Based on observation and interview during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication rooms (Interlaken). Specifically, the Interlaken medication room refrigerator temperatures were not consistently documented. Findings include: The facility policy, Medication Refrigerator Temperature Logs, created 12/2019, documented medication refrigerator temperatures were documented once in the morning and once in the evenings. If the refrigerator temperature was above 46 degrees Fahrenheit or below 36 degrees Fahrenheit both maintenance and the Director of Nursing should be notified. During an observation on 9/3/2024 at 2:11 PM the Interlaken medication room refrigerator did not have documented temperatures for the day shifts on 8/6/2024, 8/7/2024, and 8/12/2024; and for the evening shifts on 8/3/2024, 8/4/2024, 8/5/2024, 8/6/2024, and 8/11/2024. During an interview on 9/6/2024 at 8:30 AM, Licensed Practical Nurse #4 stated medication refrigerator temperatures were taken and documented twice a day to ensure medications were stored at proper temperatures. On 9/3/2024 at 2:11 PM they noticed many missing dates for 8/2024. The 8/2024 log was no longer in the refrigerator log binder. During an interview on 9/6/2024 at 9:36 AM, Registered Nurse Unit Manager #3 stated refrigerator temperatures were monitored to make sure medications were stored at proper temperatures and the temperature was recorded on a log twice a day. If medication temperatures were out of range medications should not be used. If medication refrigerator temperature checks were not completed there would be no way to know if the temperatures were within an acceptable range. They noticed multiple missing temperatures on the refrigerator temperature log the last day or two. They filled in the temperature for multiple missing dates and should not have. They were not sure why they documented refrigerator temperatures when they did not know the actual temperatures and the temperatures could not be verified. During an interview on 9/6/2024 at 10:30 AM, the Administrator stated refrigerator temperatures were monitored and documented twice a day because certain medications had to be stored at certain temperatures to ensure effectiveness. If the refrigerator temperatures were not monitored, the medications in the refrigerator should not be administered to residents. They did not expect medication room refrigerator temperatures to be documented days later when temperatures were unknown. 10NYCRR 483.45 (g)(h)

Based on observation, interview, and record review during recertification survey conducted 9/3/2024-9/6/2024, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional needs, taking into consideration the preferences of each resident for 2 of 3 residents (Resident #29 and #50) reviewed. Specifically, Residents #29 and #50 were missing food items or had the wrong items on their meal trays. Findings include: The facility policy, Meal Tray Accuracy, dated 12/2022, documented residents were provided with appropriate supplements, adaptive equipment, and items requested at mealtimes within the current diet order to ensure accuracy of residents' meal trays. 1) Resident #29 had diagnoses including tachycardia (fast heartbeat), anxiety, and hypertension (high blood pressure). The 6/22/2024 Minimum Data Set assessment documented the had severe cognitive impairment, was dependent on staff with eating, and weighed 112 pounds. A 6/7/2024 Physician #10 order documented the resident was to receive a ground solid diet. The comprehensive care plan initiated 3/17/2023 and revised on 8/7/2024 documented the resident was at risk for an alteration in nutritional status related to dysphagia (difficulty swallowing), decreased mobility, and age, and required assistance with feeding. Interventions included a ground solid diet with honey thickened liquid, 2 handled cups for beverages, fortified potatoes daily, weekly weights due to significant weight loss, and quarterly nutritional assessments. The 7/5/2024 progress note by Registered Dietitian #9 documented Resident #29 lost 5 pounds in the last month. They recommended weekly weights, added fortified potatoes daily, and Ensure Compact (nutritional supplement) twice daily. During an observation and interview on 9/4/2024 at 12:52 PM the resident's lunch meal included 2 ounces ground meatloaf with piquant sauce, 4 ounces diced pears, 4 ounces creamed corn, 4 ounces water, 4 ounces apple juice, and 4 ounces milk. Fortified potatoes were listed on the meal ticket and were not on the tray. Certified nurse aide #6 stated the fortified potatoes were missing from the tray and they did not request them from the kitchen. 2) Resident #50 had diagnoses including obesity, insulin dependent diabetes, and dysphagia (difficulty swallowing). The 6/29/2024 Minimum Data Set assessment documented the resident was moderately cognitively impaired and was independent with eating. A 1/16/2023 Physician #10 order documented the resident was to receive a regular diet. The comprehensive care plan initiated 4/11/2023 and revised on 8/26/2024 documented the resident was at risk for elevated blood sugars due to diabetes mellitus. Interventions included a dietary consult, monitoring for signs and symptoms of high and low blood sugars, administration of insulin based on the blood sugar, and honoring preferences for snacks within diet restrictions. During an interview on 9/3/2024 at 12:51 PM, Resident #50 stated the food was not hot and lacked flavor. During an observation on 9/4/2024 at 12:43 PM, Resident #50's lunch meal tray was used as a test tray and a replacement was requested. The tray was missing the low calorie cranberry juice and yogurt. The tray had Pepsi and the meal ticket documented Diet Pepsi. The yogurt was on ice in the meal cart and provided to the resident. The replacement tray did not include low calorie cranberry juice. The corn was overcooked and dry. The outer casing had a plastic-like texture and was difficult to chew. During an interview on 9/5/2024 at 9:43 AM, Certified Nurse Aide #6 stated meal trays were often missing items or had the wrong items. If a resident's tray was missing an item, staff should catch it and notify the kitchen staff to bring the item. They stated they were not sure why Resident #29 got fortified mashed potatoes, but they should have notified the kitchen staff they were missing from the resident's tray on 9/4/2024. During an interview on 9/5/2024 at 10:09 AM Licensed Practical Nurse #4 stated meal trays were often missing items or had the wrong items. They stated fortified potatoes ordered for residents because they required extra nutrients and calories. Fortified potatoes were ordered for residents who were losing weight. If the resident did receive them, they might not meet their caloric needs. During an interview on 9/6/2024 at 9:36 AM, Registered Nurse Unit Manager #3 stated when residents got the wrong items or missing items on their meal trays the kitchen staff should be notified. During an interview on 9/6/2024 at 10:35 AM, Registered Dietitian #9 stated they expected trays to have all items listed on the resident's meal ticket. The meal ticket was initially checked for accuracy by the server and double checked by staff bringing trays to the residents. If something was missing from a tray staff should notify the server and if it was not available from the unit kitchen area, the server should call the main kitchen. If a resident did not get their fortified potatoes, they were not receiving the calories, protein and nutrients needed and may have weight loss and delayed wound healing. They stated Resident #29 received fortified potatoes because their weight was down, and the resident usually ate the potatoes because they liked them. A diabetic should Diet Pepsi because there were more carbohydrates and calories in the regular Pepsi. It was important to give Resident #50 Diet Pepsi as that was their preference. 10NYCRR 415.14

Based on observation, interview, and record review during the recertification survey conducted 9/3/2024-9/6/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen had multiple unclean areas, expired food, and unwrapped and undated food. Findings include: The facility policy, Food Storage, dated 10/2001 documented food and supplies would be received and stored properly by the general kitchen worker. Food was rotated so the first food in was the first food out. The facility policy Infection Control for nutritional services dated 2/2002 documented the work area was kept clean and sanitary. All work surfaces, except the cooking surface, and all floors in the Nutritional Services food preparation area were cleaned daily with an approved disinfectant. Storage areas shall be adequate, cleaned thoroughly weekly, and inspected daily by the Director of Nutritional Services. All refrigerator units were cleaned thoroughly weekly. Food stored in opened original containers must be covered and dated. The following observations were made in the main kitchen on 9/3/2024: - at 9:41 AM, the kitchen hoods were soiled and unclean with grease buildup over the stove top. Food debris was on the floor and under the cooking area. - at 9:44 AM, there was grime and grease buildup on the back wall and the floor surrounding the deep fryer. Food debris was on the floor under the fryer including 2 chicken tenders and French fries. - at 9:47 AM, the cooking area cooler had 4 undated wrapped sandwiches. - at 9:50 AM, the walk-in meat cooler had food debris on the floor under the food storage racks. An undated hotel pan of cooked ground beef was on the bottom shelf covered with plastic wrap. Manager of Nutrition #7 stated they thought it was cooked that morning and they would put a date on it immediately. - at 10:00 AM, the walk-in freezer ceiling had dripping condensation throughout the cooler and ice buildup in the corners of the ceiling. - at 10:02 AM, the food storage rack had 4 gallon jugs of apple cider vinegar that expired 12/2022, and a 1 gallon jug of apple cider that expired 3/2023. Manager of Nutrition Services #7 stated they did not realize the vinegar was expired. - at 10:09 AM, the food storage rack had 11 packages of hot dog rolls that expired on 8/30/2024, and 1 package of hot dog rolls that expired on 8/19/2024. 6 of the expired packages had green mold spots on the underside of the rolls. - at 10:10 AM, the food storage rack had 5 packages of dinner rolls that expired between 8/25/2024 and 9/1/2024. 2 of the expired packages had green mold spots. - at 10:29 AM, the food storage area walk-in cooler rack had a plastic covered storage bin filled with large packages of shredded lettuce and spinach. 2 packages of lettuce were brown and filled with a tan liquid, and a soft and mushy cucumber was at the bottom of the bin. - at 10:38 AM, the metal cart washroom floor was wet and had food debris, and the hose handle was on the floor by the doorway. Manager of Nutrition Services #7 stated the hose handle should have been kept on the wall mount and not on the dirty floor. During an interview at 9/6/024 at 10:36 AM, Manager of Nutrition Services #7 stated they were ultimately responsible for maintaining a clean kitchen. They stated a janitor was scheduled to clean the kitchen and the kitchen floors every night. If something was spilled in the refrigerator, the person who spilled the item was responsible for cleaning it. Their assistant was responsible for completing the inventory and ordering twice a week. The stock person should date the inventory, rotate the inventory, and put it away. Staff were educated to discard dented cans and moldy food items. The Assistant Manager of Nutrition Services should catch any items missed by staff. Food should be labeled with the date to prevent potentially hazardous food from reaching the resident. Moldy food should always be discarded because if it was eaten, the resident could become sick. Grease on equipment should be cleaned by the cook. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 10/11/22-10/14/22, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 3 medication carts (the stepdown unit medication cart) reviewed. Specifically, all prescribed controlled drugs on the stepdown unit were stored in an untethered medication cart and not in a permanently affixed compartment as required. Findings include: The 12/10/2020 facility policy addendum titled Medication Administration/Storage--Covid documented narcotics would be removed from the medication lock box in med room for individual med pass and placed back in the lock box in the medication room in lock box designated per hall for C hall and top of A hallway following completion of medication pass. Step down narcotics will follow the same medication count each shift, however, they will remain in step down medication cart. Medication carts will be locked and tethered to the wall when not in use. During an observation on 10/12/22 at 3:27 PM, the medication cart for the step down hall of Stillwater unit was locked, the narcotic box was locked, and the cart was not tethered to the wall. At the time of the inspection the cart was not in use and was not tethered to the handrail. The medication cart contained the following controlled drugs: 32 tablets of hydrocodone/APAP (opioid pain killer with acetaminophen) 5/325 milligrams (mg), 52 tablets of oxycodone (opioid pain killer) 2.5 mg, 34 tablets of Xanax (antianxiety) 0.25 mg, 12 tablets of Ambien (sedative) 5 mg, 16 tablets of Ativan (antianxiety) 0.5 mg, 30 vials of morphine (opioid) 20mg/ml, and 27 tablets of oxycodone 5 mg. During an interview on 10/12/22 at 3:30PM, licensed practical nurse (LPN) #1 stated all narcotics for the step down hall were kept in the cart. The cart was supposed to be locked and tethered to the handrail when it was not in use. LPN #1 locked the cart to the handrail at the time of inspection. They stated the narcotic box contained drugs that were not needed for the shift and only narcotics needed for the current medication pass should be in the cart. They were not sure why all the narcotics were stored in the cart. They stated possible medication diversion was the reason the cart should be locked to the wall. During an interview on 10/12/22 at 3:34 PM, the registered nurse (RN) Unit Manager #2 stated they believed only the narcotics needed for the current shift should be in the medication cart. They stated the cart was supposed to be locked to the wall when not in use. They were not sure why it was not locked at the time of the observation. The danger of narcotic diversion was the reason for the recommended locking of the cart. During an interview on 10/14/22 at 11:09 AM, the Director of Nursing (DON) stated narcotics were kept in medication storage rooms and required a 2 nurse count for the transfer of keys for the storage cabinet. The nurses were to only take what was needed for their medication pass and return to the locked storage after the medication pass. Narcotics were kept under triple lock, in the locked medication room and double locked cabinet. Narcotics should not be left in the medication cart when not in use, the only exception was the stepdown cart. During COVID-19 the stepdown hall was used for isolation. The narcotics were stored in the medication cart to prevent the nurse from having to go back and forth from the hallway. The facility added a third medication cart, but only had two narcotic lock boxes (permanently affixed) in the medication storage room. They did not want 2 nurses to have to share responsibility for one med closet. The expectation was for the stepdown medication cart to be tethered to the wall when not in use. This was not permanently affixed storage. Narcotics for the stepdown unit were stored in the cart, so it needed to be triple locked when not in use. The goal was to prevent misappropriation of drugs, and the potential for staff abuse/accessibility. 10NYCRR 483.45(h)(2)