Based on record review and interviews during the recertification survey conducted 3/18/2024-3/21/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 6 of 6 anonymous residents. Specifically, 6 anonymous residents present at the Resident Council meeting stated they did not know how to file a grievance. Findings include: The facility policy, Grievances, Concerns and Suggestions revised 7/29/2019 documented all the residents would have a right to voice grievances without fear of reprisal. The social worker was responsible to present and explain to the resident/family/designated representative information pertinent to a resident's grievance rights upon admission. The policy did not include education provided to the resident on how to file a grievance. The facility's Grievance, Concerns, and Suggestion Tracking Logs dated 7/1/2023 to 12/31/2023 and 1/1/2024 to 6/30/2024 documented there were no grievances for these time periods. During a Resident Council Meeting on 3/18/2024 at 2:07 PM, six anonymous residents stated they did not know how to file a grievance. They stated they verbalized concerns to the Social Services Director. One anonymous resident stated they did not hear back about a resolution. During an interview on 3/20/2024 at 12:02 PM, the Social Services Director stated they did not have any grievances. They stated if someone had a complaint or concern, and the facility was not able to solve this issue in a timely manner, then it would become a grievance. They had no concerns that reached the level of a grievance. If a resident wanted to file a grievance they could visit them, and they would assist the resident to fill out the complaint form. They would review it with the resident and attach any supporting documentation. If they wanted to file an anonymous grievance, the resident could talk to the Ombudsman. If they did not want to talk with the Ombudsman, they could slip a note under the Social Services Director's door. There was no formal education or information provided to residents on the grievance process. They stated they were the only staff member that had grievance forms, but all staff had access to their office and the forms were in a clearly labeled binder. During an interview on 3/20/2024 at 12:23 PM, the Administrator stated they talked with the Social Services Director and stated that anything of concern to a resident could be a grievance, such as missing items. Any concerns voiced by residents should be written up as a grievance and followed up on. They were reevaluating the grievance process with the Social Services Director. They did not know if the residents had been educated on how to file a grievance. The residents had not been educated since they started as Administrator in December of 2023. They were aware the residents had the right to file an anonymous grievance but did not know the current process at the facility. 10NYCRR 415.3(C)(1)(ii)

Based on record review and interview during the recertification survey conducted 3/18/2024 - 3/21/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility's infection prevention control plan was not reviewed annually and did not include water management as required. Findings include: The facility policy Infection Prevention and Control Program dated 2018, documented the Infection Prevention and Control Committee, Medical Director, Director of Nursing Services, and other key clinical administrative staff review the infection control policies at least annually. The review would include updating or supplementing policies and procedures as needed. There was no documented evidence the facility's Infection Prevention and Control Program plan included water management and measures to prevent the growth of Legionella (a bacteria that causes Legionnaire's disease) and other opportunistic waterborne pathogens in building water systems. There was no documented evidence the policies and procedures of the facility's Infection Prevention and Control Program had been reviewed or revised since 2018. During an interview on 3/20/2024 at 3:08 PM, registered nurse/Infection Preventionist stated they were hired in July of 2023, and was not sure if the infection prevention control plan had been updated or reviewed since 2018. They were not aware that water management was required to be included and reviewed with the infection prevention control plan. Registered nurse/Infection Preventionist stated it was important to have the infection prevention control plan reviewed and up to date to ensure all the best practices to protect the resident's health. During an interview on 3/20/24 at 3:31 PM, registered nurse #2 stated they were responsible for clinical education and staff development. They worked at the facility for the last year and the infection prevention control plan had not been reviewed. They had recently purchased a new program they planned to adapt as their infection prevention control plan. They were not sure the last time the plan had been reviewed. They were currently using the new program plan, but it had not been reviewed and approved by the Medical Director and the Quality Assurance Team. They were aware water management should be included in the infection prevention control plan and planned to review and approve the plan. During an interview on 3/21/23 at 10:27 AM, the Administrator stated the infection prevention control plan should be reviewed annually. They were made they did not have documentation that it was reviewed annually. They just initiated a new infection control program, but the plan still had to be approved by leadership and the Quality Assurance Team. They were not aware the current plan did not include water management. 10 NYCRR 415.19(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 11/8/21-11/10/21, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident #83) reviewed. Specifically, Resident #83's wound dressing was not changed as ordered. Findings include: The facility policy Clean Wound Dressing revised 7/9/19 documents it is the policy of the facility that clean wound dressings will be applied and changed as per medical provider's orders by a licensed nurse. Resident #83 was admitted to the facility with diagnoses including malignant neoplasm (cancer) of specified parts of peritoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen), Type 2 diabetes, and right hip replacement. The 10/11/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with bed mobility, had one Stage I pressure ulcer (reddened area of the skin that does not turn white when pressed), had a pressure reducing device for chair and bed, was on a turning/repositioning program, received nutrition, or hydration interventions to manage skin problems, pressure ulcer care, and application of non-surgical dressings and ointments/medications. The skin assessment dated [DATE] documented the resident had a Stage II (partial-thickness skin loss) pressure area on the right rear thigh measuring 1.0 centimeter (cm) x 0.5 cm. The medical provider was notified on 10/28/21. A nurse practitioner (NP) progress note dated 10/29/21 documented the resident had a Stage II pressure area on the right hip measuring 1 cm x 1 cm x 0.1 cm. There was no appreciable drainage, the wound base was pink, and the periwound (surrounding skin) was red. The NP documented they were originally told that it was on the back of the right side, but it was quite high up and they believed that when the resident was sitting it was over a bony prominence somewhere in line with the inferior trochanter (hip bone/femur area). The plan was Calmoseptine (skin protectant) to the hip wound and cover with AGB (Allevyn Gentle Border, wound dressing). A NP progress note dated 11/4/21 documented the resident had a Stage II pressure area on the right hip, the area was superficial and measured 1 cm x 1.5 cm x 0.1 cm. The area had not changed, if anything was a little bigger and was superficial. The plan was to do the same dressings to the hip. A physician order dated 11/5/21 documented skin prep (skin protectant) to wound bed of open area on the back of the right leg, cover with AGB every day shift. The comprehensive care plan (CCP) initiated 11/5/21 documented the resident had a Stage II pressure ulcer on the right thigh related to immobility. Interventions included administer treatments as ordered and monitor for effectiveness. The 11/21 Treatment Administration Record (TAR) documented skin prep to wound bed of open area on the back of the right leg, cover with AGB every day shift for skin treatment, with a start date of 11/6/21. The TAR documented the treatment was not done on 11/8/21 with a code of 9 (other/see nurses note) documented by licensed practical nurse (LPN) #1. There was no documented corresponding nursing progress note. During a wound treatment observation on 11/9/21 at 10:29 AM with LPN #1 the resident's dressing was removed and was dated 11/7. The pressure ulcer was located on the right lateral bottom buttock, near the thigh crease and was a circular superficial area with no erythema (redness) or drainage noted. The treatment was completed, and a new dressing was applied by LPN #1. The LPN stated the dressing was to be done daily and they must have missed it on 11/8/21. During an interview with LPN #1 on 11/9/21 at 2:33 PM the LPN stated the treatment was not done on 11/8/21 and they did not know why they did not complete the treatment. During an interview on 11/10/21 at 1:26 PM Infection Preventionist registered nurse (RN) #8 stated if an ordered dressing change was not done there was a lack of monitoring for signs and symptoms of infection, and for healing or worsening of the wound. During an interview on 11/10/21 at 2:16 PM RN Unit Manager #6 stated if a wound treatment was not performed as ordered there could be an increased risk of infection. During an interview on 11/10/21 2:49 PM the Director of Nursing (DON) stated the if a wound treatment was not done daily as ordered, the risk of infection could increase, or the wound could worsen. The DON stated the number 9 above the LPN initials in the TAR meant the treatment was not done. 10NYCRR 415.12(c)(1)

Based on observation, record review and interview during the recertification survey conducted from 11/8/21-11/10/21, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents reviewed (Resident #26). Specifically, Resident #26's blood pressure medication was administered, and the resident's blood pressure and heart rate were not obtained prior to administration per physician ordered parameters. Findings include: The facility policy Medication Administration - General Guidelines revised 7/17/18 documents medications are administered in accordance with orders from the medical provider. Resident #26 had diagnoses including end stage renal (kidney) disease, atrial fibrillation (abnormal heartbeat) and congestive heart failure. The 8/26/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required supervision with setup or one-person physical assist with most activities of daily living (ADL) and was receiving dialysis treatment. A physician order dated 6/4/21 documented metoprolol tartrate (blood pressure/heart failure medication) 75 milligrams (mg), give one tablet by mouth twice a day for atrial fibrillation, hold for systolic blood pressure (SPB, top number of blood pressure reading) <100 and/or heart rate (HR) < 60 (beats per minute), and call if held. During a medication administration observation on 11/9/21 at 7:57 AM, LPN #1 administered 75 mg of metoprolol to Resident #26 and did not check the resident's blood pressure or heart rate as ordered. LPN #1 stated at the time of the observation there were no parameters for the blood pressure medication. The LPN stated the resident received this medication every morning and the certified nurse aides (CNAs) did not check the resident's blood pressure earlier that morning. LPN #1 reviewed the electronic medication administration record (MAR) and the resident's current orders. The LPN stated the resident's blood pressure was scheduled to be taken every Thursday morning. During the observation, Resident #26 requested that LPN #1 check their blood pressure a couple of times during the day because their blood pressure had been low the previous week and it made them feel sick. The November 2021 MAR documented metoprolol 75 mg, give 1 tablet by mouth two times a day (at 8:00 AM and 8:00PM) for atrial fibrillation, hold for SBP < 100, HR <60, call if held. The start date was documented as 6/4/21. The MAR did not include documented blood pressures or heart rates, and the area to record blood pressures had an X documented from 11/1-11/9 at 8:00 AM. The MAR documented on 11/9/21 at 8:00 PM a blood pressure reading of 116/74 and the metoprolol was administered. During an interview on 11/9/21 at 12:46 PM, LPN #1 stated they had not taken Resident #26's blood pressure yet and explained that if they were required to take the blood pressure there would be a prompt from the electronic MAR to do vital signs prior to being able to select yes to administer medication. The LPN stated they should review the order and add a prompt for vital signs to be taken when administering the blood pressure medications. The LPN stated the resident's blood pressure should be taken because it could be lower than normal due to the medication, and this could make the resident sick. During an observation and interview on 11/10/21 at 7:52 AM, LPN #2 administered Resident #26's metoprolol tartrate 75 mg after checking their blood pressure. LPN # said they wanted to check the blood pressure because it had been running low and the resident received outpatient dialysis treatment. The LPN stated the MAR does not always prompt the nurse to document a blood pressure, but the resident had ordered parameters for blood pressure and heart rate. During an interview with Resident #26 on 11/10/21 at 8:01 AM, they stated the nurse took their blood pressure in the late afternoon on 11/9/21. The resident stated their blood pressure should be taken twice a day because of the ordered blood pressure medication and with dialysis their blood pressure can become very low. 10NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted [DATE]-[DATE], the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication cart (short hall medication cart) reviewed. Specifically, the medication cart for the short hall contained 2 insulin pens that were not labeled with the date they had been opened. Findings include: The facility policy Insulin Injection Administration revised [DATE] documents the procedure includes: obtain insulin pen from refrigerator and allow warming to room temperature. Label with resident identifiers, date opened, and expiration date. If using an insulin pen, follow manufacturer instructions. The undated facility policy Medication Storage documents medications are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier, and in accordance with federal and state laws and regulations. Manufacturer instructions for Novolog Flex pen documents dispose of after 28 days, even if there is insulin left in the pen. During an observation of the short hall medication cart on [DATE] at 10:49 AM, 2 insulin pens (Novolog Flexpen and Lantus Solostar Pen) used for Resident #83 were observed with no documented opened date. Licensed practical nurse (LPN) #1 stated they should check to make sure insulin was not expired every time it was given. The LPN stated that the nurse opening the pen the first time was responsible for making sure the opened date was placed on the pen. The LPN stated that the insulin was good for 30 days after opening. During an interview on[DATE] at 2:21 PM with registered nurse (RN) Unit Manager #6, they stated the opened date should be put on the insulin pen because the insulin was only good for 30 days after opening. The person opening the pen for the first time was responsible for writing the date opened on the pen. The RN Unit Manager stated they expected that every time insulin was administered the date opened should be checked to make sure the medication is not expired. During an interview on [DATE] at 2:44 PM with the Director of Nursing (DON) they stated insulin pens should have the date placed on them when opened. The nurse who opens the insulin pens was responsible, and the pen was good for 30 days. Medication nurses should be checking for the date every time insulin was administered to make sure it is not expired. 10NYCRR 483.45(g)(h)

Based on observation, interview, and record review during the recertification survey conducted 11/8/21- 11/10/21, the facility failed to ensure the resident menus were followed for 1 of 5 meals observed. Specifically, on 11/9/21 the approved, preplanned, and posted menu documented boiled potatoes were to be served at the lunch meal. 10 residents on the short hall were served mashed potatoes which was not an approved menu substitution, was not updated on the posted menu, and residents were not notified of the change. Finding included: The facility's 1/7/21, Week 4 Day 3 Menu documented the boiled potatoes were to be served with the lunch meal. The facility policy Menu Item Substitution dated 1/2016, documents appropriate menu substitutions will be made in the event pre-planned menu items are unavailable. The food production employee will notify the general manager or clinical designee of unavailable menu items. The clinical staff will approve menu substitutes. Notice of menu substitution will be posted adjacent to the menu on all resident units. Menu substitution will be tracked on the menu substitution form. Menus and substitutions will be kept on file for 30 days. The 3/18/18, Dietary Server (Health Care Server) job description documented the server will follow menus and diets. The 2018, [NAME] job description documented the cook will prepare and cook meals from a planned menu using production sheets and standardized recipes to maintain quality, quantity, and palatability. During the lunch meal observation on the short hall dining room on 11/9/21 at 12:50 PM, the residents were served mashed potatoes instead of the planned boiled potatoes. There was no signage or notification to indicate there was a menu item substitution at the lunch meal. During an interview on 11/09/21 at 1:04 PM, licensed practical nurse (LPN) #1 stated mashed potatoes were brought up to the short hall kitchenette instead of the boiled potatoes. During an interview with health care server #14 on 11/9/21 at 1:06 PM, they stated they were aware mashed potatoes were provided to the short hall kitchenette, they did not report the item substitution to their supervisor or ask why the boiled potatoes were not provided. During an interview with the Operations Manager on 11/10/21 at 11:22 AM, they stated they were not made aware mashed potatoes were substituted for boiled potatoes for the short hall meal service. The Operations Manager stated [NAME] #13 made the item substitution and had reported the Health Care Dining Manager was aware of the item substitution. During an interview with [NAME] #13 on 11/10/21 at 11:44 AM, they stated there were no diced potatoes for the boiled potatoes, so they had to substitute mashed potatoes. The Health Care Dining Manager was notified of the item substitution. During an interview with Health Care Dining Manager on 11/10/21 at 11:57 AM, they stated they provided the cooks with the meal production sheets. The Manager stated they were not informed the boiled potatoes were not served and mashed potatoes were substituted. It was the responsibility of the cook to tell them if there was an item substitution to make sure it was an appropriate substitution, staff and residents were made aware, and the substitution form could be filled out. During an interview with [NAME] #10 on 11/10/21 at 12:06 PM, they reported the Health Care Dining Manager provided the kitchen with the production and tally sheets. This paperwork indicated the total number of portions that were to be provided to the unit, each dining room, and the serving size. There were not enough potatoes so mashed potatoes were provided. [NAME] #10 stated [NAME] #13 should have called the Health Care Dining Manager to let them know there was not enough boiled potatoes and mashed potatoes would be served. During a follow up interview with the Operations Manager on 11/10/21 at 12:17 PM, they stated they expected the cook to let the Health Care Dining Manager know of any menu substitutions. [NAME] #13 reported they told a HC server to alert the Health Care Dining Manager of the substitution. [NAME] #13 did not follow the proper procedure. The only place menu item substitutions were documented was is in the clinical office. The main kitchen did not keep track of menu substitutions. During an interview on 11/10/21 at 12:43 PM, registered dietitian (RD) #12 stated the Health Care Manager handled menus item substitutions. The RD stated If they were notified ahead of time, they would approve substitutions as needed. During an interview on 11/10/21 at 12:51 PM, [NAME] #13 reported boiled potatoes were not served on 11/9/21 during the lunch meal for the short hall residents. They provided mashed potatoes instead. [NAME] #13 stated they did not have enough boiled potatoes to make the 50 needed orders. When an item needed to be substituted the normal procedure was to alert the Health Care Dining Manager. [NAME] #13 stated they did not follow the proper procedure and told a HC Server to alert the Health Care Dining Manager instead. The cook stated since they did not hear back from the Health Care Dining Manager, they just provided mashed potatoes instead of boiled potatoes. There was no menu item substitution list in the main kitchen for the cooks to follow. During a follow up interview on 11/10/21 at 1:57 PM, the Health Care Dining Manager stated they were unsure if the main kitchen had an approved menu item substitution list. 10 NYCRR 415.14(c)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00285046) surveys conducted from 11/8/21-11/10/21, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 3 residents (Residents #3 ,4, and 34) reviewed. Specifically, Resident #3 did not receive incontinence care and was not shaved as planned, Resident #4 did not receive timely meal assistance, and Resident #34 did not receive nail care as planned. Findings include: The facility's undated certified nursing assistant (CNA) competency skill check list included feeding (enhancing the dining experience), incontinence care, and hygiene (nail and skin care). The facility policy Urinary Incontinence - Toileting Needs revised 6/28/18 documented any resident who is incontinent of bladder will receive appropriate treatment and services. 1) Resident #3 had diagnoses including progressive supranuclear palsy (PSP, a brain disorder causing problems with walking, balance, and eye movements) and pseudobulbar affect (nervous system disorder). The 10/14/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, did not reject care, required extensive assistance of 2 for toileting and personal hygiene, and was frequently incontinent of bladder and bowel. The comprehensive care plan (CCP) revised 6/27/19, documented the resident was incontinent related to diagnosis of PSP. Interventions included the use of incontinence briefs with inserts and to toilet every 2 hours while awake. The resident had an ADL self-care deficit related to PSP. Interventions included extensive assistance of 2 staff for toileting using a sit to stand lift, extensive assistance of 1 with personal hygiene, and shaving was to be offered daily. The undated care instructions ([NAME]) documented the resident required extensive assistance of 2 staff for toileting using a sit to stand lift, incontinence briefs with inserts, extensive assistance of 1 with personal hygiene, and shaving was to be offered daily. The CNA (certified nurse aide) Documentation Report documented that Resident #3 was toileted on 11/9/21 at 3:38 AM and 2:44 PM. There was no documentation the resident was offered to be shaved from 11/1-11/9/21. On 11/8/21 the following observations were made of Resident #3 sitting in their recliner chair in their room: - at 10:55 AM, their hair was messy, they were unshaven, and there was a yellowish substance in the crease of their chin on the right side; - at 12:54 PM, they were unshaven, had not received their lunch meal, and there was a strong smell of urine in the room; - at 1:20 PM, registered nurse (RN) Unit Manager #6 was observed feeding the resident lunch and there was a strong urine odor detected in the room from the doorway; and - at 5:40 PM, the resident remained unshaven. On 11/9/21 the following observations were made of Resident #3 sitting in their recliner chair in their room: - at 8:20 AM, the resident was being assisted with their meal and remained unshaven; - at 10:57 AM, the resident remained unshaven, had an orange substance in the crease of their chin and on the collar of their shirt, and there was a strong smell of urine in the room; - at 12:36 PM, a visitor entered the resident's room. The visitor stated the resident was always clean shaven prior to entering the facility. The visitor stated they usually found the resident unshaven and needing to be toileted and stated there was currently a strong smell of urine in the room; - at 1:20 PM, licensed practical nurse (LPN) #3 brought the resident their medication and CNA #4 entered the room. Both LPN #3 and CNA #4 left the room at 1:21 PM; - at 1:59 PM, the resident's visitor asked the surveyor to come into the room. The resident reported they had not been changed since getting up before breakfast. - at 2:22 PM, CNA #4 went into the resident's room. CNA #4 stated they were unsure if the resident had been toileted or received incontinence care. They stated they got the resident up at 8 AM and that was the last time they had provided any toileting or incontinence care. The CNA stated the resident required extensive assistance of 2 and they did not have any help; - at 2:25 PM, CNA #4 and an unidentified CNA were observed providing incontinence care to the resident. The resident's brief was saturated with urine. CNA #4 stated the resident was care planned to be toileted every 2 hours and they did not have time to do that today. CNA #4 reported the last time the resident received incontinence care was 8 AM. On 11/10/12 at 9:16 AM Resident #3 was observed sitting in their recliner chair in their room and was unshaven. During an interview with LPN #3 on 11/10/21 at 12:31 PM, they stated they provided oversight for CNAs. The CNAs should review the [NAME] for the resident assistance level and to see how often a resident needed to toileted or changed. Typically, residents who were incontinent should be checked and changed every 2 hours or as needed. They were not made aware by CNA #4 that Resident #3 had not received incontinence care until 2:25 PM on 11/9/21. If they were made aware, they would have helped or told the RN Unit Manager. They expected to be notified if a CNA was unable to provide care for a resident and that was a long time for a resident to go without receiving any incontinence care. The CNAs were responsible for shaving the residents. During an interview with CNA #4 on 11/10/21 at 12:36 PM, the CNA stated each resident's ADL care was listed on the [NAME]. They stated the unit was short staffed on 11/9/21. The CNA stated Resident #3 waited a long time to receive incontinence care on 11/9/21. The CNA stated they did tell LPN #3, but nobody helped. The CNA stated the resident needed to be shaved and they did not shave the resident due to the lack of staff available to help. During an interview on 11/10/21 at 2:10 PM, RN Unit Manager #6 stated CNAs were expected to follow the resident's care plan. They stated shaving should be offered daily, Resident #3 had not been consistent with shaving, and staff should document if the resident refused. The RN stated they were unaware Resident #3 had not received incontinence care from 8 AM until 2:22 PM on 11/9/21 and that was too long for a resident to wait. Staff were expected to report if they were unable to provide care. They reported there were only 2 CNAs and 2 LPNs working yesterday until 9:30 AM and the RN stated they were helping with resident care yesterday morning. They stated it was important to provide ADL care for hygiene and dignity reasons. During an interview on 11/10/21 at 2:34 PM, the Director of Nursing (DON) reported CNAs were responsible for direct care such as shaving and cleaning the resident's face after meals and following the care plan. The LPNs should be checking to make sure things are getting done. It was important to maintain the resident's dignity. The DON stated they were unaware Resident #3 had not received incontinence from 8 AM until 2:22 PM on 11/9/21 and that was unacceptable. Staff should report if they were unable to provide care as planned. 2) Resident #4 had diagnoses including dementia, dysphagia (difficulty swallowing), and anorexia (loss of appetite). The 10/14/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, a poor appetite nearly every day, required extensive assistance of 1 at meals, had an unplanned weight loss, and received a mechanically altered diet. The 1/20/21, Comprehensive care plan (CCP) documented the resident had an activities of daily living (ADL) deficit. Interventions included limited assistance of 1 at meals and lap tray with Dycem mat (non-skid mat) at mealtime. The undated care instructions ([NAME]) documented the resident received an altered consistency diet, required limited assistance of 1 staff at meals, and used a lap tray with a Dycem mat at mealtime. On 11/9/21 at 8:38 AM, the Director of Nursing (DON) was observed bringing the resident their breakfast tray. The resident was observed lying in their bed and the DON placed the breakfast tray on the resident's over the bed tray table located at the foot of the bed. The DON exited the room without assisting the resident. There was no Dycem observed on the tray table. During an observation on 11/9/21 between 8:38 AM and 8:55 AM, no staff was observed entering the resident's room other than the housekeeper. During observations on 11/9/21 at 9:23 AM, the resident remained in bed with their breakfast untouched. At 9:32 AM, CNA #4 entered the resident's room. The CNA reported there were only 2 CNAs currently working and they were trying to do everything. The CNA stated they were going to assist the resident with their breakfast meal. During an interview on 11/10/21 at 12:31 PM, CNA #4 stated Resident #4 required supervision at meals and needed assistance placing items in front of them at mealtime. The resident's family had requested not to get the resident up for breakfast. The CNA stated the DON told them the resident's tray was in their room and by the time they were able to help the resident with their meal it was cold, and they requested a new tray. During an interview on 11/10/21 at 2:10 PM, registered nurse (RN) Unit Manager #6 stated they were unsure why Resident #4 was not gotten up. The RN stated they were aware the resident had to wait an hour before staff assisted them with their meal and that was unacceptable. Staff was expected to assist the resident once they had received their meal tray. If staff were unable to assist the resident, they should have asked for help. During an interview on 11/10/21 at 2:34 PM, The DON stated after they placed the resident's tray in their room, they reported to CNA #4 the resident was still in bed and would need assistance with their meal. It was unacceptable for a resident to wait 1 hour for assistance with meals. 3) Resident #134 had diagnoses including right tibia (leg bone) and right humerus (arm bone) fractures. The admission Minimum Data Set (MDS) assessment had not yet been completed. The 11/1/21 comprehensive care plan (CCP) documented the resident had an activity of daily living (ADL) deficit related to right tibia and right humerus fractures. The resident required extensive assistance of 2 with personal hygiene. The undated care instructions ([NAME]) documented the resident was to receive nail care and required extensive assistance of 2 with personal hygiene. Resident #134 was observed lying in their bed in their room on: - 11/8/21 at 10:22 AM, there was a dark substance under their fingernails; - 11/9/21 at 8:21 AM, there was a dark substance under their fingernails. The resident stated their nails had not been cleaned; and - 11/10/21 at 9:08 AM, there was a dark substance under their fingernails and the resident stated they had not yet been cleaned. During an interview on 11/10/21 at 12:31 PM, licensed practical nurse (LPN) #3 stated certified nurse aides (CNAs) were responsible for nail care and nail care was provided per the resident's care plan. During an interview on 11/10/21 at 12:36 PM, certified nurse aide (CNA) #4 stated they had provided the resident with a bed bath but did not complete nail care. The CNA stated the resident's nails should have been cleaned, and they were not clean at this time. During an interview on 11/10/21 at 2:10 PM, registered nurse (RN) Unit Manager #6 stated nail care should be completed when the resident received their shower or bed bath. The CNAs were responsible for completing the task and the licensed practical nurse (LPN) should check to make sure the task was completed. The RN stated they were unaware Resident #134 wanted their nails cleaned. The RN stated clean nails were important for hygiene and resident dignity. During an interview on 11/10/21 at 2:34 PM, the Director of Nursing (DON) stated CNAs were responsible for direct care and the LPN should be checking to make sure tasks were completed. CNAs should be following the resident's [NAME]. Clean nails were important for hygeine and resident dignity. The DON stated they did not complete any formal ADL care audits. 10NYCRR 415.12 (a)(1)(4)

Based on observation, interview, and record review during the recertification survey conducted from 11/8/21-11/10/21, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meal trays tested (breakfast, lunch, dinner). Specifically, food was not served at palatable and safe temperatures for the 11/8/21 dinner meal and the 11/9/21 breakfast meal. The 11/8/21 dinner meal and the 11/9/21 lunch meal were not palatable or appetizing. Findings include: The facility's mealtimes were documented as 8 AM for breakfast, 12:30 PM for lunch, and 6 PM for dinner. The facility policy Sanitary Conditions revised 2/22/16, documented all perishable foods must be 45 degrees Fahrenheit (F) or below. Hot foods should be held at 140 degrees F or above. During a resident meeting on 11/8/21 at 1:58 PM, 3 anonymous residents reported the food was often cold and the meat was often tough to chew. During the dinner meal observation on 11/8/21 at 6:07 PM, the BBQ chicken breast was measured at 131 degrees F and the macaroni salad was measured at 61 degrees F. The BBQ chicken breast was dry and overcooked. The macaroni salad was not cold and was unpalatable. During the breakfast meal observation on 11/9/21 at 8:38 AM, a resident was provided their breakfast tray in their room. The resident was unable to feed themself. At 9:32 AM, staff began to provide the resident set-up assistance. The resident's tray was tested for temperatures and a new tray was provided. The scrambled eggs were measured at 70 degrees F. During the lunch meal observation on 11/9/21 at 12:50 PM, the mashed potatoes were measured at 134 degrees F, the green beans were 129 F, and the baked cod was 137 degrees F, chewy and overcooked. During an interview on 11/10/21 at 11:22 AM, the Operations Manager was not aware the residents thought the meat items were overcooked. The Operations Manager wase unsure why the macaroni salad was 61 degrees F when served. The macaroni salad had been stored in the main kitchen below 40 degrees F. The fish may have become chewy because it was overcooked in the main kitchen. During an interview with [NAME] #13 on 11/10/21 at 11:44 AM, they stated the cod was heated up at the last minute before it was taken from the oven to the warmer and before being placed on the rolling cart to be brought upstairs. The fish was then placed in the steam wells on the unit until serving. The cook stated there was over an hour between the cod being cooked and served to the residents. They stated the BBQ chicken was also taken from the oven to the warmer before being placed on the rolling cart to be brought upstairs. The chicken was then placed in the steam wells on the unit until serving. It was over an hour between the chicken being cooked and being served to the residents. [NAME] #13 stated cold food should be 41 degrees F or below when served and hot foods should be 145 degrees F or above when served. The cook stated they had never heard of the residents complaining of overcooked meat items. During an interview with the Health Care Dining Manager on 11/10/21 at 12:36 PM, they stated food issues were brought up at resident council meetings. There were some reports of mushy vegetables. The Manager stated the health care servers could leave them a note or a voicemail if they heard of any resident complaints regarding the food. During a follow up interview with the Health Care Dining Manager on 11/10/21 at 1:57 PM, they stated it was expected that the residents be served their meal when it was delivered to them and 1 hour was too long to wait to be served. They expected cold foods to be served at 41 degrees F or below and hot foods to be served at 145 degrees F or above. It was important to serve food at the proper temperatures for food safety reasons and to ensure palatability. 10NYCRR 415.14(d)(1)(2)

Based on observation and interview during the recertification survey conducted from 11/8/21-11/10/21 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, there were undated and unlabeled foods, unclean areas and dented cans observed in the main kitchen. Findings include: The facility dining services policy Sanitary Conditions dated 2/22/2016 documents food is stored in such a manner as to be protected against contamination. Storage areas must be kept dry and clean from debris. Plastic containers with tight-fitting lids or resealable plastic bags should be used to store dry items that have been opened. All products that have been previously opened should be labeled and dated. The facility dining services policy Equipment and Utensil Cleaning and Sanitization dated 2/17/16 did not include the procedure for cleaning food service equipment other than dishware, pots, pans, and utensils. The following was observed during a kitchen tour on 11/8/21: - at 10:16 AM ice machine scoops were resting uncovered on top of the ice machine; - at 10:20 AM 15 maple syrups (in two-ounce cups) were located under the cold preparation counter and were not labeled. The Operations Manager stated they were from breakfast on 11/7/21; - at 10:25 AM the area around the deep fryer was unclean and with sticky, soiled layers of grease; - at 10:38 AM, there was 1 dented can of beef stew in dry storage room. - at 10:41 AM in the dairy refrigerator there was a tray of brownies with a use by date of 10/28 (two small pieces had been cut out of the sheet), multiple boiled eggs in a large plastic container with a use by date of 11/2/21, an unmarked large plastic container of olives, an unmarked half-full container of blue berry filling, an unmarked yellowish sauce or soup and 12-2oz containers of unlabeled tartar sauce. During an interview on 11/8/21 at 10:59 AM, the Operations Manager stated the food service company policy was certain items like tartar sauce could be held for 7 days, and three days for perishable/cooked items. The Operations Manager stated these food items should be discarded immediately. The Operations Manager was not sure whether the unmarked yellowish liquid was a sauce or a soup. During an observation on 11/09/21 9:32 AM the deep fryer area was not clean. The sides of the deep fryer, the back wall, the side of the stove next to the deep fryer were unclean with sticky, soiled layers of grease. During an observation on 11/09/21 9:40 AM scoops for sugar, breadcrumbs and flour were resting inside the plastic bins. The Operations Manager and cook #13 both stated that the scoops should have been kept in a separate clean holder. The following was observed in the main kitchen on 11/09/21: - at 9:47 AM 1 dented can of beef stew remained in the dry storage room. - at 9:45 AM pans, plates, pots, bins located in the drying rack were wet. 3 uncovered ice scoops were resting directly on top of the ice machine. During an interview on 11/10/21 at 12:00 PM the Operations Manager stated it was a daily problem that scoops were left inside bins or on top of the ice machine. The Operations Manager stated the pan on top of the ice machine for scoops was missing. Staff had been given verbal orders not to put scoops inside bins. The Operations Manager stated food items should be properly labeled and dated after being prepared. The brownies and other outdated items should have been discarded and were not. It was the responsibility of all kitchen staff to discard unlabeled/outdated food items immediately. There was not enough space to properly air-dry pans/pots/plates/bin before reusing the items. Usually, the three-bay sink would be used in conjunction with the dishwasher so there was not an overwhelming number of items to wash by hand. The Operations Manager stated before the COVID pandemic the deep fryer would be cleaned by an outside vendor and the vendor had not been in to clean it since then. The back wall near the deep fryer had not been cleaned in a while and should have been. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey 11/8/21 - 11/10/21 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including COVID-19 for 1 of 1 resident (Resident #83) reviewed for pressure ulcers, 1 of 2 residents (Resident #183) reviewed for transmission based precautions and 3 observed staff (certified nurse aide, CNA #4, registered nurse (RN) Unit Manager #6 and the Director of Nursing, DON). Specifically, licensed practical nurse (LPN) #1 did not perform appropriate hand hygiene and did not keep clean supplies separate from dirty supplies during a wound dressing for Resident #83; CNA #15 was observed not wearing appropriate PPE (personal protective equipment) when entering the room of Resident #183 who was on isolation/transmission-based precautions for potential COVID-19 exposure; and CNA #4, RN #6 and the DON were observed not wearing masks appropriately. Findings include: The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, documented all healthcare personnel (HCP) and other facility staff shall wear a facemask while within 6 feet of residents. Extended wear of facemasks is allowed; facemasks should be changed when soiled or wet and when healthcare personnel (HCP) go on breaks. The 9/10/21 Centers for Disease Control and Prevention (CDC) guidance, titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (COVID-19) Spread in Nursing Homes, directs nursing homes to implement source control measures. Per such guidance, source control means the use of well-fitting masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection against exposure to infectious droplets and particles produced by infected people. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection documents HCP (health care personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Transmission-based precautions Resident #183 had diagnoses including unspecified dementia and chronic kidney disease with heart failure. The admission Minimum Data Set (MDS) assessment had not yet been completed. The resident's baseline care plan documented the resident required limited assistance of 1 for most activities of daily living (ADLs) and setup for meals. The care instructions did not document the resident was on transmission-based precautions. During an interview on 11/8/21 at 10:51 AM the Administrator stated Resident #183 was placed on isolation precautions for potential exposure to COVID-19. The resident's family representative called the facility on 11/8/21 to inform them that a visitor the resident had on 11/6/21 tested positive for COVID-19 on 11/8/21. Resident #183 would be rapid tested, and PCR (polymerase chain reaction) tested for COVID-19 today (11/8/21). The resident was fully vaccinated. Isolation precautions were established outside the resident's room, and staff were to wear an N95 mask when entering the resident's room. During an observation on 11/8/21 at 1:10 PM a yellow sign was hanging outside of Resident #183's room and documented staff were to wear a gown, N95 mask, eye protection and gloves, put on personal protective equipment (PPE) before entering the room, and maintain 6 feet distance when possible. During an observation on 11/8/21 at 6:12 PM CNA #15 took a supper tray to Resident #183. They set the tray down on top of the PPE cart and put on a gown, gloves, and a surgical mask. CNA #15 did not put on an N95 mask or eye protection as directed by the sign near the resident's door. CNA #15 entered the resident's room with the tray. The CNA assisted the resident with meal set up, removed their PPE, performed hand hygiene, exited the room, then put on a new surgical mask. During an interview with the Infection Preventionist (IP) on 11/9/21 at 11:50 AM they stated Resident #183 was on isolation precautions due to potential COVID-19 exposure from a visitor. The IP stated staff were expected to wear a gown, gloves, eye protection and an N95 mask when they entered the room. The IP stated if staff were dropping off a meal tray, they did not need to wear a gown. During an interview with CNA #15 on 11/10/21 at 11:34 AM they stated on 11/8/21 a gown, gloves, face shield and N95 mask were required when entering Resident #183's room. They made a mistake by not wearing an N95 mask or eye protection. They did not know why Resident #183 was on precautions at the time. The CNA stated they could have put themself at risk for contracting COVID-19. The CNA stated they usually got report from the supervisor at the nursing station but it was hectic that night. The CNA stated they eventually found out Resident #183 was on precautions for potential COVID-19 exposure. During an interview with the Director of Nursing (DON) on 11/10/21 at 2:39 PM they stated the nursing supervisor should inform incoming staff of any residents on isolation precautions and what PPE they should be wearing. Staff would get this information at the nursing station when they reported on duty. Wound Care Resident #83 was admitted to the facility with diagnoses including cancer, wound dehiscence (when a surgical incision reopens), and ileostomy (small intestine is diverted through an opening in the abdomen). The 10/11/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for most activities of daily living (ADLS), received surgical wound care, and application of nonsurgical dressings. The comprehensive care plan (CCP) initiated 11/5/21 documented the resident had a Stage II pressure ulcer on the right thigh related to immobility. Interventions included administer treatments as ordered and monitor for effectiveness. A physician order dated 11/5/21 documented skin prep (skin protectant) to wound bed of open area on the back of the right leg, cover with AGB (Allevyn Gentle border, a dressing) every day shift. The 11/21 Treatment Administration Record (TAR) documented skin prep to wound bed of open area on the back of the right leg, cover with AGB every day shift for skin treatment, with a start date of 11/6/21. A wound care treatment was observed with LPN #1 on 11/09/21 at 10:29 AM. LPN #1 checked the treatment order, placed a barrier on top of the treatment cart and placed supplies including skin prep, sterile water, sterile gauze and an AGB dated 11/9/21 on the barrier. The LPN did not perform hand hygiene before placing the barrier and the supplies on the cart. The LPN washed their hands with soap and water and donned clean gloves. A dressing dated 11/7 was removed from the wound and placed on the clean barrier. The pressure ulcer was located on the right lateral bottom buttock, near the thigh crease and was a circular superficial area with no erythema (redness) or drainage noted. LPN #1 cleansed the wound with sterile water and used part of the clean barrier to absorb liquid and protect the resident's bed. LPN #1 patted the wound dry and applied clean gloves. The LPN did not perform hand hygiene after cleansing the wound and applying new gloves. The LPN applied skin prep and covered the wound with the AGB dressing, placed the used barrier and used supplies on the resident's recliner, removed their gloves and washed their hands, picked up the barrier and used supplies and removed them from the room and placed them on top of the treatment cart. During an interview with LPN #1 on 11/9/21 at 2:33 PM they stated during the observed wound treatment they used a towel as a barrier to collect the fluid from cleansing the wound and tucked it under to protect the resident's bed from getting wet. The LPN stated the clean supplies were off to the left and out of reach and they had used the clean barrier to place the soiled dressing and gloves on. The LPN stated they should not have used the clean barrier to place unclean supplies. The LPN stated they should have had a waste can at the bedside to place the dirty items and used a different barrier. The LPN stated their hands were not soiled so they did not perform hand hygiene before putting new gloves on. The LPN stated dirty dressings and gloves should have been bagged before removing them from the room and taken directly to the dirty utility room. During an interview with registered nurse (RN) Infection Preventionist #8 on 11/10/21 at 1:26 PM they stated during a wound dressing hand hygiene should be performed at the beginning, after removing the old dressing and when moving from one wound to another. The RN stated after removing the old dressing gloves should be removed and hand hygiene performed before putting on new gloves. The RN stated a barrier should be used to place clean supplies and dirty and clean should never be mixed. The barrier should be kept separate and clean. Dirty dressings and supplies should be disposed of immediately in the trash, located at the bedside. Dirty dressings should never be placed on any clean surface. During an interview with RN Unit Manager #6 on 11/10/21 at 2:16 PM they stated hand hygiene should be performed before beginning a treatment. After removing old dressings gloves should be removed and hand hygiene performed before putting on new gloves. The RN stated clean and dirty supplies should not both be on a clean barrier. If these practices were not followed the risk of infection could be increased. During an interview with the Director of Nursing (DON) on 11/10/21 at 2:49 PM they stated hand hygiene should be performed before beginning a treatment, after removing an old dressing, before putting on new gloves, and after the treatment was completed. A barrier should never have clean and dirty supplies together. Mask Wearing Observations of inappropriate mask wearing included: - on 11/09/21 at 7:52 AM, CNA #4 was observed exiting resident room [ROOM NUMBER] wearing their mask below their chin; - on 11/09/21 at 8:51 AM, the Director of Nursing (DON) was assisting Resident #9 and their surgical mask was not covering their nose; and - on 11/10/21 at 9:01 AM, RN Unit Manager #6 was observed walking by the front of the nursing station with their mask below their chin. During an interview on 11/10/21 at 12:28 PM, CNA #4 stated the surgical mask should be worn all day and should not be removed in resident areas. During an interview on 11/10/21 at 2:10 PM, RN Unit Manager (UM) #6 stated the surgical masks and eye protection should be worn all day. Surgical masks should be worn over the nose covering the mouth and should never be resting below the chin. They stated the mask should be worn appropriately because staff are putting themselves and the resident at risk for an infection like COVID-19. The RN stated they were not aware their mask was below their chin and they must have forgotten to put the mask on appropriately when leaving their office. During the interview RN UM #6's surgical mask was observed below their nose. During an interview on 11/10/21 at 2:34 PM, the DON stated that staff should always be wearing surgical masks with goggles and/or a face shield. The DON was not wearing goggles or a face shield and stated they forgot it in their office. The DON stated staff should not have their masks below their nose or under their chin as this was an infection control issue. 10NYCRR 415.19(a)(1-3)

Based on observation, record review and interview during the recertification survey conducted 11/8/21-11/10/21 the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 3 dishwashers (main kitchen dishwasher, short hall and long hall dining room dishwashers). Specifically, the main kitchen dishwasher had a component that was not working, the short hall dining room dishwasher was not working, and there was water underneath and around the long hall dining room dishwasher. Findings include: During an interview on 11/8/21 at 9:45 AM, health care server #14 stated the short hall dining room dishwasher had been broken for 2 months. They stated that kitchen staff would have to bring dishes down the stairs to the main kitchen, and sometimes to the memory care unit long hall dining room to wash dishes. There was no out of order sign observed on the dishwasher in the short hall dining room. During an observation on 11/8/21 at 9:50 AM the long hall dining room dishwasher was leaking. There were towels on the floor underneath the dishwasher. There was a sign on the dishwasher that documented do not open door while the light switch was turned off. There was a green bucket under the sink catching water. During an interview 11/8/21 at 9:50 AM, food service worker #17 stated that the short hall dishwasher was to be replaced and was still in use. The food service worker stated when it would stop working, they would have to use the main kitchen dishwasher to wash all dishes, glasses, and utensils. The food service worker stated they knew if the dishwasher was down, the breaker would click, and the light would turn off. They stated they had reported that the long hall dishwasher leaked to their immediate supervisor. During an interview on 11/8/21 at 10:27 AM, the Maintenance Director stated that a fuse for the main kitchen dishwasher booster pump had been replaced that morning. During an observation on 11/8/21 at 10:27 AM the sanitizer solution in the main kitchen three bay sink was within proper range. The main kitchen Dishwashing Machine Temperature Log documented the hot water temperatures were not recorded from 11/6/21 to 11/7/21 and the machine was out of order on 11/8/21. During an interview on 11/8/21 11:03 AM the Administrator stated they were not aware of the main kitchen dishwasher being down prior to that day. During an interview on 11/9/21 at 9:42 AM the Dining Operations Manager stated the facility had tried to use the main kitchen dishwasher yesterday and the fuse installed on 11/8/21 had popped. The vendor was scheduled to come 11/9/21 to repair/diagnose the dishwasher. During an interview on 11/9/21 at 1:57 PM, the Dining Operations Manager stated the main kitchen dishwasher went down over the weekend. They stated they had found out 15 minutes prior to the surveyor's arrival. The Manager stated they then told their supervisor, the Dining Operations Supervisor, and immediately directed the kitchen staff to start utilizing the three-bay sink located near the main kitchen dishwasher. Both the Dining Operations Manager and the Dining Operations Supervisor stated that they had not told the Administrator about this and immediately contacted the maintenance staff. The Dining Operations Manager stated after the maintenance department looked at the dishwasher the vendor was called to diagnose and correct the issue. They both stated there were no work orders for the dishwasher put in over the weekend and they put in a work order when they were made aware of the issue. There had been no major issues with the main kitchen dishwasher for last few months, just some broken detergent hoses. The vendor was due to be at the facility at 3 PM today. During an interview on 11/9/21 at 2:08 PM the Maintenance Director stated they were not made aware of the main kitchen dishwasher being down until yesterday morning. The Director stated they were told by the Food Operations Manager just prior to the survey team coming to the facility on Monday. During an observation on 11/9/21 at 2:20 PM, the floor around the long hall dishwasher had wet towels on it with puddles of water. During an interview on 11/9/21 at 2:20 PM. The Maintenance Director stated they were not aware that there was leaking water under the long hall dishwater or that there were wet towels on the ground around that piece of equipment. The Director stated they had not been told by any staff about this and was not sure why it was not reported via a work order. They stated that the surveyor had misread the Dishwashing Machine Temperature Log. The Director stated that the main kitchen dishwasher was never down, and that only the water temperature gauge for the booster pump water was down for that amount of time. During an observation on 11/9/21 at 2:27 PM, the short hall dishwasher was not working. During an interview on 11/10/21 at 10:58 AM the Dining Operations Manager stated that some components in the booster pump of the main kitchen dishwasher had corroded. It was cleaned off and it was back up and working. The wash temperature gauge had not been working since 10/6/21 and that it was still not working. They stated if the gauge was not working it could affect the sanitation of items going through the main kitchen dishwasher. During an interview on 11/10/21 at 11:18 AM the Dining Operations Manager stated they knew how to put work orders into the system but did not believe health care servers had access to the work order system. During an interview on 11/10/21 at 1:45 PM the Maintenance Director stated that the facility had no work orders on dishwashers within the last 6 months. The Director believed the water around/under the long hall dishwasher was from an overspray of water, and water would puddle on the ground. No one had made them aware that the short hall dishwasher was down. Unit secretaries, receptionists and directors would have access to the work order system. The Director stated the health care servers should report issues to their Supervisor who would generate a work order on the computer. Maintenance would look at list of work orders throughout the day. Every maintenance staff could review and assign work orders to themselves. 10NYCRR 483.90(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure each resident had the right to have reasonable access to the use of a telephone where calls could be made without being overheard for 1 of 1 resident (Resident #19) reviewed for privacy. Specifically, Resident #19's personal cell phone was broken, and he used a facility telephone in a common area or staff office and was not offered a private area to make phone calls. Findings include: Resident #19 was admitted to the facility on [DATE] and had diagnoses including dementia and bipolar disorder. The 9/27/18 Annual Minimum Data Set (MDS) assessment documented the resident had intact cognition and it was very important to the resident to make private phone calls. When interviewed on 4/15/19 at 10:27 AM, the resident stated his personal cell phone broke and his wife was in the process of purchasing a new cell phone for him. He stated he used the corded facility telephone at the nursing station and he would like a private area to talk on the telephone. When interviewed on 4/16/19 at 2:02 PM, certified nurse aide (CNA) #3 stated if a resident did not have a telephone in their room the resident could use the telephone at the nursing station or could use the telephone in the Unit Manager's office. When interviewed on 4/16/19 at 2:12 PM, licensed practical nurse (LPN) #4 stated if a resident did not have a telephone the resident could use the telephone at the nursing station or the Unit Manager's desk telephone. When interviewed on 4/16/19 at 2:30 PM, registered nurse (RN) #5 Manager unit stated residents who did not have telephones in their room could use the telephone at the nurse's station or in her office. She stated resident #19 had used the telephone in her office and was not aware he did not have a personal telephone at this time. She stated if a resident used the telephone at the nurse's station staff would give the resident space. She was unaware if the facility had a designated area for residents to make telephone calls without being overheard to ensure their privacy. On 4/16/19 at 3:41 PM, the Assistant Administrator stated the facility does not provide residents with private telephone service in their room per the facility admission agreement and the facility did not have a resident telephone usage policy. When interviewed on 4/16/19 at 4:03 PM, the Administrator and Assistant Administrator stated they were unaware that telephones at the nurse's station and telephones in staff offices did not provide residents with reasonable access to make telephone calls in private. 10NYCRR 415.3(d)(3)

Based on observation, interview and record review during the recertification survey, the facility did not provide separately locked, permanently affixed compartments for storage of controlled drugs or ensure drugs and biologicals were labeled in accordance with accepted professional principles for 1 of 1 medication room observed. Specifically, a refrigerated controlled substance was stored in a tackle box that was not secured by two locking mechanisms and not permanently affixed to the refrigerator. Additionally, an open bottle of influenza vaccine was not dated when opened. Findings include: The 6/25/18 Controlled Medications Administration Policy documented medications listed in Schedules II, III, IV and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. On 4/16/19 at 9:28 AM, the facility's medication storage room was observed with licensed practical nurse (LPN) #6. The unlocked medication refrigerator was inspected and contained an open vial of influenza vaccine that did not document an open date. A tackle box was observed in the refrigerator and LPN #6 stated it contained discontinued Ativan (a benzodiazepine, a Schedule IV controlled substance) that was awaiting destruction. She took the tackle box out of the refrigerator, placed it on the counter and opened it using a single key. A box labeled Ativan was observed inside. She locked the box and placed it back in the unlocked refrigerator. LPN #6 stated nurses were supposed to date vials when they were opened, they were to be discarded after 30 days and she would not know what date the vial was opened if it was not documented on the box/bottle. She stated she was not sure if controlled substances needed to be permanently affixed or doubly locked in the refrigerator. She stated 4 nurses had keys to access the medication room door and only she had the key that unlocked the tackle box. On 4/17/19 at 10:50 AM, registered nurse (RN) #5 Unit Manager stated in an interview, controlled substances were to be doubly locked using 2 different keys. She was not aware the box containing Ativan in the refrigerator needed to be permanently affixed so it could not be removed. She stated vials were to be dated when opened, thrown away after 30 days and was not aware that was not done for the influenza vial. 10NYCRR 415.18(e)(2) 10NYCRR 483.45(g)(H)

Based on record review, and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment for 1 of 1 laundry rooms (first floor laundry room). Specifically, two top load washers were not maintained per manufacturer instructions. Findings include: During an observation on 4/15/19 at 11:25 AM, the first floor laundry room had two top load washers and two dryers. During a record review of the manufacturer instructions for top load washers #1 and 2, the following tasks were required monthly: - check all hoses and the drain for leaks; - check the lid switch for proper operation; and - check to make sure the washer is level. The instructions also documented the filter screens in the fill hoses were required to be cleaned semi-annually. During an interview on 04/16/19 at 2:29 PM, the Environmental Services Director stated there was no documentation to verify that top load washers #1 and #2 were maintained according to manufacturer instructions. She stated that there was no policy for the maintenance schedule of washing machines. 10 NYCRR 415.19(a)(1)(c)