**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/19/2024, the facility did not ensure that each resident was provided with a safe, clean, comfortable, and homelike environment. This was identified on one (Starboard Unit) of two units observed during the Environmental Task. Specifically, Resident #292 was using a ripped, inverted (turned inside out) fitted bed sheet on three separate observations. The finding is: The facility's policy titled; Homelike Environment last revised on 7/1/2017 documented that the facility will ensure that residents live in an environment that is clean and neat, with appropriate furnishings in a state of good repair. The housekeeping and nursing staff would observe the environment for needed repairs including but not limited to ripped/torn soiled curtains, damaged furniture, etc. Resident #292 was admitted with diagnoses including Atrial Fibrillation, Congestive Heart Failure, and Type 2 Diabetes Mellitus. Resident #292's Minimum Data Set (MDS) assessment had not been completed because they were recently admitted to the facility. A Nursing admission assessment dated [DATE] documented that Resident #292 was alert, friendly, and cooperative. Resident #292 was oriented to time, place, and person. Resident #292 was observed on 12/15/2024 at 10:15 AM, lying in bed with an inverted (inside out) and ripped fitted bed sheet that was covering the resident's mattress. Resident #292 was observed on 12/16/2024 at 10:33 AM, sitting in a wheelchair. An inverted and ripped fitted bed sheet was covering the resident's mattress. Resident #292 was observed on 12/17/2024 at 8:30 AM lying in bed with an inverted fitted bed sheet that was ripped. During an interview on 12/17/2024 at 8:30 AM, Registered Nurse #1 (Unit Manager) stated that Resident #292 was recently admitted to the facility, and the room was set up by the Housekeeping Department. Registered Nurse #1 stated Certified Nursing Assistant (CNA) assigned to Resident #292 did not report any issues with the bed sheet. During an interview on 12/17/2024 at 8:43 AM, Certified Nursing Assistant #1 stated they were focused on Resident #292's care and did not notice the fitted sheet on the mattress. Certified Nursing Assistant #1 stated if they had seen the ripped bed sheet, they would have changed the sheet with a new one. During an interview on 12/17/2024 at 11:00 AM, the Housekeeping Director stated they did not know who cleaned the room before Resident #292's admission. The Housekeeping Director stated they expected the housekeeping staff to use linens that are in good condition. During an interview on 12/19/2024 at 12:31 PM, the Director of Nursing Services stated the resident's bed sheets are changed during the resident's shower days, and when visibly soiled. The Director of Nursing Services stated that Certified Assistant #1 should have changed the torn bed sheet. 10 NYCRR 415.5(h)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36 was admitted with diagnoses of Cough, Chronic Obstruction Pulmonary Disease, and Asthma. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, which indicated Resident #36 had severely impaired cognition. A physician's order dated 12/15/2024 at 11:33 AM documented to implement Droplet/Contact Precautions. A review of the nursing progress note dated 12/15/2024 at 11:39 AM documented that Resident #36 had an elevated body temperature of 100.3 degrees Fahrenheit, sore throat/hoarseness, cough, congestion, and complaint of overall not feeling well. Resident #36 was provided a rapid Coronavirus (COVID-19) swab test and the result was positive. The Physician Assistant was notified and had a new order to begin the Coronavirus disease (COVID-19) protocol. Droplet/Contact precautions were in place. The Comprehensive Care Plan titled Contact/Droplet/Isolation Precaution, dated 12/15/2024 documented Resident #36 was positive for Coronavirus disease (COVID-19) infection. Interventions included but were not limited to maintaining Transmission-Based Precautions per the physician's orders and maintaining strict single-room isolation for positive Coronavirus Disease (COVID-19) residents. Resident #41 was admitted with diagnoses of Anemia, Stage 4 Chronic Kidney Disease, and Chronic Atrial Fibrillation. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #41 had intact cognition. A physician's order dated 12/7/2024 documented Contact Precautions for Extended Spectrum Beta-Lactamase in urine (people with ESBL could be resistant to some antibiotic treatment). The Comprehensive Care Plan titled Contact/Droplet/Isolation Precaution dated 12/7/2024 documented the resident had Extended Spectrum Beta-Lactamase in urine and Coronavirus (COVID-19) infection Exposure. Interventions included but were not limited to maintaining precautions per the physician's order and wearing proper Personal Protective Equipment. The Comprehensive Care Plan titled Coronavirus (COVID-19), effective 11/14/2024 and last revised 12/16/2024, documented the resident was exposed to Coronavirus (COVID-19) on 12/15/2024. Contact/Droplet precautions were in place per the physician's orders. A physician's order dated 12/15/2024 documented Contact/Droplet Precautions for [COVID-19 infection] Exposure. During an observation on 12/15/2024 at 10:02 AM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. During an interview on 12/15/2024 at 10:02 AM, Licensed Practical Nurse #1 stated that the Contact Precaution signage observed at the doorway was for Resident # 41 who had bacteria in their urine. During an observation on 12/15/2024 at 12:45 PM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. Both residents were observed in the room. Resident #41 was out of bed with no mask. Resident #36's behind the privacy curtains that were drawn. A visitor was observed at Resident #36's bedside and was wearing a surgical mask. The visitor was not wearing a gown, gloves, or eye protection while interacting with Resident #36. During an interview on 12/15/2024 at 12:46 PM, Resident #36's visitor, who was wearing a blue surgical mask stated that Resident #36 just tested positive for Coronavirus (COVID-19) infection this morning and the resident was waiting to be moved to another room. Resident #36's visitor stated that Resident #36 has been symptomatic since Friday (12/13/2024), but tested negative for Coronavirus (COVID-19) on Friday (12/13/2024). During an observation on 12/15/2024 at 12:54 PM, a Contact Precaution signage was observed posted at the doorway where Resident #36 and Resident #41 resided. Both residents were observed in the room. Resident #41 was out of bed by their bedside and wore a blue surgical mask. Resident #36 was observed in their bed and did not wear a mask. Resident #36's visitor remained in the room and was wearing a blue surgical mask and no other Personal Protective Equipment. During an interview on 12/15/2024 at 12:55 PM, Licensed Practical Nurse #1 stated this morning they were aware that Resident #36 was being moved out of their room due to a newly positive test result for Coronavirus (COVID-19) infection. Licensed Practical Nurse #1 stated that Resident #41, who is Resident #36's roommate, is now considered exposed and would either be placed with other exposed residents or remain in the room by themselves. During an interview on 12/15/2024 at 1:00 PM, the Infection Preventionist stated both Resident #36 and Resident #41 were tested for Coronavirus (COVID-19) infection today (12/15/2024) and Resident #36's test results came back positive. The Infection Preventionist stated both residents should be placed on Droplet Precautions because Resident #36 tested positive for Coronavirus (COVID-19) Infection and should be placed on Droplet Precautions as per the facility policy. The Infection Preventionist stated that Resident #36 will be moved to another room for isolation. The Infection Preventionist stated that the correct Transmission-Based Precaution signage was not yet posted but staff and family members were notified about the resident's positive COVID-19 infection results. During an additional interview on 12/15/2024 at 1:53 PM, the Infection Preventionist stated they were responsible for keeping track of all residents who required to be placed on Isolation Precautions. The Infection Preventionist stated Resident #36 should have a blue Droplet and Contact precaution signage at the doorway to indicate positive Coronavirus (COVID-19) infection status and Resident #41 should have an orange Droplet/Contact precaution signage to indicate their exposure to a positive Coronavirus (COVID-19) infection resident. The Infection Preventionist stated they expected the appropriate signage to be posted once the residents completed their move to their designated rooms. The Infection Preventionist stated that the signage was not posted at the door of the room where both residents stayed while waiting for a room change to eliminate confusion. During an interview on 12/16/2024 at 2:21 PM, Registered Nurse #2, the unit manager, stated that primarily the Infection Preventionist was responsible for posting isolation precaution signage. Registered Nurse #2 stated they were aware Resident #36 tested positive for Coronavirus (COVID-19) infection and that Resident #41 was exposed to Resident #36. Registered Nurse #2 did not post the updated Transmission-Based Precautions signage after Resident #36 tested positive for COVID-19 infection. During an interview on 12/18/2024 at 12:57 PM, the Director of Nursing Services stated there should be a blue Droplet and Contact precaution signage for residents who tested positive for Coronavirus (COVID-19) infection and an orange Droplet and Contact precautions signage for residents who were exposed to a positive resident Coronavirus (COVID-19) infection. 10 NYCRR 415.19(a) (1-3) Based on observations, record review, and interviews during the Recertification Survey initiated on 12/15/2024 and completed on 12/19/2024, the facility did not ensure it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Port unit) of two nursing units. Specifically, 1) Resident #79 was identified with a COVID-19 infection and was observed with a Transmission Based Precautions signage outside their room. On 12/16/2024, Housekeeper #1 was cleaning Resident #79's room wearing Personal Protective Equipment including gloves. Housekeeper #1 handed a surgical mask to Resident #20, who was passing by the room in their wheelchair, from the housekeeping cart while wearing the same gloves used to clean Resident #79's room and 2) Appropriate Transmission-Based Precautions signage was not posted when Resident #36 tested positive for COVID-19 infection on 12/15/2024. Additionally, a visitor was observed not wearing appropriate Personal Protective Equipment while visiting Resident #36 on 12/15/2024. The finding is: The facility's policy titled Transmission-Based Precautions (Isolation Precautions), dated August 2024, documented the facility will use Transmission-Based Precautions to manage specific, highly transmissible, or epidemiologically important pathogens based on the mode of transmission: contact, droplet, and airborne. The facility will implement Transmission-Based Precautions when the resident is known or suspected to be infected based on the route of transmission of the infectious agent. Residents on Transmission-Based Precaution will have isolation signage posted outside the resident's room. Residents who tested positive for Coronavirus disease (COVID-19) will have blue droplet/contact precaution signage posted. Residents who were exposed to positive Coronavirus disease (COVID-19) residents or whose swab test results were pending will have an orange droplet/contact precaution signage posted. The Infection Preventionist will follow up with the Housekeeping Director to ensure housekeeping readiness to work in isolation conditions, compliance with different requirements of Transmission-Based Precautions, and disposal of cleaning products and supplies to reduce the risk of room-to-room transmission. Housekeepers will put on appropriate Personal Protective Equipment when entering the resident's room and remove all Personal Protective Equipment before exiting the resident's room. Nursing staff will post appropriate isolation signage outside the resident's room. 1) During an interview on 12/15/2024 at 9:59 AM, the Administrator and Director of Nursing Services stated the facility was experiencing a COVID-19 infection outbreak among residents and there were currently eight positive COVID-19 residents who were placed in rooms in the COVID-19 designated area of the Starboard unit. A Social Work progress note dated 12/16/2024 at 8:11 AM documented Resident #79 was moving (to the COVID-19 isolation area on the Starboard unit) as the resident was positive for COVID-19 infection. During an observation on 12/16/2024 at 11:55 AM, Resident #79 was observed sitting in a wheelchair in their room on the Port unit awaiting transfer to the Starboard unit isolation area. Resident #79 was wearing a surgical mask. There was contact/droplet isolation signage at the room doorway. The signage documented N95 mask; providers and staff must put on gloves before room entry; discard gloves before room exit; put on a gown before room entry; discard the gown before room exit; make sure eyes, nose, and mouth are fully covered before room entry with an N95 mask covered with a blue surgical mask and a face shield; remove the blue surgical mask face protection before room exit. Housekeeper #1 was observed in the room coming in contact with the resident environment and was observed mopping the floor. Housekeeper #1 was wearing a gown, gloves, an N95 mask, and goggles; however, the housekeeper did not have a surgical mask over the N95 mask or a face shield. On 12/16/2024 at 12:05 PM, Resident #79 was transferred out of their room to their new room on the Starboard unit by a staff member. Housekeeper #1 was still in the room cleaning. The Housekeeping Supervisor was standing outside of the room in the hallway. On 12/16/2024 at 12:10 PM Housekeeper #1 was still in the same room cleaning when Resident #20 was observed self-propelling their wheelchair passing the room that was being cleaned by Housekeeper #1. Housekeeper #1 was observed reaching for a surgical mask from their housekeeping cart that was outside the room. Housekeeper #1 was wearing the same gloves that were used for cleaning the room, to retrieve the mask, and then handed the surgical mask to Resident #20. Resident #20 took the surgical mask. The surveyor immediately informed Licensed Practical Nurse #1 and Registered Nurse #2 (unit manager) of the observation. Licensed Practical Nurse #1 immediately took Resident #20 into the bathroom to wash the resident's hands. Registered Nurse #2 stated Housekeeper #1 should have been wearing a surgical mask over the N95 mask and will have to be re-educated about infection control. During an interview on 12/16/2024 at 1:58 PM, Housekeeper #1 stated they were cleaning the room and placing all of the dirty linens in a bag because residents in the room were being moved. Housekeeper #1 stated they made a mistake when they gave Resident #20 the surgical mask with the same gloves that were used for cleaning. Housekeeper #1 stated they knew what the signage at the doorway instructed and they should have had a covering over the N95 mask. During an interview on 12/17/2024 at 1:47 PM, the Housekeeping Director stated the housekeepers are expected to follow directions on the isolation signage. The Housekeeping Director stated it was an infection control breach when Housekeeper #1 handed the surgical mask to Resident #20 while wearing gloves that were used to clean Resident #79's room. During an interview on 12/18/2024 at 8:39 AM, the Infection Preventionist stated the facility had a COVID-19 outbreak. Resident #79 tested positive for COVID-19 infection on the morning of 12/16/2024. The Infection Preventionist stated Housekeeper #1 should have been wearing a surgical mask to protect the N95 mask. The Infection Preventionist stated Housekeeper #1 breached infection control protocols when they handed the surgical mask to Resident #20 with the same gloves that were used to clean a COVID-19 room. During an interview on 12/18/2024 at 1:00 PM, the Director of Nursing Services stated Housekeeper #1 was nervous and thought they were doing the right thing by handing a surgical mask to Resident #20, but that was a breach of infection control protocol. Additionally, Housekeeper #1 was expected to follow the isolation signage at the doorway and cover the N95 mask with a surgical mask.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the abbreviated survey (NY 00311733) dated 4/7/23, the facility did not ensure that Resident #1's environment was free of accident hazard. Specifically, Resident #1 was given food they were allergic to (fish, seafood). The findings are: The Policy and Procedure for food allergies dated 12/2018 documented it is the policy of the facility to ensure that all resident food served accommodates for resident allergies and/or intolerances.Procedure: The Admitting RN will evaluate admissions documentation for food allergies. Allergy/intolerance can also be updated as identified. Information regarding food allergies will be documented in the Dietary section of the medical record and will be entered into the computer system in the Dietary office. Food allergy information will be printed on each meal slip for the individual in the note section of meal tickets for identification. The Food Service Director/Food Service Supervisor and/or the Dietitian will make alterations to the menu system for individual residents identified with food allergies/intolerances to ensure those items are not reflected on the meal ticket to be provided to the resident. All known food allergens will be avoided when meals and snacks are provided to the resident. Resident # 1 was admitted on [DATE] with diagnoses that include Depression, anxiety disorder, Malignant neoplasm of bronchus or lung. The Minimum Data Set (MDS-an assessment tool) MDS dated [DATE] documented Resident#1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS documented the resident had no behaviors. The MDS documented that Resident #1 was independent in eating and may require one staff member as support. The Physician Orders (PO) dated February 2023 documented Resident#1 had allergies including fish and shellfish. EpiPen 0.3 mg/0.3 mL injection, auto-injector, inject 0.3 milliliter (0.3 mg) by intramuscular route once as needed for anaphylaxis (a severe, potentially threatening allergic reaction). Resident#1's face sheet documented the resident had allergies that included fish and shellfish. The Comprehensive Care plan (CCP) titled Therapeutic diet dated 9/1/21 and updated on 3/23/2023 included interventions as follows: food allergy: shellfish, all fish- dietary to omit from meal pattern. The CCP dated 11/5/22 titled Resident is allergic to fish and shellfish. The CCP documented goals: Resident will not be given drugs/food containing allergens as listed. Interventions documented: Do not give resident drug/food to which resident is allergic to. A review of the lunch meal ticket dated 2/26/23 documented the Resident#1's allergies in red (Fish/shellfish). The meal ticket documented for the supervisor to check all meals. The meal ticket also documented that the resident was to be served puree hamburger on that date. A nursing progress note (NPN) dated 2/26/23 at 10:57 PM documented by Licensed Practical Nurse#1 (LPN #1) that at approximately 1:05 pm went to evaluate, Resident#1 who was complaining that the lunch tray was not a hamburger as requested. The NPN documented that while waiting, the resident tasted the food served and notified staff that they believed it was crab. Resident was allergic to shellfish; and stated they only ate half a teaspoon before noticing. The Physician Assistant (PA) was notified immediately, and 1 dose of Benadryl given for prophylactic measures. The NPN documented that the resident had no shortness of breath, respiratory distress, swelling, or wheezing observed. Oxygen was applied for comfort. On 4/7/23 at 10:30 AM, the kitchen was observed along with the crabby cake ingredients that was served to the resident on 2/26/23. The Crabby cakes box by miss Friday's ingredients included imitation crab meat, Alaska [NAME], Pacific [NAME], and snow crab. An investigation by the facility found on Sunday 2/26/23, during the lunch meal service, Resident#1 was served lunch tray. After being served puree lunch tray, Resident#1 notified the staff, passing in the hallway, that they believed pureed meal was not hamburger as they requested, and tasted like crab. The staff member notified the Registered Nurse Supervisor#1 (RNS#1) who responded to the Resident along with the unit LPN. Upon arrival, Resident stated to RNS#1 that there was fish in their meal that they ate, and alerted staff of her shellfish/fish allergy. The meal/puree food that was served was light in color and RNS#1 noted that resident consumed approximately a half of a teaspoon of the puree meal. The meal ticket did reflect shellfish/fish allergy. Upon RNS#1's assessment, the resident appeared in no apparent distress, and was able to speak and respond at her baseline. The PA#1 was made aware, and orders obtained to administer one time dose of Benadryl as prophylaxis. Upon investigation, it was determined that the dietary staff did not follow protocol regarding ensuring meal tray accuracy check was maintained and this was an isolated incident. The Food service supervisor #1 was interviewed on 4/7/23 at 10:30 AM and stated Crabby Cakes by Miss Fridays have ingredients that should not be served to someone who has allergies to shellfish and fish. Dietician #1 was interviewed on 4/7/23 at 1:15 PM and stated Resident#1 has food allergies and this was documented in the notes in their assessment. Dietician #1 stated that food allergies are also documented on meal tickets. Kitchen staff should have identified food allergy and should not have served imitation crab cakes to the resident. Dietician #1 also stated that the resident shouldn't have been served this because of fish ingredients. Food service Director #1 (FSD#1) was interviewed on 4/7/23 at 2:08 pm stated that a crab cake was given to Resident#1. The FSD#1 stated that allergies are highlighted in red on the food ticket and apparently that day the crab cakes were accidentally given. The crabcakes contain fish and the resident has an allergy to fish and shellfish. Resident#1 should not have been given the crabcakes. The Certified Nurse Assistant (CNA) #1 was interviewed on 4/7/23 at 2:45 PM and stated that on 2/26/23 they just gave the resident the tray, the tray was missing a soda and the meal was pureed. CNA#1 stated the Resident had no concerns at the time when the tray was served. LPN#1 was interviewed on 4/7/23 at 3:00 pm and stated the trays were given out without any concerns identified. After CNA#1 gave the tray, and after concern was brought to staff attention, resident was assessed, PA#1 was made aware, and Benadryl was given for allergy. The Director of Nursing Services (DNS) was interviewed on 6/15/23 at 2:15 PM and stated CNA#1 gave the resident a puree tray and it was hard to distinguish by looking at the food whether the resident was served food that the resident had an allergy to. The DNS stated that CNA#1 was not made aware by the resident of any concerns regarding the food when the tray was served to the resident. The resident was a self-feed and when the resident knew the meal contained crab, CNA#1 intervened and notified the nurse. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 21) of six residents reviewed for unnecessary medications. Specifically, nursing staff were not rotating the Subcutaneous (sq) injection sites, when Lovenox (an Anticoagulant) was administered. The finding is: The Policy and Procedure for Injection Site Rotation dated [DATE] documents that rotation of the injection site helps reduce irritation and bruising and improves absorption. Resident # 21 was admitted with diagnosis that included Thrombocytopenia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The MDS documented Resident # 21 received 7 days of anticoagulants and 7 days of injections during the MDS assessment look-back period. The Physician's order dated 2/27/2023 documented to administer Lovenox Enoxaparin 40 milligrams (mg)/0.4 milliLiter (mL) subcutaneous syringe- inject 0.4 milliliter (40 mg) by subcutaneous route once daily by injection for prophylactic measures. A review of the Medication Administration Record (MAR) for March 2023 documented the Lovenox injection was administered to the left abdomen on 11 consecutive days at 9 PM, (March 19- March 29). The MAR for April 2023 documented Resident # 21 was administered Lovenox to the left abdomen on 7 consecutive days (April 1- April 7). On 4/17/23 at 1:54 PM, Resident #21's abdomen was observed with ecchymosis (bruising) to left lower abdomen. Resident # 21 was interviewed on 4/17/23 at 1:54 PM and stated they (Resident #21) were unaware of where the last injection of Lovenox was given and they do not monitor where they get their injections. Licensed Practical Nurse (LPN) # 3, the 3 PM - 11 PM nursing shift medication nurse, was interviewed on 4/18/2023 at 3:45 PM and stated that Lovenox is given subcutaneously and the injection site should be rotated; however, because of technical reasons, the Electronic Medical Record (EMR) drop down box does not allow the nurse to record any other site on the MAR except the left abdomen. LPN #3 further stated the medication nurse cannot verify the actual site of the previous injection because the MAR only allows the left abdomen site to be selected. The Director of Nursing Services (DNS) was interviewed on 4/18/2023 at 11:52 AM and stated that the site of Lovenox administration should be documented and the injection site should be rotated. The medication should not be given to the same site on consecutive days because it can cause tissue damage and discomfort for the resident. The Physician was interviewed on 4/19/2023 at 3:12 PM and stated bleeding, pain, and tissue damage can occur if the injection of Lovenox is not rotated. 10NYCRR 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that procedures that assure the accurate acquiring dispensing and administering of all drugs and biologicals meet the needs of each resident. This was identified for one (Resident #64) of five residents reviewed for unnecessary medication. Specifically, Resident #64 had a Physician's order dated 11/22/2022 for Lasix (diuretic) 40 mg for 10 days. The Medication was renewed on 12/1/2022 and 1/1/2023 for an additional 10 days. Review of the Medication Administration Record (MAR) revealed the medication was dispensed by the Pharmacy after the duration date and administered to the resident without a current Physician's order. The finding is: Resident #64 was admitted with diagnoses that included Morbid Obesity, Atrial Fibrillation, Peripheral Vascular Disease, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. The resident was non-ambulatory and received a Diuretic for seven of seven days during the assessment look-back period. A Physician's order dated 11/22/2022 documented to administer Furosemide 40 milligram (mg), give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Pharmacy Electronic Shipping Manifest (medication invoice) dated 11/30/2022, 12/22/2022, 12/30/2022 and 1/17/2023 documented Furosemide 40 mg was requested and accepted. A Physician's order dated 12/1/2022 and with a start date of 11/22/2022 documented Furosemide 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 12/2022 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at (5pm) for 10 days. The start date was (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix 40 mg from 12/1/2022 to 12/31/2022 outside the duration date of 12/2/2022 without a Physician's order. A Physician's order dated 1/1/2023 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg tablet, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 1/2023 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at (5pm) x 10 days. Start date (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix from 1/1/2023 to 1/3/2023 and from 1/9/2023 to 1/19/2023 outside the completion date without a Physician's order. Lasix was held from 1/4/2023 to 1/8/2023 due to elevate a Blood Urea Nitrogen (BUN) level of 44 mg/deciliter (dl) and Creatinine level of 1.49 mg/dl. The laboratory report indicated the normal reference range for BUN was 8-23 mg/dl and Creatinine level was 0.50-0.90 mg/dl. A Pharmacy review dated 1/12/2023 documented the resident has an order of Lasix Furosemide with a stop dated of 10 days that was started on 11/22/2022 with an end date of 12/2/2022. The recommendation was to consider discontinuing and or starting a new Lasix order with or without a stop date. The Pharmacist documented the reason for the recommendation was if Lasix was administered outside the date parameter it could lead to a medication error. Physician Assistant (PA) #1 was interviewed on 4/19/2023 at 1:53 PM. PA #1 stated they had written the initial order for Lasix 40 mg on 11/22/2022 for Edema of bilateral lower extremities. PA #1 stated they were in the facility every day and saw improvement in the resident's lower extremities and continued the order for Lasix 40 mg. PA #1 stated they did not enter the order but after assessing the resident that they should have written a note and given a verbal order to the nurses on the unit. PA #1 stated that the 12/1/2022 order should have been a standing order for Lasix without the 10-day duration date. PA #1 further stated that the Lasix could have contributed to the resident's abnormal renal function and Dehydration. The Pharmacist Director was interviewed on 4/19/2023 at 2:02 PM. The Pharmacist Director stated that when a medication is ordered for 10 days that they dispense a 10-day supply and that each time the medication is renewed they would dispense an additional 10-day supply. The Pharmacist Director stated that they received a Physician order for Lasix on 11/22/2022 and a renewal signed by the Physician on 12/1/2022. The Pharmacist Director stated on 11/30/2022, 12/22/2022, 12/30/2022 and 1/16/2023, they received an electronic request for the for Lasix 40 mg and that they (Pharmacist Director) dispensed Lasix 40 mg by linking the request to the most recent order which was the 12/1/2022 renewal order. The Pharmacist stated in the EMR the previous order was not discontinue;, however, stated the process was to obtain a new Physician's order with each request and they should have linked each request to a new Physician's order. The Pharmacist stated that if Lasix was administered past the duration date the medication can contribute to Dehydration and Renal Function problems. The Director of Nursing Service (DNS) was interviewed on 4/19/2023 at 2:53 PM. The DNS stated that when the order is uploaded in the EMR, there is a function that allows the staff to enter the 10-day duration. The DNS stated when staff enters the 10 days duration on the 11th day the system would automatically discontinue the medication. The DNS stated if the Physician would like the medication to continue the Physician or the PA would give a new telephone order to the nurse who would then enter the new order in the EMR. The DNS stated the Lasix order should have been discontinued and a new order obtained from the Physician or PA for a standing order without a stop date. The DNS stated after 12/11/2022 the nurses should not have administered the medication, and the nurses should have verified the order with the PA or the Physician before administering the Lasix. 10NYCRR 415.18(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that residents are free of significant medication error. This was identified for one (Resident #64) of five residents reviewed for unnecessary medication. Specifically, Resident #64 was administered Lasix (diuretic) outside the specified duration date. The finding is: The facility Medication Administration policy dated 2/2019 documented the nurse will review physician's orders and compare against medication administration record and to compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label. The policy documented to always check three (3) times prior to administration of medication. Resident #64 was admitted with diagnoses that included Morbid Obesity, Atrial Fibrillation, Peripheral Vascular Disease, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. The resident received a Diuretic for seven of seven days during the assessment look-back period. A Medical Progress note dated 11/22/2022 documented the resident was seen for follow up and laboratory report review. The resident was noted with increased lower extremity Edema (swelling). Start Lasix 40 milligram (mg) daily (QD) for 10 days and increase Potassium (KCL) to 20 milliequivalent (meq) twice (BID) daily for 10 days then resume QD dosing. A Nursing progress note dated 11/22/2022 documented the Physician Assistant (PA) was in on rounds and ordered to start Lasix 40 mg and an additional 20 meq of Potassium for 10 days. A Physician's order dated 11/22/2022 documented to administer Furosemide (Lasix) 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Medical note dated 11/25/2022 documented the patient was seen for follow up and laboratory report review. Improving lower extremity edema with Lasix in progress. Laboratory results on 11/22/2022 revealed the Blood Urea Nitrogen (BUN) level was 18 milligrams/deciliter (mg/dl) and the Creatinine level was 0.51 mg/dl. According to the laboratory report, the normal reference range for BUN is 8-23 mg/dl and Creatinine is 0.50-0.90 mg/dl. A Review of the Medication Administration Record (MAR) dated 11/2022 documented Lasix 40 mg give 1 tablet by oral route once daily in the evening for 10 days. The start date was 11/22/2022 for diagnosis of Edema. The MAR documented the resident received the Lasix from 11/22/22 to 11/30/22. A Basic Metabolic Panel (BMP) laboratory report dated 12/1/2022 documented a low Potassium level of 2.7 millimoles per liter (mmol/L). The normal Potassium range per the laboratory report was 3.4-5.1 mmol/L. A Nursing note dated 12/1/2022 documented the PA reviewed the laboratory report for 12/1/2022. The Potassium (K+) was 2.7. The PA ordered Potassium Chloride (KCL) 40meq for 1 dose then 40 meq BID for 3 days, then after change to KCL 40 meq daily. A Physician's order dated 12/1/2022 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 12/2022 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at 5pm for 10 days. The start date was 11/22/2022 for diagnosis of Edema. The MAR documented the resident received Lasix 40 mg from 12/1/2022 to 12/31/2022, outside the duration date of 12/2/2022 without a Physician's order. A Physician's order dated 1/1/2023 and with a start date of 11/22/2022 documented to administer Furosemide 40 mg tablet, give 1 tablet (40 mg) by oral route once daily in the evening for 10 days for Edema. A Review of the MAR dated 1/2023 documented Lasix 40 mg give 1 tablet by oral route daily in the evening at 5pm x 10 days. Start date (11/22/2022) for diagnosis of Edema. The MAR documented the resident received Lasix from 1/1/2023 to 1/3/2023 and from 1/9/2023 to 1/19/2023 outside the completion date without a Physician's order. Lasix was held from 1/4/2023 to 1/8/2023 due to elevated BUN level of 44 mg/deciliter (dl) and Creatinine level of 1.49 mg/dl. A Pharmacy review dated 1/12/2023 documented the resident has an order of Lasix with a stop date of 10 days that was started 11/22/2022 with an end date of 12/2/2022. The recommendation was to consider discontinuing and or starting a new Lasix order with or without a stop date. The Pharmacist documented the reason for the recommendation was if Lasix was administered outside the date parameter it could lead to a medication error. A BMP laboratory report dated 1/4/2023 documented a Blood Urea Nitrogen (BUN) level of 44 (8-23 mg/dl), and Creatinine Serum level of 1.49 H (0.50-0.90 mg/dl). The laboratory report was reviewed by the Physician Assistant (PA), and they (PA) recommended to hold Lasix for 5 days and repeat the BMP on 1/10/2023. A Nursing note dated 1/4/2023 at 8:18 PM documented as per the PA hold Lasix for 5 days and repeat a BMP on 1/10/2023. A Nursing note dated 1/8/2023 at 1:51 PM documented Lasix hold maintained at this time 5 of 5 days. No signs and symptoms of adverse reactions noted at this time. A BMP laboratory report dated 1/10/2023 documented a BUN level of 35 mg/dl and Creatinine level of 1.12 mg/dl. Licensed Practical Nurse (LPN) #2 was interviewed on 4/18/2023 at 3:40 PM. LPN #2 stated when the Physician orders a medication for ten days the nurse that enters the order in the electronic medical record (EMR) also includes the end date. LPN #2 stated that the nurse that entered Lasix in the system should have entered Lasix with a stop date. LPN #2 stated when an order is active, the medication appears on the resident's current MAR and discontinued medications would appear under the discontinued tab. LPN #2 stated if the nurse that entered the order in the system did not set a stop date, then the medication will still show up on the resident's MAR. LPN #2 stated that they did not check the Physician's order prior to administering Lasix 40 mg on 12/2/2022. LPN #2 stated that they (LPN #2) should have verified the resident's order to ensure that the Physician's order for Lasix was current prior to administering the medication. LPN #4 was interviewed on 4/19/2023 at 11:23 AM. LPN #4 stated they were the LPN that entered the original order in the resident's EMR. LPN #4 stated if Lasix was ordered for 10 days, that when they (LPN #4) entered the order they had the option to enter the medication for the duration of (10) days as ordered. LPN #4 stated when they entered the order, they should have entered the Lasix for 10 days as ordered to prevent an error. LPN #4 stated after 12/11/2022 they should have notified the Supervisor and the Physician for clarification on if the Lasix should have been continued. Registered Nurse (RN) #2 was interviewed on 4/19/2023 at 11:58 AM. RN #2 stated when the Physician orders a medication with a duration date, when the order is entered in the system, a duration date should be set up in the system. RN #2 stated that the system would X out the medication when the duration date is reached unless the medication is extended by the PA or the Physician. RN #2 stated that if the Physician wishes to continue the medication after the duration date the Physician would give a new order for an additional 10 days. RN #2 stated after 12/11/2022 the medication should have been entered in the system as a new order with a new end date. RN #2 stated if a medication is sent to the Pharmacy with a 10-day duration, the medication would be dispensed for only 10 days and if the Physician or the PA gave a new order for the medication to continue, the Pharmacy would dispense medication for another 10 days. RN #2 stated that they did not know where the nurses obtained the medication to be administered to the resident after 12/11/2022. RN #2 stated that there was an Emergency medication box; however, only 1 to 2 Lasix tablet is kept in the box. The Assistant Director of Nursing Services (ADNS) was interviewed on 4/19/2023 at 12:49 PM. The ADNS stated that they (ADNS) were responsible for reviewing the monthly Pharmacy reviews. The ADNS stated when the medication was entered into the EMR the medication was entered incorrectly because the medication was entered without a duration date. The ADNS stated the Physician's order was for Lasix to be administered for ten days; however, when the nurse entered the medication, it was not scheduled for 10 days in the EMR and should have been. PA #1 was interviewed on 4/19/2023 at 1:53 PM. PA #1 stated they had written the initial order for Lasix 40 mg on 11/22/2022 for Edema of bilateral lower extremities. PA #1 stated they were in the facility every day and saw improvement in the resident's lower extremities and continued the order for Lasix 40 mg. PA #1 stated that they did not enter the order but after assessing the resident that they should have written a note and given a verbal order to the nurses on the unit. PA #1 stated that the 12/1/2022 order should have been a standing order for Lasix without the 10-day duration date. PA #1 further stated that the Lasix could have contributed to the resident's abnormal renal function and Dehydration. The Pharmacist Director was interviewed on 4/19/2023 at 2:02 PM. The Pharmacist Director stated that when a medication is ordered for 10 days, they dispense a 10-day supply and that each time the medication is renewed they would dispense an additional 10-day supply. The Pharmacist Director stated that they received a Physician order for Lasix on 11/22/2022 and a renewal signed by the Physician on 12/1/2022. The Pharmacist Director stated on 11/30/2022, 12/22/2022, 12/30/2022 and 1/16/2023, they received an electronic request for Lasix 40 mg and that they (Pharmacist Director) dispensed Lasix 40 mg by linking the request to the most recent order which was the 12/1/2022 renewal order. The Pharmacist stated in the EMR the 12/1/2022 order was not discontinued, however, stated the process was they should have obtained a new Physician's order with each request for renewal of the Lasix, and that each request should have been linked to a new Physician's order. The Pharmacist stated that if Lasix was administered past the duration date that the medication can contribute to Dehydration and Renal Function problems. The Director of Nursing Service (DNS) was interviewed on 4/19/2023 at 2:53 PM. The DNS stated that when the order is uploaded in the EMR, there is a function that allows the staff to enter the 10-day duration. The DNS stated when the staff enters the 10 days duration on the 11th day the system would automatically discontinue the medication. The DNS stated if the Physician would like the medication to continue the Physician or the PA would give a new telephone order to the nurse who would then enter the new order in the electronic record. The DNS stated that the Lasix order should have been discontinued and a new order obtained from the Physician or PA for a standing order without a stop date. The DNS stated after 12/11/2022 the nurses should not have administered the medication, and that the nurses should have verified the order with the PA or the Physician before administering the Lasix. 10NYCRR 415.12(m)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/13/2023 and completed on 4/19/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial and subsequent tour of the kitchen on 4/13/2023 and 4/14/2023. Specifically, the facility did not ensure that emergency dry food and food products delivered with no expiration dates were tracked and that safety of consumption and discard dates of these food products were determined as per the manufacturer's recommendations. The finding is: The facility's policy titled Food Receiving/Storage Procurement- General dated 10/2022 documented that when food, food products or beverages are delivered to our facility, staff will inspect these items for safe transport and quality upon receipt and ensure their proper storage, covering, labeling, and dating all Potentially Hazardous Food/Time/Temperature Control for Safety (PHF/TCS) foods stored in the refrigerator or freezer as indicated. Perishable and non-perishable food items will be stored/discarded as per the manufacturer's recommendations. Food items that display a best by date will be used for consumption as indicated by the manufacturer recommendations. Foods with a use by or expire date will be consumed or discarded by that date. During an initial tour of the kitchen on 4/13/2023 at 10:43 AM, an inspection of the emergency dry storage room was conducted. Several boxed food items including ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water were observed with facility-applied sticker labels indicating expiration dates of January 2023, March 2023 and February 2023 respectively. The food products were uncovered from the boxes and the ravioli in tomato sauce was noted to have a best by date by January 2023, the cheese sauce was noted to have a best by date by March 31, 2023 and the light tuna chunk was noted to have a best by date by February 2023. The Food Services Director (FSD) was interviewed immediately and stated that the items should be discarded. Dietary Aide (DA) #1 was interviewed on 4/14/2023 at 12:53 PM and stated they (DA#1) were responsible for receiving and stocking the food delivery. DA #1 stated that they checked for products' expiration dates at the time of delivery and would not accept any expired items. DA#1 stated that they considered best by date the same as expiration date. DA#1 stated that when they noticed the cheese sauce that was delivered on 4/5/2023 with a best by date of 3/31/2023, they would have seen it as expired and should have notified the Director of Food Services. DA#1 stated that when they noticed the chunk light tuna that was delivered on 4/4/2023 with a best by date in February 2023, they would have seen it as expired and should have notified the Director of Food Services. DA#1 stated that they did not notify the Director of Food Services (FSD) about the cheese sauce. DA#1 did not recall if they notified the FSD about the ravioli and the light tuna. A subsequent tour of the emergency dry storage room was conducted on 4/14/2023 at 1:17 PM. Canned green beans and canned sliced carrots were inspected and noted without expiration dates on the boxes. The delivery date of the canned green beans was noted to be 8/9/2022, the expiration date on the body of the cans were incomprehensible. The delivery date of the canned sliced carrots was noted to be 8/10/2022, the expiration date on the body of the cans were incomprehensible. A facility-applied sticker was observed on the packaging of the sliced carrots indicating an expiration date of May 2025. The Food Services Director (FSD) was interviewed immediately and stated that canned vegetables were normally good for one year past best by date and should be discarded by August 2023. The FSD stated that they did not know how an expiration date of May 2025 was determined for the canned sliced carrots. The FSD stated that the facility's purchasing staff had reached out to the vendor to obtain the manufacturer's recommendations for foods with best by date to determine how long those foods will be safe to consume beyond best by date and whether or not those foods are safe to consume. The FSD stated that they will now request the vendor to provide expiration dates for the canned vegetables with incomprehensible expiration dates. The FSD was re-interviewed on 4/14/2023 at 1:35 PM and stated that all dietary staff were expected to reach out to them (FSD) whenever there were uncertainty related to food's safety of consumption and or the food's discard dates. The FSD stated that all dietary staff will receive an in-service about reading the dates on the food packaging. The FSD stated that they (FSD) were still waiting for the manufacturer's reference for the ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water at this time. The Food Service Supervisor (FSS) was interviewed on 4/18/2023 at 1:33 PM and stated that they (FSS) were also the cook. The FSS stated they only received food delivery on rare occasions when both the primary stock person and the Food Service Director were absent. The FSS stated that when they received an order, they would reconcile the order and the marked date of delivery on the packages. The FSS stated that they do not inspect the expiration dates and that the stock person responsible would check, determine, and label the expiration dates when they (stock person) sorted and stocked the foods. The FSS stated that they were in-serviced on food safety and on how to determine discard dates for food that did not have an expiration date in the past. The FSS stated that all food's discard dates should be three months beyond best by date. The FSS stated that food with best by date of February 2023 should be discarded by May 2023. The FSD was re-interviewed on 4/18/2023 at 1:52 PM and stated that they (FSD) were still waiting for the manufacturer's reference for the ravioli in tomato sauce, aged cheddar cheese sauce and light tuna chunk in water at this time. They (FSD) were also still waiting for the manufacturer's clarification of the canned green beans and canned sliced carrot which had incomprehensible expiration dates. The FSD stated that they (FSD) had referenced the United State Department of Agriculture (USDA) government website when determining the safe consumption dates and discard dates for foods with best by dates. The FSD stated that they should reference the manufacturer's recommendations to accurately determine actual expiration/discard dates of foods in their inventory that did not have expiration dates. The USDA reference titled Food Product Dating dated 10/2/2019 was provided and reviewed. The reference documented that a Best if used by/Before date indicates when a product will be of best flavor or quality. It is not a purchase or safety date. The Administrator was interviewed on 4/19/2023 at 10:30 AM and stated that they (Administrator) expected that the food safety and discard dates would be determined by following the manufacturer's recommendations, especially with foods that had best by date. The Administrator stated that the facility currently did not have the manufacturer reference available to determine the exact expiration/discard date for food items that did not have expiration dates on them. The Administrator stated that there was no way to be certain how long each food item with a best by date can be kept beyond its best by date. The Administrator stated that the facility had reached out to obtain the manufacturer reference and was still waiting for the manufacturer's reference for the food items at this time. 10NYCRR 415.14(h)