An observation was conducted on 07/28/25 at 12:26 PM, and Certified Nurse Aide (CNA) 3 assisted R26 with her meal tray and verified that the resident did not receive her built up eating utensils. During an interview on 07/31/25 at 8:39 AM, the Dietary Manager (DM) stated the built-up utensils were written by the computer system to include on R26's meal trays. The DM stated for R26 not receiving them was a mistake and that the resident typically will have a set of built-up utensils available in her room. During an interview on 07/31/25 at 12:00 PM, Director of Nursing (DON) stated it was important to provide R26 with built up utensils so she could properly feed herself. NJAC 8:39-27.5(b)

Based on record review, observations, and interviews the facility failed to ensure one Certified Nursing Assistant (CNA) 1 was effectively trained in understanding misappropriation. As a result, money was exchanged from one of one resident (Resident (R) 93) to CNA1. This had the potential for staff not to recognize a gift could be viewed as misappropriation, when a resident was dependent on the caregiver for personal needs. Findings include: Review of a document provided by the facility titled Certificate of Completion for CNA1, dated 04/01/24, indicated CNA1 completed training abuse, neglect, and exploitation. Review of a document provided by the facility titled, Certified Nursing Assistant, dated 07/2024 indicated the job description for a CNA was to .Attend and participate in facility in-service training programs as instructed including resident rights, prevention of abuse and neglect, dementia care, behavioral management and competencies for Certified Nursing Assistants. Review of a document provided by the facility titled, Facility Assessment, dated 07/18/25, indicated .Facility resources needed to provide competent support and care for our resident population every day and during emergencies.Staff training/education and competencies. During an interview on 07/30/25 at 3:32 PM, the Director of Nursing (DON) stated the abuse prevention training that CNA1 took included misappropriation and that gifts/money were not to be taken from residents even if it was a gift since the staff were paid to do a job. NJAC 8:39-13.4(c)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and facility policy review, the facility failed to ensure initial and weekly weights were implemented for two out three residents (Resident (R) 26 and R92). This lack of monitoring of residents' weight loss/gain can delay in identifying potential nutritional problems.Findings include: Review of a facility policy titled, Weight Assessment and Intervention dated 03/22 indicated .Residents are weighed upon admission and at intervals established by the interdisciplinary team such as: weekly for four weeks, the monthly unless otherwise indicated. The threshold for significant unplanned and undesired weight loss is based on the following criteria.1 month-5 percent weight loss is significant.6 months-10 percent weight loss is significant. Review of R26's EMR titled admission Record located under the Profile tab indicated the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R26's EMR titled Nutritional Evaluation located under the Prog (Progress Notes), dated 04/23/25, indicated the resident's weight during her hospital stay was 180 pounds. There was no documentation the weights were obtain upon R26's admission to the facility. Review of R26's EMR titled 5-day Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 04/28/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was cognitively impaired. The assessment indicated R26 weighed 180 with no weight gain/loss during the assessment period. Review of R26's EMR titled Weights located under the Wts (Weights)/Vitals tab, dated 06/10/25, indicated the resident's weight was 165.6 pounds. There was no documentation the weights were obtain upon R26's re-admission to the facility. During an interview on 07/29/25 at 12:08 PM, Licensed Practical Nurse (LPN) 1 who was also the second-floor manager stated R26 would frequently refuse to be weighed. A request was made for any records which would reflect this during this interview and there was no information provided by the end of the survey. During an interview on 07/29/25 at 1:56 PM the Director of Nursing (DON) stated that R26 frequently refused to be weighed. A request was made for any records which would reflect this during this interview and there was no information provided by the end of the survey. During an interview on 07/31/2025 at 9:04 AM, the Registered Dietician (RD) stated an initial weight was to be completed within 48 hours after admission. The RD stated it was important to get a baseline weight so the resident can be monitored for loss/gain. The RD stated R26 typically refuses to be weighed, and the refusals were to be documented in the nursing progress notes. During this interview, the RD reviewed R26's EMR and could not identify refusals to be weighed during her time at the facility. 2. Review of R92's (closed record) admission MDS with an ARD of 07/01/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 06/25/24, a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R92's cognition was severely impaired, and had diagnoses of basal cell carcinoma of skin of nose, type 2 diabetes mellitus without complications, and adult failure to thrive. Review of R92's Care Plan, dated 06/26/24, located in the EMR under the Care Plan tab revealed Nutritional Status as evidenced by therapeutic diet, obese BMI [body mass index] Per MNA [mini nutrition assessment] resident triggers for malnutrition with a goal of Will not experience a significant change in weight through next review. Interventions included Encourage and assist as needed to consume foods and/or supplements and fluidsoffered at and between meals, Notify physician and responsible party of significant weight changes, Provide diet/supplements per orders mighty shake QD, prostat [nutritional supplement] QD, and Weights as ordered. Review of R92's Nutrition Evaluation, dated 06/26/24, located in the EMR under the Form tab revealed a diet order of a CCHO [carbohydrate controlled] regular texture, Weight used to calculate resident BMI: 225 lbs [pounds] hospital weight, and Per 6/25 nursing evaluation, edema noted to BIL [bilateral] LE [lower extremities]. Review of R92's weights, located in the EMR under the Vitals tab revealed a 16% weight loss in two months. This included:On 06/26/24 at 225.0 Lbs (hospital records)No admission weight obtained on 06/25/24On 07/02/24 at 190.0 LbsOn 07/06/24 at 190.4 LbsOn 07/07/24 at 190.4 LbsOn 07/08/24 at 190.2 LbsOn 07/17/24 at 187.6 Lbs Review of R92's Nutrition Notes, dated 07/22/25, located in the EMR under the Progress Note, revealed Per calorie count, resident noted with general intake of 0-25% of foods/drinks. Resident continues on CCHO, soft and bite sized texture diet with thin liquids. Skin: per 7/11 wound consult, fungal dermatitis noted to BIL groin and BIL buttocks, stage 2 pressure ulcer notes to sacrum (initial exam). Recommend prostat 30 ml QD [every day] for additional protein for skin healing. Recommend mighty shake 4 oz QD for additional calories and protein. RD [Registered Dietitian] placed call to residents on and discussed current intake/calorie count, and discussed both supplements, and [family member] agreed. RD discussed with resident MDs [physician] as well. RD will continue to remain available and involved in resident care and will continue to monitor and intervene PRN [as needed]. Interview on 07/31/25 at 9:05 AM, RD was asked if an admission weight was obtained for R92. RD stated, No admission weight was obtained. RD confirmed the first weight was obtained one week later. RD stated R92's weight should be taken within the first 48 hours. RD confirmed she used R92's hospital weight of 225 Lbs. RD was asked if R92's weight was 225 Lbs and his last weight at 186.7 Lbs before discharge, did he have a 16% weight loss. RD stated R92 had edema upon admission which could account for his weight loss and had a wound. RD confirmed there was no documentation of the edema and R92 was discharged before supplements were started.NJAC 8:39-27.1(a)

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 21 residents reviewed (Resident # 89). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 89's records. The resident was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 11/21/23, the resident was assessed as being discharged to home or lesser care. A review of Resident # 89's progress notes dated 11/21/23 revealed that the resident had a transfer to hospital, as the resident had an increase in respiratory distress, chest congestion which started on 11/20/23 and the symptoms had gotten worse. On 2/21/24 at 10:15 AM, the surveyor interviewed the MDS Coordinator, who stated that the MDS under section A for Resident # 89 should have indicated discharge to the hospital and that it was an error that it indicated discharge to home or lesser care. During an interview on 2/28/24 at 1:00 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. A review of the policy regarding accuracy of resident assessment, reviewed 1/2/24, revealed Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. NJAC 8:39-11.2(e)1

Based on interview, and record review, it was determined the facility failed to follow professional standards and practices to accurately document in the medical record the status of a resident's progress or changes in his/her condition. The resident was transferred from the facility to the hospital. The concern was cited for 1 (Resident #199) of 21 residents reviewed and is evidenced by the following: Resident #199 is not in the facility and will investigate the closed record and conduct interviews. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are (ii) accurately documented. The medical record must contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. A review of the 5 Day 5/1/23 Minimum Data Set (MDS), a facility assessment tool, revealed the resident's Brief Interview for Mental Status (BIMS) 15 out of 15 indicating intact cognition. The admission record indicated the resident was admitted to the facility with diagnoses that included but were not limited to hypertension, chronic kidney disease, diabetic nephropathy, gout, anemia, bladder cancer, atrial fibrillation, benign prosthetic hypertrophy, hyperlipidemia, diabetes mellitus II. A review of the nursing progress notes revealed missing nursing documentations for 4/29/23, 4/30/23, 5/1/23, 5/4/23, and 5/5/23, the day the resident was transferred to the hospital. On 2/20/23 at 1:50 PM, the surveyor discussed the concerns of lack of nursing documentation for Resident #199 on the day of change in condition 5/5/23, with Director of Nursing (DON) in training, sitting DON/Regional Clinical Services, and the Licensed Nursing Home Administration (LNHA). The surveyor requested from the facility for any additional documentations, grievances, or investigations during the resident's stay. On 2/22/24 at 10:00AM, the DON and LNHA provided documentation of the timeline on the day resident was transferred to the hospital. The timeline revealed that on 5/5/23 the resident was transferred on 5/5/23 at 7:30 AM via 911 ambulance for complaint of chest pain. The resident was admitted with atrial fibrillation and pneumonia. The timeline provided was not documented in the resident's EHR. On 2/23/24 at 9:50 AM, interviewed the sitting DON regarding nursing documentation and the DON stated, It is the expectation that nursing will document every shift in the EHR under the progress notes. The surveyor reviewed with the DON and the LNHA, the missing nursing documentations on 4/29/23, 4/30/23, 5/1/23, 5/4/23, and 5/5/23. The professional standards of practices §483.70(i)(1), mentioned above was also reviewed with the DON and the LNHA. On 2/28/24 at 10:40 AM, interviewed the LPN on the 3rd floor, the LPN stated, ''We do skilled nursing notes, we should document on residents that has something going on. I document on residents that go out, when the doctor was notified and of course the family and who I spoke to. I document on how the resident was transported, the reason that they're going out. I try to document on all the residents daily. The surveyor reviewed the current facility policy and procedures titled Charting and Documentation revised 5/27/22 and Acute Condition Changes revised 3/2018, which revealed The following information is to be documented in the resident medical record: Changes in the resident's condition. NJAC 8:39-35.2(d)

2. The surveyor reviewed the medical records for Resident #72 and revealed the following: According to the January 2024 OSR sheet, Resident #72 had an order dated 1/9/2024 for Midodrine HCl 5 mg two times a day with parameters to hold the medication when the SBP is more than 130. The January 2024 and February 2024 eMAR revealed several dates the nurse gave the Midodrine HCl 5 MG medication when the resident's systolic blood pressure was above 130. Midodrine HCl 5 MG was given when the SBP was above 130 by the 3-11 nurse on 1/11/24, 1/13/24, 1/19/24, and 2/11/24 and by the 7-3 nurse on 1/29/24, 1/30/24, 2/3/24, and 2/16/24. The surveyor interviewed LPN#2 on 2/22/24 at 10:48 AM. LPN#2 stated that the medication should not be given if it is outside of the ordered parameters. According to the January 2024 OSR, Resident #72 had physician orders for skin prep to the left great toe, moisture barrier cream to the sacrum, left and right buttocks treatments, and incentive spirometry therapy. The January 2024 electronic Treatment Administration Record (eTAR) revealed that the evening shift nurse did not document the treatment on 1/18/24 of the following: 1. Skin prep wipes are to be applied topically to the left great toe every day and evening shift for redness. 2. Apply moisture barrier cream every shift for protection to the sacrum post-care. 3. Apply moisture barrier cream every shift for protection to the left buttock post-care. 4. Apply moisture barrier cream every shift for protection to the right buttock post-care. 5. Incentive spirometry therapy every shift for lung therapy. According to February 2024 OSR, Resident #72 had physician orders for Celebrex 10 mg capsule by mouth in the evening, Nuplazid 30 mg by mouth in the evening, pain score every shift, anti-depressant and anti-psychotic side effect tracking every shift, and A&D ointment one time a day for dry skin apply to the left and right foot, skin prep wipes are to be applied topically to the left great toe every day shift for wound care, apply moisture barrier cream every shift for protection to the sacrum, left and right buttock post-care, and incentive spirometry therapy. The February 2024 eMAR revealed that on 2/3/24, the evening shift nurse did not document the following medications: 1. Celebrex 100 mg capsule by mouth in the evening. 2. Nuplazid 30 mg capsule by mouth in the evening. 3. Pain score every shift. 4. Anti-depressant side effect tracking every shift. 5. Anti-psychotic side effect tracking every shift. 6. A&D ointment one time a day for dry skin apply to the left foot. 7. A&D ointment one time a day for dry skin apply to the right foot. The February 2024 eTAR revealed that on 2/2/24, the day shift nurse did not document the following treatments: 1. Skin prep wipes are to be applied topically to the left great toe every day shift for wound care. 2. Apply moisture barrier cream every shift for protection to the sacrum post-care. 3. Apply moisture barrier cream every shift for protection to the left buttock post-care. 4. Apply moisture barrier cream every shift for protection to the right buttock post-care. 5. Incentive spirometry therapy every shift for lung therapy. 3. The surveyor reviewed the medical records for Resident #196 and revealed the following: According to the December 2023 OSR, Resident #196 had physician orders for quetiapine fumarate 0.5 mg tablet by mouth at bedtime, disruptive behavior: yelling to the point of exhaustion every shift, pain score every shift, anti-psychotic side effect tracking every shift, vital signs every shift, silver sulfadiazine cream 1 % apply to sacral area topically every day shift for wound care, and incentive spirometry four times a day. The December 2023 eMAR revealed that on 12/15/23, the evening shift nurse did not document the following: 1. Quetiapine fumarate 0.5 mg tablet by mouth at bedtime. 2. Disruptive behavior: yelling to the point of exhaustion every shift. 3. Pain score every shift. 4. Anti-psychotic side effect tracking every shift. 5. Vital signs every shift. The December 2023 eTAR revealed that on 12/21/23 and 12/27/23 respectively, the day and evening shift nurse did not document the following: 1. Silver sulfadiazine cream 1 % is applied topically to the sacral area every day shift for wound care. 2. Incentive spirometry four times a day. 4. The surveyor reviewed the medical records for Resident #197 and revealed the following: According to the April 2023 OSR sheet, Resident #197 had an order dated 4/14/2023 for Midodrine HCl 5 mg every 8 (eight) hours with parameters to hold the medication when the SBP is more than 150. Do not administer after the evening meal or 4 (four) hours from bedtime to avoid supine hypertension. The April 2023 eMAR revealed that on 4/14/23, 4/15/23, 4/16/23, and 4/17/23, the Midodrine HCl 5 mg was given without the blood pressure written in the order. The April 2023 eMAR revealed that on 4/14/23, 4/15/23, 4/16/23, and 4/17/23, the Midodrine HCl 5 mg was given at 2200 (10:00 PM) 4 hours from bedtime. The April 2023 eMAR revealed that on 4/14/23, 4/15/23, 4/16/23, and 4/17/23, the Midodrine HCl 5 mg was given at 2200 after the evening meal or 4 hours from bedtime. The April 2023 eMAR revealed that the Midodrine HCl 5 mg was not documented on 4/14/23 at 1400 (2:00 PM), 4/15/23 at 0600 (6:00 AM), and 4/17/23 at 1400 (2:00 PM) and 2200. According to the April 2023 OSR sheet, Resident #197 had an order dated 4/18/2023 for Midodrine HCl 2.5 mg every 8 (eight) hours with parameters to hold the medication when the SBP is more than 150. Do not give after 8:00 PM. The April 2023 eMAR revealed that on 4/18/23, 4/19/23, and 4/20/23, the Midodrine HCl 2.5 mg was given at 2200 after 8:00 PM. The April 2023 eMAR revealed that the Midodrine HCl 2.5 mg was not documented on 4/20/23 at 1400. According to the April 2023 OSR sheet, Resident #197 had a physician order of Famotidine 20 mg by mouth two times a day, vital signs every shift, bacitracin ointment to the right lower arm skin tear every day, phytoplex z guard external paste 57-17% apply to sacral region topically every shift, incentive spirometry 4 times a day. The April 2023 eMAR revealed that the incentive spirometry was not documented on 4/13/23 at 1800 (6:00 PM) and 2200. The April 2023 eMAR revealed that on 4/14/23 and 4/20/23, the day shift nurse did not document the vital signs every shift. The April 2023 eTAR revealed that there were several dates that the nurse did not document the treatments was done on the following dates: 1. Bacitracin ointment to the right lower arm skin tear every day on 4/14/23, 4/17/23, and 4/20/23 on day shift. 2. Phytoplex z guard external paste 57-17% apply to the sacral region topically every shift on 4/14/23 on the day shift. 3. Incentive spirometry 4 (four) times a day on 4/13/23 at 1800 and 2200, on 4/14/23 at 1000 (8:00 AM) and 1400, and on 4/17/23 at 1000 and 1400. On 2/28/24 at 12:56 PM, the surveyors discussed the above concerns with the Administrator, Director of Nursing (DON), and interim DON. There was no information provided. A review of the facility's policy titled Documentation of Medication Administration with a revised date of November 2022 indicated under Policy Interpretation and Implementation 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). The medication administration record may be a paper record or an electronic equivalent. 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: f. reason(s) why a medication was withheld, not administered, or refused (as applicable); g. initials, signature, and title of the person administering the medication. NJAC 8:39-27.1(a) Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for 3 of 21 residents reviewed (Resident # 19, #197, and #72) and b.) failed to document for accountability of medications and treatments administered for 3 of 21 residents reviewed (Resident #72, #196, and #197). 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 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. The surveyor reviewed the medical records for Resident #19 and revealed the following: According to the February 2024 Order Summary Report (OSR) for Resident #19 had an order dated 2/2/24 for Midodrine HCl Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for Hypotension, Hold for SBP (Systolic Blood Pressure) > or equal to 110. The February 2024 electronic Medication Administration Records (eMAR) revealed that the order was written without a specified column to check the SBP and there was no proof that SBP was taken at the time that Midodrine was administered. On 2/28/24 at 10:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated the resident's BP was supposed to be checked prior to administration of midodrine, but after reviewing the eMAR, the LPN stated that nothing had come up which requested the resident's BP was to be taken and she was not able to prove if BP had ever been taken time of administration of the midodrine for Resident #19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial tour on 11/15/21 at 11:05 AM, the surveyor observed Resident #69's enteral feeding bottle and water flush bag were not labeled and dated. The surveyor observed the 1000 mls enteral feeding bottle was half empty. A review of the resident's Face sheet, that the resident was admitted to the facility with diagnoses that included dysphagia oropharyngeal phase, ulcer of the esophagus without bleeding (an open sore in the throat), and gastrostomy status (a surgical opening to the stomach). A review of the CMDS dated [DATE], indicated a BIMS score of 15, which reflected that the resident's cognition was intact. The CMDS indicated that the resident had a feeding tube. A review of the November 2021 electronic Medical Record (eMAR) revealed an order dated 11/3/21 for Glucerna 1.5 rate 35 mls/hr to start at 5 PM and run until 700 mls has infused that was discontinued and re-ordered the same date on 11/16/21. On 11/15/21 at 11:15 AM, the surveyor interviewed the Registered Nurse (RN#1) responsible for Resident #69. RN#1 stated that Resident #69 is the only resident on their assignments who is currently receiving an Enteral feeding and the Enteral feeding begins during the 3-11 PM shift. On 11/16/21 at 8:10 AM, the surveyor observed Resident #69 in their bedroom asleep with enteral feeding infusing. At that time, the enteral feeding bottle and water flush bag were not labeled. On the same day at 10:25 AM, RN#1 stated to the surveyor that the enteral feeding bottle should be labeled with the time and date the bottle is hung. RN#1 further stated, I'm not sure with the water flush bag has to be labeled as well but would find out. Furthermore, the surveyor and RN#1 went inside the resident's room and RN#1 acknowledged that either the enteral feeding bottle or water flush bag were labeled. The RN also acknowledged the enteral feeding bottle and water bag were not labeled the previous day on 11/15/21. On 11/16/21 at 10:30 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for Resident #69. The RN/UM informed the surveyor that the tube feeding bottle and water flush bags should be labeled with the date and time the bottle is opened and hung. The RN/UM stated that the tube feeding is good for 24 hours once opened. The RN/UM acknowledged that both the feeding tube bottle and water flush bag were not labeled. On 11/17/21 at 9:45 AM, the surveyor conducted a phone interview with RN#2 who had Resident #69 during the 3-11 PM, shift on 11/15/21. RN#2 stated that I was too busy to label the tube feeding when I hung it and forgot to do it later during my shift because I was too busy with all my patients. The surveyor asked the RN if they knew about the facility's policy regarding labeling of enteral feeding and RN#2 stated, I know the policy, but I was too busy. On the same day at 11:55 AM, the surveyor conducted a phone interview with LPN#2 who had Resident #69 during the 3-11 PM, shift on 11/16/21. LPN#2 stated, I wrote out a label for the tube feeding, but did not put it on the tube feeding bottle because another patient needed me and I forgot to put the label on when I went back to Resident #69. The surveyor asked LPN#2 if they knew about the facility's policy regarding labeling Enteral feeding, and LPN#2 stated, yes, but I forgot to go back and label the bottle. On 11/16/21 at 12:33 PM, the survey team met with the LNHA and the DON and were made aware of the above concerns. A review of the facility Enteral Nutrition Policy with a version date of 11/2018 that was provided by the Administrator indicated On the formula label documents initials, date and time the formula was hung/administered, and initial that the label was checked against the order. NJAC 8:39-19.4 (a) (1) Based on observation, interview, and record review, it was determined that the facility failed to a.) clarify a physician order with regard to fluid consistency for 1 of 21 residents (Resident#23) and b.) label and date the enteral feeding (method of supplying nutrients directly into the gastrointestinal tract) and water flush bottle for 1 of 1 resident (Resident #69) in accordance with facility policy and procedure and professional standards of practice. This 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. 1. On 11/15/21 at 10:31 AM, the surveyor observed Resident #23 in his bed receiving a Jevity feeding via a jejunostomy feeding tube (J-tube) at a rate of 60 milliliters/hour (mls/hour). The resident's headboard was at a 45-degree angle and the resident was observed with their eyes closed. A review of the resident's Face sheet (an admission summary), that the resident was admitted to the facility with diagnoses that included dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), anorexia (eating disorder that involves self-starvation), schizoid personality disorder (characterized by a lack of interest in social activities), and personal history of traumatic brain injury. A review of the November 2021 Order Summary Report (OSR) revealed an order dated 10/6/21 for a Regular diet Pureed (PU4) texture, Mildly Thick (MT2) consistency. The surveyor reviewed the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care dated 9/16/21 for Resident #23, which reflected the resident had a brief interview for mental status (BIMS) score 5 out of 15 indicating that the resident had a severe impairment. The surveyor reviewed Resident #23's interdisciplinary care plan (IDCP) dated 10/20/21 that revealed under the focus area will not take by mouth (PO) medications without thin liquids which had a goal that the resident will accept medication, treatment or procedure. On 11/18/21 at 9:45 AM, the surveyor interviewed Resident #23 who stated that they will only take their medication with thin liquid. On 11/18/21 at 11:40 AM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) who's Resident #23's medication nurse. LPN #1 stated that Resident #23 is confused and forgetful but can make their needs known and the resident have a history of being non-compliant with their diet including refusing Nectar Thickened Liquid (Mild Thickened Liquid). LPN #1 stated that he will always attempt to give the resident Nectar thickened liquid with their medications, but the resident will refuse. Furthermore, LPN #1 stated that the physician is aware and that the resident refusal to take medications with Nectar Thickened Liquid. When surveyor asked LPN #1 if he consulted with the physician about the resident receiving medications through a J-Tube or having the physician clarifying the physician order, the LPN #1 stated that he should have consulted with the physician and clarified the order for liquids during medication administration. On 11/18/21 at 11:55 AM, the surveyor interviewed the Director of Rehabilitation who stated that the resident was last seen by the Speech Therapist in March. The resident had no re-evaluation because their condition hasn't improved but she stated that all residents at the facility are screened by the therapy department which includes Physical Therapy, Occupational Therapy and Speech Therapy. She stated that twice weekly they will do rounds and check on all the residents. They will have team meetings every 5 days to discuss each resident at the facility and will address any concerns that are brought up by the team. She stated that Resident #23 has a history of being non-compliant with their doctor. She stated that the physician is aware that the resident is not compliant with their diet, particularly with the Nectar Thickened Liquid. She also stated that she checked on Resident #22 and the resident had no negative effects. On 11/18/21 at 12:45 PM, the surveyor team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The LNHA stated that the facility including the resident's physician have spoken to the resident on numerous occasions regarding the resident's non-compliance and the risk and benefit. The DON further stated that there was no negative effect to the resident and that the order for fluids during medication administration should have been clarified to reflect the IDCP intervention that resident can have thin liquids with a goal to accept medications. The LNHA stated that resident is not a candidate for receiving medication through a J-tube due to the thinnest of the tube, the placement of the tube and the resident's history of having their J-tube clogged. A review of the facility's policy for Physician Orders: Obtaining and Transcribing dated 9/29/15 and was provided by the DON indicated the following: Validate (a physician order) Review of a physician order that has been received or verified by another nurse to ensure it is a complete order that reflects the order (s) of the consult, referral, etc. or documented changes to those orders; that transcription of the orders is complete and correct; and that follow-through has been implemented. NJAC: 8-39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) provide wound treatment consistent with professional standards of practice to an existing pressure injury and b.) implement an element of the facility policy and procedure concerning a wound dressing, for 1 of 1 Resident (Resident#46) observed during wound treatment observation. This deficient practice was evidenced by the following: On 11/15/21 at 10:40 AM, the surveyor was informed by Resident #46 that there was a pressure wound on their coccyx area that I was not sure if 100% healed. On 11/16/21 at 9:48 AM, the surveyor interviewed the Registered Nurse (RN) who informed the surveyor that Resident#46 was cognitively intact with periods of forgetfulness. The RN stated that the resident had a pressure wound to the sacrum and I will get back to you with the stage of the wound. She further stated that the resident was being seen by a wound doctor who comes I think every Monday. She indicated that she was not sure if the wound was facility-acquired. On that same date and time, the RN informed the surveyor that Resident#46 was on a supplement, turning and positioning, cushion on both bed and wheelchair, and incontinence care to promote wound healing. The RN stated that the wound is getting better. On 11/16/21 at 9:53 AM, the surveyor observed the resident seated in a cushion wheelchair in their room. The resident informed the surveyor that it was the nurse who does wound care treatment to their sacrum and that the wound was getting better. A review of the resident's Face sheet (an admission summary), reflected that the resident was admitted to the facility with diagnoses that included Hyperlipidemia (abnormally high levels of fats in the blood), hypertension (elevated blood pressure), unspecified malignant neoplasm of the skin (unusual growth on the skin), muscle weakness, and difficulty walking. A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool dated 10/23/21, indicated that a Brief Interview for Mental Status (BIMS) score of 14, which reflected that the resident's cognition was intact. The CMDS showed that the resident had an unstageable wound that was not a facility acquired. A review of the November 2021 Physician's Orders dated 11/16/21, revealed an order to cleanse the sacrum with NS (normal saline), pack with NS soaked gauze, then apply skin prep (an antimicrobial skin cleanser) to the peri-wound area and cover with dry gauze and bordered foam. A review of the wound consult dated 11/8/21 signed by the Medical Assistant (MA) revealed that the sacral wound was improving. On 11/16/21 at 10:40 AM, the surveyors observed the RN perform a wound treatment to Resident #46's sacral wound with the assistance of the Infection Preventionist Nurse (IPN). The RN disinfected the first table, let the table dry, and place the NS, gauze, and skin prep. The RN did not disinfect the second table inside the resident's room where the RN placed clean gloves, alcohol-based hand rub (ABHR), and the foam dressing. The table that was not disinfected had the resident's water container and tissue paper box. The surveyors observed the IPN did not change gloves and perform hand hygiene after touching the resident's wheelchair, bed, and surrounding environment, and immediately touched the resident's sacral area to help the RN after the RN cleansed the wound with NS. Afterward, the RN took her pen from her uniform pocket, signed the foam dressing, and returned the pen to her uniform pocket without disinfecting the pen before and after use. The RN then took and used the gloves from the undisinfected table, apply soaked NS gauze to the sacral wound, applied skin prep to the peri-wound, and covered the sacral wound with a foam dressing. The RN discarded unused supplies into the garbage. The RN and the IPN performed hand hygiene, and the RN disposed of the garbage outside the resident's room. Both the RN and the IPN did not disinfect the two tables used in wound treatment. On 11/16/21 at 11:07 AM, during the interview, the IPN informed the surveyors that as a standard of practice even though not our facility policy; the tables to be used for treatment should be disinfected first. Both the IPN and the RN acknowledged that both tables inside the resident's room that were used for wound treatment should have been disinfected before and after treatment. On that same date and time, the surveyor asked the RN why she did not disinfect her pen before and after use when she took and returned it to her uniform pocket and the IPN stated it's okay for her not to disinfect the pen because she doesn't share her pen. Furthermore, the surveyor asked the IPN why she did not change her gloves and perform hand hygiene after touching the resident's immediate environment and before touching the resident's sacral area after the RN cleaned the wound, the IPN stated that's a good point. On 11/16/21 at 12:33 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the above observations and concerns. On 11/18/21 at 11:51 AM, the surveyors met with the LNHA and the DON. The DON stated that it was the facility policy to disinfect tables before and after wound treatment, the pen should be disinfected before and after use, and hand hygiene should be appropriately done during the 11/16/21 wound treatment observation. The LNHA further stated that the IPN should have stopped the wound treatment at that time and followed the appropriate wound treatment procedure. A review of CDC Hand Hygiene in Healthcare Settings guidance for Healthcare Providers page last reviewed January 8, 2021, included, When and How to Wear Gloves: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene immediately after removing gloves. Changes gloves and perform hand hygiene during patient care, if gloves become damaged, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs A review of the facility Clean Dressing Change Policy with a revision date of 4/29/16, provided by the DON included, A clean dressing change technique will be used as clinically appropriate. Purpose: To promote wound healing; prevent infection; assess the healing process; and protect the wound from mechanical trauma. Process #2 Prepare for the procedure: .2.2. Clean the surface of the over bed table and dry thoroughly .#4. Prepare supplies using clean technique: 4.1. Prepare a clean field using a clean drape, disposable pad, towel, etc, on which to prepare supplies. NJAC 8:39-27.1 (b)

**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 two (2) of two (2) medication refrigerators that were inspected. This deficient practice was evidenced by the following: On [DATE] at 9:50 AM, the surveyor inspected the 2nd floor medication room refrigerator in the presence of a Registered Nurse (RN). The surveyor observed two opened vials of Protein Purified Derivative (PPD) that were opened and not dated. The surveyor also observed an opened vial of PPD that had an opened date of [DATE] and was expired. The surveyor interviewed the RN who stated that once a vial of PPD is opened that it should be dated because an opened vial of PPD only have a 30-day expiration date. On [DATE] at 10:30 AM, the surveyor inspected the 3rd floor medication room refrigerator in the presence of a Licensed Practical Nurse (LPN). The surveyor observed two opened vials of PPD that were not dated. The surveyor interviewed LPN who stated that an opened vial of PPD should have been dated. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. An opened vial of PPD have an expiration date of 30-days. On [DATE] at 1:00 PM, the surveyor met with the Licensed Nursing Home Administrator 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 dated [DATE] that was provided by the DON indicated the following: Labels for stock medications include all necessary information, such as: The expiration date when applicable. NJAC: 8:39-29.4 (a) (h) (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 schedule the administration of medications on hemodialysis treatment days. This deficient practice was identified for 1 of 4 residents (Resident #62) reviewed for dialysis. This deficient practice was evidenced by the following: On 1/9/20 at 10:13 AM, the surveyor observed Resident #62 in bed, lying on an air mattress. The resident informed the surveyor that the resident goes to dialysis three days per week Monday, Wednesday and Friday. The resident stated they leave the facility in the morning and returned in the afternoon, but was not specific as to what time. The surveyor reviewed Resident #62's medical records that revealed the following: According to the admission Record, Resident #62 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included End Stage Renal Disease. Resident #62's Comprehensive Minimum Data Set an assessment tool dated 12/11/19, revealed the resident had no cognitive impairment. The resident scored 15 of possible 15 on the Brief Interview for Mental Status indicating no long or short term memory deficits. The January 2020 physician's Order Summary Report indicated that Resident #62 received hemodialysis on Monday, Wednesday and Friday and a 7:45 PM pick up time. There were several medications Resident #62 was receiving which included the following: Docusate Sodium 100 mg (milligrams) (a stool softener) 2 capsules once daily; Famotidine 20 mg once daily (treat acid reflux); Lactulose 10 GM (gram)/15 ml (milliliters) 30 ml (laxative to treat constipation) once daily; Nephro-Vit (vitamin specific to a person with kidney disease and receiving dialysis) 1 mg once daily; Eliquis 2.5 mg (blood thinner to reduce the risk of stroke, blood clots and embolisms) twice daily; Midodrine 10 mg (to treat low blood pressure) twice daily; Ipratropium-Albuteral inhaler 0.5-2.5 (3) mg/3 ml (treat symptoms of wheezing) three times a day; Sevelamer 800 mg (lowers phosphorus levels in the blood for kidney dialysis) three times a day and Amitiza 24 mcg (micrograms) (a laxative to treat constipation) twice daily. The December 2019 and January 2020 Electronic Medication Administration Record (EMAR) revealed the above medications were scheduled for and documented as administered by the nurses at the following times: 1. Docuate Sodium 100 mg at 8:00 AM. 2. Famotidine 20 mg at 9:00 AM (on the December 2019 EMAR administered at 8:00 AM). 3. Lactulose 30 ml at 9:00 AM. 4. Amitiza 24 mcg at 8:00 AM and 2100 hours (9:00 PM). 5. Nephro-Vit 1 mg at 9:00 AM. 6. Eliquis 2.5 mg at 9:00 AM and 9:00 PM (on the December 2019 EMAR administered at 8:00 AM and 9:00 PM). 7. Midodrine 10 mg at 6:00 AM, 1400 hours (2:00 PM) and 2200 (10:00 PM). 9. Sevelmaer 800 mg at 11:30 AM. 10. Ipratropium-Albuteral 3 mg/3 ml at 12:00 PM. There were three medications that were only included on the December 2019 EMAR and scheduled for the following times: 1. Finasteride 5 mg once daily (to treat urinary retention) at 8:00 AM. 2. Gabapentin 300 mg three times a day (to treat nerve pain and also used to treat seizures) at 6:00 AM, 2:00 PM and 10:00 PM. 3. Zyvox 600 mg (antibiotic) twice a day for 10 days at 9:00 AM and 9:00 PM. Resident #62's care plan titled [the resident] has Renal insufficiency related to chronic renal failure had interventions that included 1. Confer with physician and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed and 2. Coordinate dialysis care with treatment center. The Progress Notes dated 12/6/19 to 12/23/19 revealed that there was no documentation indicating what time the resident left the facility to go to dialysis or when the resident returned to the facility after hemodialysis treatment. The Progress Notes dated 12/6/19 - 1/14/20 had no documentation of what time the resident left the facility for hemodialysis. The documentation in the Progress Notes from 1/8/20 to 1/14/20 indicated different times the resident returned from hemodialysis, which were between 2:00 PM - 5:00 PM. The Consultant Pharmacist (CP) did not include a recommendation to schedule Resident #62's medications according to the resident's dialysis schedule on the The Electronic Pharmacist Information Consultant form dated 1/7/20. On 1/15/20 at 10:00 AM, the surveyor interviewed and reviewed the EMAR with the Licensed Practical Nurse (LPN) who was assigned to Resident #62 regarding administering medications when the resident was scheduled for a 7:45 AM pick up to go to hemodialysis. The LPN stated that he would at times administer the medications at 7:30 AM and that sometimes the resident didn't get picked up until 8:00 or 8:30 AM and he would administered the medications before the resident left the facility. The LPN stated the medications should probably be adjusted. At 10:23 AM, the surveyor called CP for an interview to determine why she did not make a recommendation to ensure that all medications were appropriately scheduled to accommodate Resident #62's hemodialysis days, including the pick up and return times. The CP was not available for the interview. On 1/15/20 at 10:51 AM, the surveyor discussed the above concern with the Administrator and Director of Nursing (DON). The DON was not able to explain why the medications for Resident #62 were not adjusted to accommodate the hemodialysis days. A review of the facility's policy titled Hemodialysis Pre and Post Care did not include any information for timely medication administration to accommodate a resident's hemodialysis schedule. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to properly store, label and dispose of medications. This deficient practice was noted in 3 of 7 medication carts and 1 of 2 medication refrigerators inspected and was evidenced by the following: On 1/9/20 at 9:30 AM, the surveyor inspected the 2nd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an unopened Humalog Insulin vial and an unopened Humalog Insulin pen that were stored inside the medication cart. The surveyor also observed an opened Lantus Insulin vial with no resident's name on the label. The label was written as house stock. The surveyor interviewed LPN #1 who stated that an unopened Humalog insulin vial and an unopened Humalog insulin pen should have been stored in a refrigerator. LPN #1 also stated an opened Lantus insulin vial should have a resident's name on the box and vial. On 1/9/20 at 9:45 AM, the surveyor inspected the 2nd floor medication cart #4 in the presence of LPN #2. The surveyor observed an opened Humalog Insulin vial that had no resident's name on the vial or box. The surveyor also observed an opened Breo 100 inhaler that was not dated. The surveyor interviewed LPN #2 who stated that an opened vial of Humalog insulin should have contained a resident's name on the vial. LPN #2 also stated that a Breo Inhaler should have been dated when opened. On 1/9/20 at 9:50 AM, the surveyor inspected the 2nd floor medication refrigerator in the presence of a Registered Nurse (RN#1). The surveyor observed an opened vial of Purified Protein Derivative (PPD) that was not dated. The surveyor interviewed RN #1 who stated that the PPD vial should have been dated when opened. On 1/9/20 at 9:55 AM, the surveyor inspected the 3rd floor medication cart #1 in the presence of LPN #3. The surveyor observed an unopened bottle of Xalatan eye drops that was stored in the medication cart. The surveyor interviewed LPN #3 who stated that an unopened Xalatan eye drops should have been stored in the refrigerator. A review of Manufacturer's Specifications for the above medications revealed the following: 1. Unopened Humalog insulin vial should be stored in a refrigerator. 2. Unopened Humalog insulin pen should be stored in a refrigerator. 3. Unopened Xalatan eye drops should be stored in a refrigerator. 4. Breo inhaler once opened had a 42-day expiration date. 5. PPD vial once opened had a 30-day expiration date. A review of the facility policy titled Storage of Medications under #4 Drugs containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. and #11 Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or other secured location. Medications are stored separately from food and labeled accordingly. NJAC: 8-39-29.4 (a) (h) and (d)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary condition to prevent contamination from foreign substances and potential for the development of foodborne illness. This deficient practice was evidenced by the following: On 11/9/19 at 9:15 AM, during the initial tour in the presence of the Culinary Director (CD) the surveyor observed the following: 1. On a shelf there was one small coffee carafe with the cover on it that had approximately a half inch of pooled water at the bottom and five large coffee urns positioned upright with their attached covers propped opened that had approximately a half inch of pooled water at the bottom of the containers. On another shelf there were four large coffee urns positioned sideways with their covers on that had approximately a half inch of pooled water at the bottom of the containers. The CD stated that the carafe and the nine coffee urns were clean and ready for use. The CD also stated that the small coffee carafe and the large coffee urns should have been air dried prior to being placed on the shelves. 2. Six of six oven knobs in the dairy kitchen had a buildup of dust and a brown, black greasy substance on them. The CD stated that the outside of the oven was cleaned daily. 3. The shelf above the steam table had a layer of dust particles and a layer of clear sticky substance on it. The CD stated that the steam table was cleaned daily. A review of the facility's policy dated 5/2/18 titled, Sanitation revealed under Policy Interpretation and Implementation #11 revealed the following: Food preparation equipment and utensils that are manually washed will be allowed to air dry and under #18 The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all task before proceeding to the next assignment. On 1/10/19 at 1:30 PM, the surveyor team met with the Administrator and Director of Nursing who offered no further information. NJAC 8:39-17.2(g)