**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during a Recertification Survey from [DATE] to [DATE], for two (2) (Residents #124 and #332) of four (4) residents reviewed, the facility did not ensure that all residents had the right to request, refuse, or formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, Resident #124 and Resident #332 had current phyisician's orders regarding their advanced directive wishes in the event of cardiac or pulmonary arrest that was not consistent with their signed Medical Orders for Life Sustaining Treatment (MOLST) directives. The findings include: The facility policy Advance Directives and Medical Orders for Life Sustaining Treatment, dated [DATE], documented it shall be the responsibility of the nursing, medical and social work teams to determine each resident's preference for Advance Directives upon admission to the Facility. The Medical Orders for Life Sustaining Treatment form will be reviewed and updated every 60 days and as needed by the medical team. The medical provider will complete sections C and E of the form to reflect the resident's Advance Directive decisions and will write an order reflecting the resident's or appropriate decision maker's wishes in the medical record. 1. Resident #124 had diagnoses that included repeated falls, adult failure to thrive and a spinal fracture. The Minimum Data Set (a resident assessment tool), dated [DATE], documented the resident was cognitively intact. Review of current physician's orders, dated [DATE], revealed Resident #124's advanced directive wishes were for Full Code (initiate cardiopulmonary resuscitation [CPR] in the event of cardiac or pulmonary arrest) as there was no Medical Orders for Life Sustaining Treatment on file. Review of Resident #124's Comprehensive Care Plan, dated [DATE], revealed the resident's advanced directive wishes were for Full Code until confirmed or determined otherwise. Review of Resident #124's Medical Orders for Life Sustaining Treatment form, dated [DATE], and signed by the Physician revealed the resident's advanced directive wishes were for Do Not Resuscitate (do not perform cardiopulmonary resuscitation rather to allow natural death). The Medical Orders for Life Sustaining Treatment form included Resident #124 was the individual making the decision and was signed by the resident. 2. Resident #332 had diagnoses that included traumatic brain hemorrhage (bleeding in or around the brain caused from an injury), high blood pressure, and depression. The Minimum Data Set, dated [DATE], included Resident #332 had moderate impairment of cognition. Review of Resident #332's Medical Order for Life Sustaining Treatment form, dated [DATE], revealed the resident's advanced directive wishes were for Do Not Resuscitate with a trial period of noninvasive ventilation (provide breathing support without the use of a tube). The Medical Orders for Life Sustaining Treatment form included Resident #332 was the individual making the decision and had signed the form. Review of the current physician's orders in the electronic health record revealed Do Not Resuscitate with a trial of intubation (breathing support via a tube into the lungs) with a start date of [DATE]. During an interview on [DATE] at 10:29 AM, Licensed Practical Nurse #3 stated in an emergency they would check the electronic health record for a resident's code status. During a follow up interview at 2:54 PM, they stated there should not be a discrepancy between the physician's order and the Medical Orders for Life Sustaining Treatment, and if there was a discrepancy nursing leadership and/or social work should be notified. During an interview on [DATE] at 12:42 PM, Registered Nurse #1 stated they would look at the electronic health record first for advanced directives and then look at the Medical Orders for Life Sustaining Treatment form, and if there was a discrepancy, they would perform the highest level of care between the two because it would be worse for the resident to not receive life sustaining care as they wanted. Registered Nurse #1 stated there is major difference between intubation and noninvasive intubation as one involved a tube being inserted into the resident and one does not. During an interview on [DATE] at 11:38 AM, Licensed Practical Nurse Manager #3 stated the Medical Orders for Life Sustaining Treatment forms are completed by social work and signed by the medical provider and then either the nurse manager or medical provider created the advanced directive order in the electronic health record. Licensed Practical Nurse Manager #3 stated Resident #332's physician's order in the electronic health record and their Medical Orders for Life Sustaining Treatment form should match and it was most likely a transcription error that caused the discrepancy. During an interview on [DATE] at 10:54 AM, the Director of Nursing stated social work staff initiated the Medical Orders for Life Sustaining Treatment and communicated the resident's wishes to nursing. The medical team then reviews and signs the form. The Director of Nursing also stated a resident's advance directives should match on all documents. Any discrepancy between the physician's order and Medical Orders for Life Sustaining Treatment forms could lead to resident's wishes for advanced directives not being followed. 10 NYCRR 415.3(f)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for one (1) (Resident #110) of one (1) resident reviewed the facility did not ensure the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, Resident #121 who was able to self-propel (move themselves) in their wheelchair was observed on multiple occasions to have their wheelchair wheels locked, who was trying to self-propel, and was unable to. The finding includes: The facility policy Restraints, dated June 2023, documented the resident has a right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Restraints of any type will not be used as a punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff. Examples of facility practices that meet the definition of a physical restraint include placing a resident in a locked wheelchair in which the resident cannot unlock chair to self-propel if he/she so desires to do so. Resident #110 had diagnoses that included Parkinson's disease, depression, and repeated falls. The Minimum Data Set (a resident assessment), dated 03/07/2025, included Resident #110 had moderate impairment of cognition, did not have restraints, and used a wheelchair for mobility. Review of the Comprehensive Care Plan, completed 03/21/2025, and [NAME] (a care plan used by certified nursing assistants to provide daily care), dated 05/12/2025, revealed that Resident #110 could be physically combative with care and required staff assistance with transfers. Neither care plan included the resident was able to self-propel their wheelchair or the use of any restraints. During an observation on 05/06/2025 at 10:35 AM, Resident #110 was seated at the dining room table with both wheelchair wheels locked. There were no activities occurring and there was nothing on the table to look at. Resident #110 was trying to push themselves away from table but was unable to release the wheelchair locks or push away from the table. During observations on 05/08/2025 at 12:45 PM, Resident #110 was at the dining room table with both wheelchair wheels locked and no activities occurring or in place. At 4:41 PM, the resident's wheelchair was locked, and the resident appeared distressed while attempting to push away from the dining room table, but was unable to due to the locked wheels. During an interview on 05/08/2025 at 4:37 PM, the Director of Rehabilitation stated Resident #110 had been on therapy several times working on mobility and activities of daily living and was able to self-propel in their wheelchair and was very capable of moving themselves around the unit. During an interview on 05/13/2025 at 9:49 AM, Certified Nursing Assistant #8 (Resident #110's primary caregiver) stated the resident was able to self-propel in their wheelchair and had fluctuating cognition. They stated Resident #110 had periods of wandering when they would go into other residents' rooms, around the resident care unit, and/or attempt to self-transfer (get themselves out of the wheelchair without assistance). Certified Nursing Assistant #8 stated when Resident #110 gets agitated, wandering, or is trying to self-transfer, they would put them at the dining room table and lock their wheelchair wheels to keep them from wandering or self-transferring. During an interview on 05/13/2025 at 10:09 AM, Licensed Practical Nurse #9 stated wheelchair wheels should only be locked during resident transfers or toileting, otherwise they should be unlocked so a resident is free to move around as they wish. They also stated they have seen Resident #110's wheelchair wheels locked when they were agitated or trying to move and had seen Resident #110 trying to self-propel and unlock the wheelchair, but were unable to. Licensed Practical Nurse #9 stated Resident #110 becomes more frustrated and agitated when their wheelchair wheels are locked. During an interview on 05/13/2025 at 1:39 PM, the Director of Nursing stated wheelchair wheel locks should only be used when transferring and for safety of residents who are unable to self-propel in the wheelchair, and putting locks on a resident who can self-propel and not release the locks could be considered a restraint. 10 NYCRR 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #43 and #131) of 12 residents reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, for Resident #43, the resident reported potential abuse and neglect to a Licensed Practical Nurse who did not report the residents concerns to nursing leadership and the alleged incident was not reported to the Department of Health. For Resident #131, the facility did not report to the Department of Health an incident where the resident was found to have a femur fracture (broken thigh bone) of unknown cause. The findings include: The facility policy Abuse Prevention and Management, dated November 2024, included the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, or mistreatment. The shift supervisor was responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager were responsible for completing the investigation and reporting. 1. Resident #131 had diagnoses including dementia, disorientation, and retention of urine. The Minimum Data Set (a resident assessment tool), dated 01/19/2025, included the resident had severe cognitive impairment and required staff assistance with standing and transferring. Review of the Comprehensive Care Plan, dated 01/13/2025, revealed Resident #131 was a high risk for falls, and had limited physical mobility related to weakness and ambulated with one assist and a rolling walker (prior to the identified fracture). In a progress note, dated 03/10/2025, Nurse Practitioner #1 documented Resident #131 complained of left hip pain with movement, the resident had a history of dementia, and wandering but no witnessed falls. Nurse Practitioner #1 was unsure if Resident #131 had an unwitnessed fall and ordered an x-ray of the left hip/pelvis. In a late entry progress note, dated 03/10/2025, Nurse Practitioner #1 documented they were notified of the left hip/pelvis x-ray results (non-displaced proximal left femur fracture). Review of interdisciplinary progress notes 03/01/2025 to 03/10/2025 there was no documentation related to any falls. The facility was unable to provide documentation that a major injury of unknown origin (femur fracture) was reported to the New York State Department of Health. During an interview on 05/13/2025 at 10:21 AM, the Director of Nursing stated if there was an injury of unknown origin, an investigation should be completed to rule out any suspicion of abuse, neglect, or mistreatment and they were responsible for reporting incidents to the Department of Health. The Director of Nursing stated an injury of unknown origin should have been reported to the Department of Health within a two-hour window (of identifying the injury) and an investigation should have been completed. During an interview on 05/13/2025 at 1:00 PM, the Assistant Administrator stated an injury of unknown origin should be reported to the Health Department, and in this case, they would assume there was miscommunication within the facility. 2. Resident #43 had diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease (a chronic lung disease that effects breathing). The Minimum Data Set, dated [DATE], included resident #43 was cognitively intact, was moderately depressed, and required staff assistance with transferring and toileting. During an interview on 05/05/2025 at 1:22 PM, Resident #43 stated an unnamed certified nursing assistant had refused to take them back to the bathroom after attempting to have a bowel movement, told the resident to just go to the bathroom in their brief and refused to take Resident #43 back to the bathroom. Resident #43 stated the certified nursing assistant was rough with them while putting them back into bed. Resident #43 stated they had reported the incident to facility staff the next day and told their family, but nothing had been done and no one had come to talk to them about their concern. Resident #43 was unable to recall the date of the incident and did not know the name of the certified nursing assistant. Review of interdisciplinary progress notes from 04/01/2025 to 05/13/2025 and accident and incident reports from 02/21/2025 to 05/13/2025 revealed no documented evidence of Resident #43's alleged concerns. During an interview on 05/08/2025 at 1:40 PM, Registered Nurse #1 stated Resident #43 had reported potential abuse, neglect, and/or mistreatment to them on 05/05/2025, but the resident was not able to provide the date of the incident or name of the certified nursing assistant. Registered Nurse #1 stated they had not reported the allegations to anyone in nursing leadership and should have as soon as they became aware. During an interview on 05/13/2025 at 10:37 AM, Licensed Practical Nurse Manager #4 stated any allegation of abuse, neglect, or mistreatment should be reported up the chain of command immediately so an investigation can be started. During an interview on 05/13/2025 at 1:39 PM, with the Director of Nursing and Assistant Director of Nursing, the Director of Nursing stated all allegations of abuse, neglect and/or mistreatment need to be reported immediately to the director of nursing and/or the assistant director of nursing so an investigation can be started. The Director of Nursing and Assistant Director of Nursing both stated they were not aware of any allegations of abuse, neglect, and/or mistreatment for Resident #43 and if staff were aware, it should have been reported to them. 10 NYCRR 415.4(f)(1-4)

Based on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for 1 (Resident #131) of 12 residents reviewed, the facility did not ensure that an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #131 had complaints of hip pain, was found to have a femur fracture (broken thigh bone) and the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. The findings include: The facility policy Abuse Prevention and Management, dated November 2024, documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment. The shift supervisor was responsible for immediate initiation of the reporting process. The Administrator, Director of Nursing, and Risk Manager were responsible for completing an investigation and reporting. Resident #131 had diagnoses including dementia, disorientation, and retention of urine. The Minimum Data Set (a resident assessment tool), dated 01/19/2025, included the resident had severe cognitive impairment, required staff assistance with standing and transferring. Review of the Comprehensive Care Plan, dated 01/13/2025, revealed Resident #131 had impaired cognitive function, was a high risk for falls, had limited physical mobility related to weakness and was able to amabulate with one assist and a rolling walker (prior to the incident). Review of a progress note dated 03/10/2025 Nurse Practitioner documented Resident #131 complained of left hip pain with movement and the resdient had a history of dementia and wandering but no witnessed falls. In a late entry progress note, dated 03/10/2025, Nurse Practitioner #1 documented they were notified of the left hip/pelvis x-ray results (non-displaced proximal left femur fracture). Review of interdiciplinary progress noted dated 03/01/2025 to 03/10/2025 revealed no documentation of any falls. The facility was unable to provide documentation that an investigation had been completed to rule out abuse, neglect and/or mistreatment. During an interview on 05/13/2025 at 10:21 AM, the Director of Nursing stated if there was an injury of unknown origin, an investigation should be completed to rule out any suspicion of abuse, neglect, and/or mistreatment and they were responsible for completing an investigation. The Director of Nursing stated an investigation should have been completed for the incident involving Resident #131 and they were unable to determine if abuse, neglect, or mistreatment could be ruled out without one (a complete investigation). 10 NYCRR 415.4(g)(1-3)

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, it was determined that for one (1) (Resident #9) of one (1) resident reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of medications left at the resident's bedside. The resident did not have an order for self-administration of medications, was not care planned for it, and had not been assessed by the interdisciplinary team to safely have medications left unsupervised at the bedside. In addition, Resident #9's room was directly next door from another resident who was identified as having wandering behaviors. This evidenced by the following: Resident #9 had diagnoses that included irritable bowel syndrome, deficiency of B group vitamins, and diabetes. The Minimum Data Set (a resident assessment tool), dated 03/08/2025, documented the resident was cognitively intact. Review of Resident #9's current Comprehensive Care Plan did not include the resident was safe to self-administer their medications or have medication left at the bedside. Resident #9's medical orders documented dicyclomine 10 milligrams, twice daily to treat irritable bowel syndrome and loperamide 2 milligrams every eight hours as needed to treat diarrhea. The was no order for Ferrasorb dietary supplement (an iron supplement which also contains B6 and B12). During an observation and interview on 05/05/2025 at 3:58 PM, Resident #9 had a bottle of Ferrasorb dietary supplement and a bottle of IBS Labs anti-diarrheal tablets (loperamide), each containing multiple pills on their bedside table. During an immediate interview, Resident #9 stated they took both medications independently. During an observation on 05/08/2025 at 9:27 AM, the two bottles of medications remained at the resident's bedside on their table. During an observation on 05/09/2025 at 12:25 PM, the two bottles of medications remained at the resident's bedside. Resident #9 was not in their room, the room door was open, and medications were visible from the doorway. During an interview on 05/09/2025 at 12:20, PM Licensed Practical Nurse #8 stated they did not know Resident #9 had medications at their bedside and that there should be a medical order (for the resident to take them independently). Licensed Practical Nurse #8 stated they had two residents with wandering behaviors on the unit and that one of them lived directly next door to Resident #9. During an interview on 05/09/2025 at 2:24 PM, Licensed Practical Nurse Manager #10 stated they have had this issue in the past with family members bringing in medications and they had reached out to the Social Worker and requested they not bring medications in without a physician's order. Licensed Practical Nurse Manager #10 stated they were unsure how long the medications had been at Resident #9's bedside and had not noticed them before. Licensed Practical Nurse Manager #10 stated if they had seen the medications at Resident #9's bedside, they would have removed them. During an interview on 05/13/2025 at 10:37 AM, with the Director of Nursing and the Assistant Director of Nursing, the Director of Nursing stated they were not aware that medications were being left at Resident #9's bedside and they do not allow self-administration of medications at the facility. The Director of Nursing stated medications should not be left at the bedside because they have residents with wandering behaviors, and it poses a safety concern and should be locked and secured. 10 NYCRR 412.12 (h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for two (2) (Residents #110 and #335) of two (2) residents reviewed for adaptive equipment, the facility did not provide special eating equipment and utensils for residents who required them to maintain the ability to eat and drink independently. Specifically, Resident #110 had therapy recommendations and was care planned for built-up and curved utensils and was observed during meals without the adaptive equipment and had difficulty eating. Resident #335 was visually impaired, had a therapy recommendation and was care planned for a lipped plate (a plate with a lip to assist with scooping food on to silverware), and was observed during meals without the lip plate. The findings include: The facility policy Activities of Daily Living Care Dining - Eating Assistance and Restorative Dining (Eating/Swallowing), dated August 2024, included the resident will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living related to dining (eating and swallowing). Residents will be assessed, if applicable, to determine their eating/swallowing needs and how to best accomplish these tasks in the safest way. Alternative dining techniques including adaptive equipment, cueing, techniques for food placement, etc. for assistance in enhancing eating/swallowing will be considered based on assessment of resident's eating/swallowing needs. Therapy services will be involved in assessment/screening process. Based on the (resident) assessment, supportive and adaptive devices/equipment (swallowing techniques, divided dish, weighted utensils, modified cups, etc.) will be implemented. 1. Resident #335 had diagnoses that included malnutrition, dementia, and heart failure. The Minimum Data Set (a resident assessment), dated 04/30/2025, included Resident #335 was cognitively intact and required supervision or touching assistance with eating. The Comprehensive Care Plan, revised on 04/25/2025, included Resident #335 was visually impaired, at risk for altered nutrition and required a lipped plate to maximize independence with eating. The undated [NAME] (a care plan used by certified nursing assistants to provide daily care), reviewed on 05/13/2025, included Resident #335 required the use of a lipped plate with meals. During an observation and interview on 05/05/2025 at 12:10 AM, Resident #335 received their lunch on a normal (non-lipped) plate of chicken cacciatore, rice and peas, and was having difficulty getting food on their utensils. Review of the meal ticket at this time revealed Resident #335 should have a lipped plate for their meals. During an immediate interview at this time, Registered Nurse #1 stated Resident #335 was blind. During an observation on 05/12/2025 at 12:15 PM, Resident #335 received pasta with meat sauce and broccoli for lunch on a normal plate, was having difficulty getting food on the utensils, and food was falling off the side of the plate. During an immediate interview, Certified Nursing Assistant #9 stated the staff (nurses and certified nursing assistants) who plate and serve the meals were responsible for ensuring adaptive feeding/eating equipment was provided and should be on the meal ticket. Certified Nursing Assistant #9 stated they served Resident #335's lunch, but did not know they needed a lipped plate. Review of the meal ticket at this time with the surveyor included a lipped plate was required. During an interview on 05/12/2025 at 12:38 PM, Resident #335 stated they had a difficult time eating their meals when they were not served on a lipped plate. 2. Resident #110 had diagnoses that included Parkinson's disease, dementia, and depression. The Minimum Data Set, dated [DATE], included Resident #110 had moderate impairment of cognition and was independent with eating. The Comprehensive Care Plan, dated 03/21/2025, and undated [NAME], reviewed on 05/12/2025, included Resident #110 used adaptive utensils (built-up utensils) with meals. In a progress note, dated 04/11/2025 at 12:42 PM, Occupational Therapist #1 documented Resident #110's care plan had been updated to include the use of built-up and curved fork and spoon utensils at all meals and use of normal soup spoon. During an observation on 05/08/2025 at 5:06 PM, Resident #110 did not have built-up and curved fork or spoon. Resident #110 had a meal of soup, steamed broccoli, pineapple, and a sandwich. During an observation on 05/12/2025 at 12:23 PM, Resident #110 was using a normal (non-built-up or curved) fork to eat a cupcake. Resident #110 was unable to cut and get the cupcake on the fork and bring it to their mouth. During an interview on 05/12/2025 at 12:34 PM, Certified Nursing Assistant #8 stated adaptive equipment for meals was listed on the meal ticket. They stated Resident #110 preferred finger food and sandwiches because they were easier to eat and did not think resident #110 liked to use the adaptive equipment and they had informed therapy of this. Review of the electronic health record from 04/01/2025 to 05/12/2025 revealed there was no documented evidence that therapy had been notified that Resident #110 did not like or use their adaptive utensils. During an interview on 05/12/2025 at 12:42 PM, Occupational Therapist #2 stated adaptive equipment recommendations are made by therapy staff if it helped the resident be more independent and the resident was accepting of using the adaptive equipment. They stated if therapy had recommended adaptive equipment and it was on the care plan, ticket, or in an order the resident should be provided with the adaptive equipment, and if a resident did not like the adaptive equipment therapy should be notified to reassess the resident. Occupational Therapist #2 stated without the adaptive equipment it would be more difficult for the resident to eat independently. During an interview on 05/13/2025 at 1:39 PM, the Director of Nursing stated recommendations for assistive devices come from therapy and staff should provide the adaptive equipment for each meal. If staff had a concern related to the adaptive equipment, it should be reported to therapy. The Director of Nursing stated any time recommendations or preferences for adaptive equipment are made, the care plan, meal ticket, and physician's orders should be updated to reflect the changes. 10 NYCRR 415.14(g)

Based on interview and record review conducted during the Recertification Survey 05/05/2025 to 05/13/2025, the facility did not appropriately label and store all medications in accordance with currently accepted professional standards of practice and in accordance with stated and federal laws for eight (8) of 14 medication carts and five (5) of eight (8) medication rooms reviewed. Specifically, medications were left unattended by staff, multiple expired medications were stored in medication carts and medication rooms, loose unlabeled and uncovered pills were stored in multiple medication carts, narcotic medications were kept for multiple deceased residents over an extended period of time (versus returning to pharmacy) and narcotic sheets were missing signatures to verify that the narcotic medication counts were completed, correct and signed by two nurses. The findings include but not limited to the following: Review of the facility policy Medication Storage/Med Cart, dated May 2024, documented the medication cart shall be secured during medication passes and must be securely locked at all times when out of the nurse's view. Medication carts should be cleaned and restocked at the end of each shift as necessary. 1. During an observation and interview of medication administration on 05/08/2025 at 10:06 AM on residential unit 2E, Licensed Practical Nurse #11 left their medication cart unattended which contained a blister packet with 29 capsules of gabapentin (medication used to treat seizures and nerve pain) and a blister packet with five tablets of folic acid (a mineral). Upon returning to the cart, Licensed Practical Nurse #11 pulled a blister packet contained multiple tablets of oxycodone tablets (narcotic medication and walked away without securing the oxycodone and went into the narcotic storage room. Licensed Practical Nurse #11 upon returning, stated they knew they should not have left the blister packets unattended. 2. During an observation and interview on 05/06/2025 at 12:09 PM on residential unit 3A, there were 11 unlabeled and uncovered loose pills of different shapes, colors and sizes found in the medication cart drawer. Licensed Practical Nurse #5 said they were unsure what the medications were but two of the pills were possibly to treat seizures. Licensed Practical Nurse #5 said they thought cleaning the medication carts was done on the night shift. Additionally, multiple medications in the cart were expired which included vitamin C, aspirin, vitamin D, glucose gel tubes and bisacodyl (laxative) with expiration dates going back to October of 2024. 3. During observations on 05/07/25 at 12:34 PM in the residential unit 1F medication cart, there was a bottle of aspirin that expired in 2024 and multiple loose unidentified and uncovered pills in the medication cart drawers. LPN #2 acknowledged the expired date and threw the bottle of aspirin away. During observations on 05/08/2025 at 10:47 AM on the residential unit 2H medication cart and medication room, multiple bottles of expired aspirin were stored in the medication cart and the medication room. Licensed Practical Nurse #3 discarded the expired bottles of aspirin at the time. 4. During an observation on 05/08/2025 at 10:31 AM on residential units IF and 2H, multiple medication blister packs (including narcotic [controlled substances] medications) and bottles of medications were stored in the medication rooms sinks and/or narcotic cupboards for multiple residents who were deceased as long ago as 01/26/2025. In an immediate interview the Licensed Practical Nurse stated the medications were for deceased residents. 5. During a record review on 05/08/2025 at 10:31 AM on residential unit 2E and 2F from 03/26/2025 through present, there were multiple missing staff signatures on the narcotic count sheets to verify the narcotic count was accurate and signed by the incoming and outgoing nurses for each shift. During an interview on 05/13/2025 at 11:02 AM, with the Director of Nursing and the Assistant Director of Nursing, the Director of Nursing stated that staff should check for expiration dates on all medications to avoid giving expired medications, and there should no loose pills in the carts. The Director of Nursing said nurses are responsible for cleaning and checking expiration dates for their assigned medication carts. The Assistant Director of Nursing stated all medications must be secured, and never left unsupervised and that all narcotics should be double locked and secured and never be out of the nurse's sight. The Assistant Director of Nursing said all nurses have had training on medication storage and should know that it is not acceptable to leave their medications unattended. 10 NYCRR 418.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/12/2025, for six (6) (Third Floor A, E, F, and G-units, Second Floor A and F-units) of 10 resident units, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated and unlabeled food items, microwaves and a freezer were dirty, there were outdated food items, food warming/holding units were not functioning properly, cups and lids were stored below sink plumbing, and there were moldy bread items. The findings are: The undated facility Food Storage Policy included all foods must be labeled with product name, date received/prepared, and expiration or use by date. Spills must be cleaned immediately, and housekeeping/maintenance maintain cleanliness and report any equipment issues. During observations and interview on 05/07/2025 from 12:05 PM to 12:40 PM, the Third Floor G-unit kitchenette had items in the refrigerator including two blue pitchers and two clear pitchers containing unknown liquids that were undated and unlabeled, and a small carton of chocolate Mighty Shake (a nutritional supplement) with a use-by date of 05/02/2025. There was a three-bay warming unit that was cold to touch and not turned on, holding several stainless-steel pans of food items including creamed corn, potatoes, and chicken patties. During an interview at this time, Certified Nursing Assistant #3 stated sometimes it (the warming bays) works and takes a while to heat up. There were three residents seated in the dining room as the aide began plating food. Additionally, a microwave was heavily soiled with food debris and splatter on all interior surfaces, there were yellow sticky spills inside the freezer, a partial loaf of cinnamon raisin bread dated 4/28/25, and a bag of hot dog rolls covered with blue and gray mold. During observations and interview on 05/07/2025 at 12:46 PM, the Third Floor F-unit kitchenette had plastic cups, lids, and paper towels stored under the drainpipe beneath the hand wash sink, a six (6) pack of English muffins covered in gray mold in an upper cabinet, and five (5) containers of four (4) ounce yogurts marked best by 03/05/2025 in the refrigerator. During an interview at this time, Licensed Practical Nurse Manager #8 stated the kitchen staff rotates the stock. Licensed Practical Nurse Manager #8 then discarded the moldy English muffins and outdated yogurts. During observations and interview on 05/07/2025 at 12:58 PM, the Third Floor E-unit kitchenette had two pitchers of unknown liquid that were undated and unlabeled, and an undated and unlabeled container of food that appeared to be rice, meat, and gravy in the refrigerator. During an interview at this time, a unit aide stated they did not know what was in the container or whose it was, and the kitchen staff comes in and checks the refrigerators. Additionally, there was a three-pack of English muffins dated 03/23/2025 in an upper cabinet. During observations on 05/07/2025 at 1:05 PM, the Third Floor A-unit kitchenette had three pitchers of unknown liquid that were undated and unlabeled, an undated item labeled tossed salad, and an undated plate of salad labeled Arnie. Additionally, the cabinet to the left of the refrigerator was broken with the door off the hinges leaning up against the wall. During observations and interview on 05/08/2025 from 12:07 PM to 12:34 PM, the Second Floor A-unit kitchenette counter had covered stainless steel pans that were being held for service in an uncovered three (3) bay stainless steel heating unit and included diced cauliflower, stuffed green peppers, ground stuffed green peppers, fish, and sauce. Additionally, the toggle switch for the heating unit was off. During an interview at this time, a unit aide stated they normally turn on the unit when they (kitchen staff) bring the food up. During observations on 05/08/2025 at 12:17 PM, the Second Floor F-unit kitchenette counter had an uncovered three (3) bay stainless steel heating unit with stainless steel pans holding various food for service. The unit was cold to the touch and did not appear to be functional. Additionally, the interior of the microwave was soiled with food debris and splatter. During observations on 05/08/2025 at 10:47 AM, the First Floor [NAME] Room pantry had an upright freezer that contained 19 unlabeled and undated 5.5-ounce cups that contained an unknown frozen brown substance. 10 NYCRR: 415.14(h); 10 NYCRR: Subparts 14-1.30, 14-1.31(a), 14-1.43(b,e), 14-1.95, 14-1.100, 14-1.110(d)

Based on interviews and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence the Infection Preventionist participated in the Quality Assurance and Performance Improvement meetings on a regular basis. This is evidenced by the following: The undated facility's Quality Assurance and Performance Improvement Program policy documented the quality and appropriateness of resident care, including the identification of trends in performance were monitored and evaluated in infection control. The policy did not include the Infection Preventionist as a committee member. The Facility Assessment, dated 04/30/2025, documented the facility had an infection prevention and control program, headed by a certified Infection Preventionist Registered Nurse, who develops and monitors the systems needed for preventing, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, and volunteers. The Infection Preventionist reports to the Quality Assurance and Performance Improvement committee each month. Review of the Quality Assurance and Performance Improvement monthly meeting attendance records for March 2025 and April 2025 revealed the Infection Preventionist was not listed as present for the meetings. During interviews on 05/09/2025 at 7:59 AM and on 05/12/2025 at 3:12 PM, Licensed Practical Nurse/Infection Prevention Nurse #2 said they worked at the facility 40-48 hours as an evening/night supervisor and they work as the Infection Prevention Nurse remotely from home. Infection Prevention Nurse #2 said they did not participate in Quality Assurance and Performance Improvement meetings, and that Infection Prevention Nurse #1 would attend the meetings. During a telephone interview on 05/13/2025 at 11:02 AM, Registered Nurse/Infection Prevention Nurse #1 said they worked remotely (were not on-site) and they were in touch with Infection Prevention Nurse #2, who was the Infection Preventionist in the building. Infection Prevention Nurse #1 stated they submitted Infection Control reports to either the Administrator or the Director of Nursing who then they presented the reports at the Quality Assurance and Performance Improvement meetings. During an interview on 05/13/2025 at 12:36 PM, with the Assistant Administrator and the Director of Nursing, the Director of Nursing stated they report the infection control data at the Quality Assurance and Performance Improvement meetings as the Infection Preventionist works the night shift and has not attended any meetings since prior to January 2025. The Director of Nursing and the Assistant Administrator stated that they were not aware the Infection Preventionist should attend the Quality Assurance and Performance Improvement monthly meetings. 10 NYCRR: 415.27(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a Recertification Survey from 05/05/2025 to 05/13/2025, 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 for seven (7) (Residents #9, #41, #45, #87, #94, #121, and #384) of 12 residents reviewed. Specifically, for Residents #45, #87, and #94, a Licensed Practical Nurse tested their blood glucose (sugar) levels using a glucometer (a machine used to test blood glucose levels using a drop of blood from the resident's finger) without cleaning the glucometer between each resident's use or after. For Resident #9, a Licensed Practical Nurse tested their blood glucose level at the dining room table without completing hand hygiene, without wearing gloves, and without cleaning the glucometer. For Resident #41 who as on enhanced barrier precautions (techniques used to prevent transmission of infectious diseases utilizing gloves and gowns with all high contact care), a licensed practical nurse tested their blood glucose without wearing a gown and without cleaning the glucometer. Residents #94, #121, and #384 were on enhanced barrier precautions and multiple staff members were observed giving hands on care without the appropriate personal protective equipment (gloves, gowns and masks, if appropriate). The findings include but are not limited to the following: The facility policy Blood Glucose Monitoring, dated May 2025, documented the facility will ensure that residents who have a diagnosis of diabetes are being monitored according to physician's orders. The charge nurse will maintain at least two glucose monitors in each med cart for use to allow adequate disinfecting time between resident use, clean and disinfect the blood glucose meter after each use according to the manufacturer's specifications using germicidal bleach wipes and train the licensed staff on the use of the glucose monitors and cleaning process. The facility policy Infection Prevention Control Program Core Practices, dated January 2025, documented guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. The facility will develop and implement policies and procedures for infection control that include hand hygiene practices consistent with accepted standards of practice and identifying use of alcohol-based hand rub versus soap and water, and Personal Protective Equipment that identifies what and when to wear. All staff will be trained on facility job-specific infection control policies and practices upon hire, annually and when situations warrant additional education is necessary. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. The facility policy Enhanced Barrier Precautions, dated November 2024 documented the facility will adhere to Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services guidelines as related to enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms while promoting resident quality of life by addressing the need for the psychosocial well-being of residents who are colonized with multidrug-resistant organisms. The facility will implement enhanced barrier precautions during high-contact resident care activities for those residents who are infected or colonized with a multidrug-resistant organism when contact precautions do not otherwise apply. Examples of high-contact resident care activities include dressing, bathing/showering, transferring, wound care and toileting. The facility will implement enhanced barrier precautions to include any resident with an indwelling medical device (central line, urinary catheters, feeding tubes) or chronic wounds (pressure injuries, diabetic foot ulcers, unhealed surgical wounds), regardless of multidrug-resistant organism colonization or infection status. 1. Resident #45 had diagnoses that included diabetes, chronic kidney disease and chronic obstructive pulmonary disease (disease of the respiratory system causing difficulty breathing). The Minimum Data Set (a resident assessment tool), dated 04/17/2025, documented the resident was cognitively intact. Review of Resident #45's current physician's orders, effective 05/13/2025, revealed to monitor the resident's blood glucose before meals and at bedtime. Resident #87 had diagnoses that included diabetes, heart failure, and depression. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. Review of Resident #87's current physician's orders, dated 04/23/2025, revealed an order for insulin on a sliding scale (amount of insulin is dependent on the blood glucose level) before meals. There was no order for blood glucose finger sticks. Resident #94 had diagnoses that included diabetes, chronic kidney disease and acquired absence of kidney. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, had an indwelling urinary catheter, and multiple unstageable pressure ulcers. Review of Resident #94's current medical orders, dated 02/05/2025, revealed blood glucose checks before meals and at bedtime, urinary catheter care every shift, and wound care to the left heel pressure ulcer. During observations of medication administration on 05/08/2025 starting at 4:16 PM, Licensed Practical Nurse #1 checked Resident #87's blood glucose with a glucometer. Without cleaning or disinfecting the glucometer, Licensed Practical Nurse #1 proceeded to check Resident #45's blood glucose with the same glucometer. Licensed Practical Nurse #1 then entered Resident #94's room. A sign by the room included the resident was on enhanced based precautions and staff were required to wear a gown and gloves when entering the room to perform high contact activities. Licensed Practical Nurse #1 wearing gloves, but no gown, checked the resident's blood glucose with the same glucometer and put it back in the glucometer case without cleaning or disinfecting it. During an interview on 05/08/2025 at 4:43PM, Licensed Practical Nurse #1 stated they did not clean the glucometer in between Resident #45, #87, and #94 or after, but should have based on their training on bloodborne pathogens and infection control, but there were no bleach wipes on the unit to clean it with. 2. Resident #41 had diagnoses that included diabetes, uropathy (obstruction of urine flow), and extended spectrum beta lactamase or ESBL (a multidrug-resistance organism) in the urine. The Minimum Data Set, dated [DATE], documented the resident had severe impairment of cognitive function and had an indwelling urinary catheter. Physician's orders, dated as active 05/13/2025, included finger stick blood glucose checks prior to meals and at bedtime. Resident #41's current Comprehensive Care Plan, dated as revised on 02/26/2024, included the resident was on enhanced barrier precautions for extended spectrum beta lactamase and staff should wear personal protective equipment (gown and gloves) for contact. During an observation on 05/07/2025 at 11:50 AM, Licensed Practical Nurse #3 obtained a finger stick blood glucose check. Licensed Practical Nurse #3 wore gloves but no gown. Licensed Practical Nurse #3 then placed the glucometer back in the medication cart without cleaning it with anything. During an interview on 05/07/2025 at 12:27 PM, Licensed Practical Nurse #3 stated they were taught to clean the glucometer with alcohol wipes and thought they cleaned the glucometer but was not sure. Licensed Practical Nurse #3 stated they were unsure if alcohol wipes were effective but that is what they were taught to do here. 3. Resident #9 had diagnoses that included diabetes, heart disease, and irritable bowel syndrome. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. Review of Resident #9's medical orders, dated 04/30/2025, revealed to check the residents blood glucose levels with meals for diabetes. During an observation and interview on 05/05/2025 at 12:04 PM, Licensed Practical Nurse #2 checked Resident #9's blood glucose level at the dining room table without wearing gloves, without performing hand hygiene, and without cleaning the table before or after. Licensed Practical Nurse #2 then placed the glucometer inside their shirt pocket without disinfecting it. Licensed Practical Nurse #2 stated they should have worn gloves and performed hand hygiene when checking the resident's blood glucose because they knew how important it was to maintain infection control. 4. During an observation on 05/07/2025 at 12:15 PM, Licensed Practical Nurse #4 wearing gloves, but no gown was in Resident #94's room for performing high contact care while transferring the resident. Resident #94 was resting on Licensed Practical Nurse #4 while waiting for additional staff to assist. Signage that read enhanced barrier precautions required for high contact care (including transfers) and a bin stocked with personal protective equipment were outside the resident's door. Certified Nurse Assistant #10 approached the room, applied gloves and began to apply a protective gown when they were told by Licensed Practical Nurse #4 that a gown was not needed because they would not be touching the resident's catheter (indwelling urinary catheter). Certified Nurse Assistant #10 wearing gloves, but no gown, then assisted with transferring Resident #94. Licensed Practical Nurse #4 stated to the Assistant Director of Nursing and Licensed Practical Nurse Manager #3 (who were in the hallway) that they thought they only needed a protective gown when touching the catheter. During an interview on 05/07/2025 at 12:27 PM, Licensed Practical Nurse #4 stated they had been employed at the facility since February 2025, had not received any training on infection control, and no orientation when hired. Licensed Practical Nurse #4 stated that Resident #94 has had a catheter (indwelling urinary catheter) for some time, but enhanced barrier precautions were not put in place until the survey started. 5. Resident #121 had diagnoses that included diabetes, high blood pressure, and anxiety disorder. The Minimum Data Set, dated [DATE], included Resident #121 was cognitively intact. Review of the Comprehensive Care Plan, dated 05/09/2025, and [NAME] (certified nursing assistant care plan) revealed Resident #121 was on enhanced barrier precautions related to colonized colostrum difficile (a spore forming bacterium that can cause infection and requires specific cleaning to neutralize). During an observation on 05/05/2025 at 9:37 AM, Certified Occupational Therapy Assistant #1 provided hands on care to Resident #121 including assisting the resident with placing and adjusting exercise bands and touching their legs. Certified Occupational Therapy Assistant #1 was wearing a mask but no gown or gloves. A sign posted at Resident #121's door included Resident #121 was on enhanced barrier precautions and staff were to wear a gown and gloves with all direct hands-on care. During an interview on 05/13/2025 at 12:10 PM AM, Certified Occupational Therapist Assistant #1 stated they did not wear a gown or gloves for the duration of Resident #121's therapy session on 05/05/2025 and they should have. During a telephone interview on 05/12/2025 at 3:12 PM, Infection Preventionist #2 stated they worked as the Infection Preventionist remotely (from home). Infection Preventionist #2 stated glucometer use and blood borne pathogens training had been conducted for the staff, and that they must complete the trainings before they could work on the units, and no one should be using glucometers for multiple residents and not cleaning it after each person. Staff had been trained to assess blood glucose in a private area (not at the dining room table) while wearing gloves and using germicidal wipes on surfaces afterwards. Additionally, Infection Preventionist #2 stated staff had been trained in orientation that full personal protective equipment (gowns, gloves, mask) should be worn for resident on enhanced barrier precautions during transferring due to it being a high contact activity. During an interview on 05/13/2025 at 11:19 AM, the Director of Nursing stated they expect staff to read the signs and adhere to them by applying full personal protective equipment anytime they entered a resident's room and gloves should be worn when checking blood glucose levels. 10 NYCRR 415.19(a) (1-3)(b)(4)

Based on observations and interview conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, for seven (7) (first floor E and F-units, second floor A, E, F, and H-units, and third floor E-unit) of 10 resident units, the facility did not properly maintain the resident call system. Specifically, the nurse call system did not function properly to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area from each resident's bedside and toilet/bathing facilities, and clean utility rooms lacked nurse call annunciators. The findings are: During an observation on 05/06/2025 at 10:27 AM, there was no centralized nurse call station panel or annunciator at the second floor H-unit nurses' station, and staff did not carry phones or pagers connected to the nurse call system. During an observation on 05/06/2025 at 10:59 AM, there was no centralized nurse call station panel or annunciator at the second floor F-unit nurses' station. During an interview on 05/08/2025 at 11:42 AM, the Director of Environmental Services stated the nurse call system was installed around 1995 with lights and an audible tone, and a phone system connected to the nurse call was put in at some point where an activated call bell would initiate a call to a nurse station phone that would show which room called, but it does not work anymore. During an observation on 05/08/2025 at 1:03 PM, there was no nurse call station annunciator at the second floor A-unit nurses' station. During an observation on 05/08/2025 at 1:05 PM there was no nurse call system annunciator in the third floor E-unit clean utility room. During an observation on 05/08/2025 at 1:06 PM, there was no nurse call system annunciator in the second floor E-unit clean utility room. During an observation on 05/08/2025 at 1:28 PM, there was no nurse call system annunciator in the first floor E-unit clean utility room. During observations on 05/08/2025 at 1:30 PM, there was no nurse call system annunciator in the first floor F-unit clean utility room or at the nurses' station. During an interview on 05/13/2025 at 12:49 PM, Licensed Practical Nurse #10 (third floor F-unit) stated other than physically looking around the unit, there is no way to know which call bell is ringing and there is not a panel on this floor for us to look at. Licensed Practical Nurse #10 stated if you are busy and doing something, you will hear it go off but will not know where without having to go around and look at each door, so it is difficult at times. During an interview on 05/13/2025 at 3:00 PM with the Director of Nursing and the Assistant Administrator, the Director of Nursing stated the call light system was old, and the Quality Assurance and Performance Improvement (QAPI) committee was aware of the issues. The Assistant Administrator stated the handhelds were breaking, the company that serviced them had gone out of business, and the facility could not get them fixed. The Assistant Administrator stated the facility would have to buy a complete new system. 10 NYCRR: 415.29, 415.29(b); 415.29(j)(1), 10 NYCRR: 713-3.25(g)

Based on observations, interviews, and record review conducted during the Recertification Survey from 05/05/2025 to 05/13/2025, the facility did not ensure they had an Infection Preventionist who was responsible for the facility's Infection Prevention Control Practices. Specifically, the facility could not provide verification and documentation of the Infection Preventionist designated onsite hours for the assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program. The findings include: The Facility Assessment, reviewed on 04/30/2025, included that the facility has an infection prevention and control program that is headed by a certified Infection Preventionist Registered Nurse who develops and monitor the systems needed for preventing, identifying, reporting, investigation, and controlling infections and communicable diseases for all residents, staff, and volunteers. The Infection Preventionist report to the QAPI committee each month For additional information see Centers for Medicare/Medicaid Services Form 2567, reference F880 - Infection Prevention and Control and F868 - Quality Assessment and Assurance Committee. During the Entrance Conference on 05/05/2025 at 9:15 AM, the Administrator stated Infection Prevention Nurse #2 (a Licensed Practical Nurse) was a full-time employee who was the facility's Infection Preventionist. The Administrator said that Infection Prevention Nurse #1 (a Registered Nurse) helps Infection Prevention Nurse #2 with the infection control data. During interviews on 05/09/2025 at 7:59 AM and on 05/12/2025 at 3:12 PM, Licensed Practical Nurse/Infection Prevention Nurse #2 said they worked at the facility 40-48 hours as an evening/night supervisor and they work as the Infection Prevention Nurse remotely from home. While they are not in the facility weekly as the Infection Prevention Nurse, they do address Infection Prevention issues when they are there (as evening/night supervisor). Infection Prevention Nurse #2 said they did not participate in Quality Assurance and Performance Improvement meetings, and that Infection Prevention Nurse #1 would attend the meetings. During an interview on 05/13/2025 at 9:31 AM, the Director of Nursing said Infection Prevention Nurse #2 was in the building approximately 40 hours (a week) and a significant amount of the time was as the evening/night nursing supervisor. The Director of Nursing stated Infection Prevention Nurse #2 had several hours of down time on the night shift and would work on infection control, data, checking orders, and antibiotic related tasks. The Director of Nursing said Infection Prevention Nurse #2 would probably spend at least 12 hours on infection control related responsibilities in house and sometimes they would approve work off-site (remote). The Director of Nursing said Infection Prevention Nurse #1 worked on data entry and reports for infection control, so Infection Prevention Nurse #2 could focus on infection control by being out on the units. During a telephone interview on 05/13/2025 at 11:02 AM, Registered Nurse/Infection Prevention Nurse #1 said they helped with infection control by tracking antibiotics, residents' immunizations, reporting and they maintained the line lists (lists of residents with current infections) for outbreaks. Infection Prevention Nurse #1 stated they worked remotely (were not onsite) and they were in touch with Infection Prevention Nurse #2, who was the Infection Preventionist in the building. Infection Prevention Nurse #1 stated they submitted Infection Control reports to either the Administrator or the Director of Nursing and then they presented the reports at the Quality Assurance and Performance Improvement meetings. During an interview on 05/13/2025 at 11:19 AM, the Director of Nursing said Infection Prevention Nurse #2 was the go-to person for infection control and Infection Prevention Nurse #1 only did reporting and documentation since they were not in the building. 10 NYCRR 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey 11/13/23-11/20/23, it was determined that for 2 (Residents #4 and #64) of 12 residents reviewed for dining, the facility did not ensure the residents were given the appropriate treatment and services to maintain or improve their ability to carry out their activities of daily living (ADLs). Specifically, neither Residents #4 nor #64 were given the assist recommended at meal time to complete their meals. This is evidenced by the following: 1.Resident #64 had diagnoses including dysphagia (difficulty swallowing), macular degeneration (impaired eyesight), and heart failure. The Minimum Data Set (MDS) Assessment documented that the resident had severely impaired cognition and required assistance from staff with meals. The current comprehensive care plan (CCP) 11/29/22 and the [NAME] (care plan used by the certified nursing assistant (CNA) for daily care) included that the resident needed to be set up for meals. Current physician orders for Resident #64 included to encourage small bites of food, sips of water, and for staff to provide cueing during meals. Resident #64's meal ticket documented the resident needed assistance and encouragement with meals and to feed if needed. Review of a dietary note dated 11/6/23, revealed that Resident #64 had had a significant weight loss of 7.5% over last three months. During an observation of dining on 11/13/23 at 12:52 PM Resident #64 sat alone at the table in the dining room not eating their lunch. Resident #64 did not receive any cues or encouragement from staff during the meal and eventually ate approximately 25% of the meal. When interviewed at this time Registered Nurse (RN) #9 stated that Resident #64 was taking part in a Restorative Dining Program with the purpose to encourage residents to eat. When asked who was responsible for encouraging the residents, RN#9 did not know. During an observation on 11/16/23 at 12:12 PM Resident #64 was sitting at the dining room table and after a few bites stopped eating. One staff member stopped to encourage Resident #64 to eat but did not offer any assistance. Resident #64 eventually consumed less than half of the meal before it was removed. 2. Resident #4 had diagnoses including dementia, osteoarthritis (pain and stiffness in joints), and depression. The MDS assessment dated [DATE], included that the resident was severely impaired cognitively and required assist from staff for eating. The current CCP and CNA [NAME] documented that Resident #4 needed assistance of staff during meals including verbal encouragement and placing utensils in the resident's hand. During an observation of breakfast on 11/16/23 at 9:18 AM Resident #4 breakfast was sitting out for an extended period of time (dried food around the edges) and had to be rewarmed. Staff were not observed cueing, encouraging, or placing any utensils in the resident's hand during the meal. Resident #4 ate less than half of breakfast. During an observation on 11/16/23 at 12:52 PM Resident #4 was sleeping in their room alone, their lunch was uncovered with only a few bites of meatloaf eaten. There were no observations of staff in the room offering any assistance with the meal. During an interview on 11/20/23 at 12:36 PM the Assistant Director of Nursing stated that there was only one staff member serving and feeding residents. During an interview on 11/20/23 at 3:15 PM the Director of Nursing stated one aide on the unit for serving and passing meals is not good. During an interview on 11/20/23 at 3:37 PM the Administrator stated they were aware of the problem with residents not getting the assistance needed with meals and that they started a new restorative program to help with this issue. 10 NYCRR 415.12(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review conducted during the Recertification and Abbreviated (NY00323359) Surveys from 11/13/23 to 11/20/23, it was determined that for nine (#12, 36, 41, 59, 61, 63, 76, 83, and 84) of nine residents reviewed that were assigned to Neighborhood 3E on 9/2/23, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was insufficient evidence in the residents' medical record to show that multiple physician ordered medications were administered to multiple residents at the scheduled times. Additionally, there was no documented evidence that the medical provider was notified of the late or not administered medications which included but is not limited to, anticoagulants (blood thinners), insulin, and multiple medications for blood pressure. This is evidenced by, but not limited to the following: The facility policy Medication Administration, Documentation, and Premedication, dated revised April 2021 included that medications are to be administered by an appropriately licensed individual and medication administration was the responsibility of the assigned nurse. The five rights of medication administration are the right to the right medication, the right dose, via the right route, at the right time, and given to the right resident. All medications are to be documented at the time of administration. 1. Resident #41 had diagnoses that included stroke, dementia, and hyperlipidemia (high lipid levels in blood). The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was severely impaired cognitively, and received an anticoagulant (blood-thinner) medication daily. Review of Resident #41's September 2023 Medication Administration Record (MAR) revealed blank boxes indicating the medication was not administered for the following medications on 9/2/23: a. Eliquis (anticoagulant medication) twice daily for deep vein thrombosis (DVT) scheduled for 8:00 PM b. acetaminophen (Tylenol) three times a day for pain scheduled for 8:00 PM. c. atorvastatin (medication for high cholesterol) scheduled for 6:00 PM Review of Resident #41's Interdisciplinary Progress Notes (IPN) dated 9/2/23 to 9/4/23 did not include that scheduled evening or night shift medications on 9/2/23 were not administered, were administrated late, or that the covering provider was notified. 2. Resident #76 had diagnoses that included diabetes, abdominal pain, and a femur (leg)fracture. The MDS assessment dated [DATE], revealed Resident #76 was cognitively intact, and was on daily insulin injections. Review of Resident #76's September 2023 Medication Administration Record (MAR) revealed blank boxes indicating the following medications were not administered on 9/2/23 as ordered by the physician: a. Insulin at bedtime for diabetes scheduled for 8:00 PM. b. lactulose (laxative) twice daily for constipation scheduled for 8:00 PM. c. acetaminophen (Tylenol) three times daily for pain scheduled for 8:00 PM. d. hydrocortisone cream apply to rash twice a day for one week scheduled for 8:00 PM. e. senna-docusate (stool softener and laxative) one tablet at bedtime for constipation scheduled for 8:00 PM. f. PUSH (nutritional supplement) one packet twice daily scheduled for 8:00 PM. Review of Resident #76's IPNs dated 9/2/23 to 9/4/23 did not include that scheduled evening or night shift medications on 9/2/23 were not administered, were administrated late, or that the covering provider was notified. 3. Resident #83 had diagnoses that included hypertension (high blood pressure), colitis (inflammatory reaction in the colon), and a femur (leg) fracture. The MDS dated [DATE] revealed Resident #83 was moderately impaired cognitively. Review of Resident #83's September 2023 Medication Administration Record (MAR) revealed blank boxes indicating the following medications were not administered on 9/2/23 as ordered by the physician: a. Budesonide twice daily scheduled for 8:00 PM (colitis) b. carvedilol twice daily for hypertension with instructions to hold for systolic blood pressure less than 120 or heart rate less than 55 - scheduled for 8:00 PM. c. acetaminophen three times daily for pain scheduled for 8:00 PM Review of Resident #83's IPNs dated 9/2/23 to 9/4/23 did not include that scheduled evening or night shift medications on 9/2/23 were not administered, were administrated late, or that the covering provider was notified. Review of six additional resident MARs for September 2023 revealed no documented evidence that the residents received a total of 22 physician ordered medications. Review of the resident IPNs revealed no evidence the covering medical provider had been notified. During an interview on 11/16/23 at 12:53 PM, the Director of Nursing (DON) stated that the Administrator received a phone call on 9/2/23 around 11:00 PM that a Licensed Practical Nurse (LPN) had left leaving one nurse in the facility. The DON stated that they (who was not yet employed by the facility at that time, but had received an offer of employment) offered to go to the facility to cover as a nurse and administer some medications. Review of a handwritten document (on a blank sheet of paper) provided by the facility on 11/16/23, titled '3rd Floor Meds Administered,' dated 8/2/23 (versus 9/2/23) revealed a list of residents, medications, and scheduled administration times. Additionally, the document included the Medical Director had been notified that multiple medications had been administered late that day. The list of residents on the document did not match the resident census for 9/2/23. The document did not include the name or signature of the nurse that administered the medications and did not include the time the medications were administered. During an interview on 11/20/23 at 12:37 PM, the Acting Administrator stated that on 9/2/23, there was a nursing shortage. The Acting Administrator stated that current DON (prior to hire date) came in and administered medications to residents on the third floor. The Acting Administrator was unsure if the medications were administered late or if the covering provider was notified of any late or missing medications. During an interview on 11/20/23 at 12:45 PM, the facility's Covering Administrator of Record stated that they were aware that the current DON had assisted on the unit but was not aware of the details. During an interview on 11/20/23 at 1:57 PM, the Medical Director stated that if medications were unable to be administered at the scheduled time, they would expect the covering (or on-call) medical provider to be notified because they would determine if the later medication should be given or not. The Medical Director stated that they were not contacted on 9/2/23 regarding late medications because they were on vacation and that the covering provider on 9/2/23 had not been contacted regarding missing or late medications. 10 NYCRR 415.12(m)(2)

Based on observations and interviews conducted during the Recertification Survey 11/13/23 to 11/20/23 it was determined for four (2E, 2F, 2G, and 3E) of nine residential care units reviewed, the facility did not ensure that all medications used in the facility were stored and labeled in accordance with currently accepted professional standards. Specifically, expired medications were stored with active medications in two medication carts (2E and 2F) and expired stock (standard medications that may be used for multiple residents) medications were stored in three medication rooms (2E, 2G, 3E). This is evidenced by the following: During an observation of medication storage on 11/16/23 at 9:46 AM, the medication room for Unit 3E had a Ziplock bag that contained 58 individually wrapped loperamide (antidiarrheal medication) 2 milligrams (mg) tablets and one unopened box of 12 loperamide 2 mg tablets both with an expiration date of August 2023. During an observation of medication storage on 11/17/23 at 10:05 AM, the medication cart for Unit 2F had one bottle of aspirin 325 mg, approximately half full of tablets, with an expiration date of May 2023. During an observation of medication storage on 11/17/23 at 10:14 AM, the medication room for Unit 2G had two unopened boxes of loperamide 2 mg tablets, a total of 24 tablets, with an expiration date of August 2023. During an observation of medication storage on 11/17/23 at 10:26 AM, the medication cart for Unit 2E had one bottle of stool softener, more than half full of capsules, with an expiration date of September 2023, one bottle of a Dairy Aid supplements with three tablets, with an expiration date of July 2023, and one opened bottle of aspirin 81 mg, with approximately 20 tablets, with no visible expiration date on the bottle and no indication of when the bottle was opened. During an observation of medication storage on 11/17/23 at 10:43 AM, the medication room for Unit 2E had one opened box of loperamide 2 mg tablets that contained 8 tablets, with an expiration date of August 2023 and one pouch of glucose gel (used to treat acute low blood sugar), with an expiration date of October 2023 During an interview on 11/16/23 at 10:03 AM, Licensed Practical Nurse (LPN) #3 stated that as the regular nurse on the unit they check for expired medications routinely but was not sure if the cart and rooms were checked by agency staff. LPN #3 stated they were unsure if there was a schedule for checking for expired medications or who was ultimately responsible for completing the task. During an interview on 11/16/23 at 10:04 AM, Registered Nurse Manager (RNM) #3 stated that nurse managers were responsible to check the medication rooms for expired medications. RNM #3 stated it was previously the responsibility of the primary nurse on the unit, but since there were no longer primary nurses the task moved to the nurse managers and were unsure if there was a set schedule to check for expired medications. During an interview on 11/17/23 at 10:12 AM, LPN #4 stated it was every nurse's responsibility to check for expired medications. Additionally, the contracted pharmacy reviews the medication carts monthly including checking for expired medications. During an interview on 11/17/23 at 3:27 PM, the Director of Nursing (DON) stated that all nurse's were responsible for routinely checking for expired medications. The DON stated they did not think there was a set schedule for checking the medication carts or the medications rooms, but that all nurses should check for expiration dates prior to administering medications and remove them at that time. The DON said that all nurses should periodically go through stock medications in the medication rooms and ensure expired medications are removed. 10 NYCRR 415.18(d)(e)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for 1 (Resident #82) of 11 residents reviewed for dining that the facility did not provide special eating equipment and utensils for a resident who required them to maintain the resident's ability to eat and drink independently. Specifically, Resident #82 was observed on several occasions consuming meals without a two handled mug with concave anti-splash lip, a lip plate, or an angled utensil (all adaptive eating equipment) as recommended. This is evidenced by the following: The facility policy and procedure titled Care Plan Adherence, dated July 2021, stated the resident care team will follow the plan of care that is developed for each resident to provide direction for their individualized care using measurable and achievable goals and is consistent with the resident's needs. The resident care team must follow the care plan for the resident at all times. The Clinical Educator is to re-educate staff to ensure they understand the importance of following the care plan and understand all policies and procedures. Resident #82 was admitted to the facility with diagnoses including Parkinson's disease, dementia, a stroke with hemiparesis (weakness and one side of the body) and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) Assessment, dated 9/22/23, revealed that the resident had severe cognitive impairment and required supervision with set up for eating assistance. Review of Resident #82's Comprehensive Care Plan (CCP) dated 5/10/23, revealed the resident was in need of assistance with activities of daily living and nutrition related to Parkinson's disease and general weakness. Interventions included a lip plate, an angled utensil, a concave anti-splash two handled cup with lid, and a spork (specialized spoon) for eating. Review of Resident #82's undated Resident Care Card (care plan used by Certified Nursing Assistants (CNA-also known as HRAC) for daily care) located in the resident's room did not include the required adaptive assistive devices the resident required. Under assistive feeding equipment the Care Card was blank. Review of an untitled document dated 2/20/23 and located in the communication binder at the nurse's station (verbalized by staff that the document included all residents daily care needs for HRACs (CNAs) to follow) revealed it was blank under the heading assistive/adaptive equipment. During an observation on 11/15/23 at 8:55 AM Resident #82 was sitting at the dining table for lunch with standard fork and spoon (for oatmeal) and a hard plastic cup and no adaptive equipment. The resident's meal ticket included a two handled mug with concave anti-splash lid, a lip plate, and a maroon spoon (specialized spoon) required. Resident #82 was sitting with both hands crossed and not participating in self- feeding throughout the meal. During an observation on 11/15/23 at 12:35 PM Resident #82 was sitting at the dining table with standard fork, spoon, plate, and cup. There was no adaptive equipment in site. During an observation on 11/16/23 from 12:04 PM to 12:44 PM Resident #82 was sitting at the dining table for lunch with a standard soup spoon and adaptive built up white handled fork. There was no lip plate or two handled mugs. The resident was drinking from a hard plastic cup but did not eat during the observation or before the plate was removed. During an observation on 11/17/23 at 12:39 PM Resident #82 was sitting at main dining table for lunch with standard fork and spoon, a divided dish (no lip), and a hard plastic cup. During an interview on 11/17/23 at 8:59 AM, CNA #8 stated that the residents daily care needs are in the communication binder. During an interview on 11/17/23 at 8:57 AM, CNA #7 stated the adaptive feeding devices that Resident #82 needs is written on the meal ticket. During an interview on 11/17/23 at 2:40 PM, CNA#7 stated that the adaptive feeding devices are kept on the resident households and the CNAs are responsible for washing and placing back on the household kitchens to use for the next meal. If the adaptive feeding devices are not available, the household staff should let the therapy department know to provide the needed adaptive devices. Review of the kitchen at this time revealed the adaptive equipment for Resident #82 was in the kitchen. During an interview on 11/17/23 at 12:41 PM, Registered Nurse Manager (RNM #2) was not aware who was responsible for updating the CCP and Resident Care Cards and that they have not been instructed to do so. RNM #2 stated all residents should have the adaptive feeding devices available, and meals served on the appropriate dinnerware and residents get the help they need but it is a challenge because we do not have a lot of aides. During an interview on 11/20/23 at 3:08 PM, the Director of Nursing (DON) stated it is the expectation that the HRACs (CNAs) and the nurses provide the residents with the appropriate assistive devices at mealtimes as noted on their meal tickets. The DON said if the devices are not available on the household the staff should call the dietitian or the kitchen staff to find out where the extra supplies are In an email dated 6/27/23 provided by the facility between the Registered Dietitian and the Speech Therapist included a recommendation for a maroon spoon and revealed a concern that some staff on units are not always reading tickets (resident's meal tickets) for a variety of reasons. 10 NYCRR 415.14(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00323359) from 11/13/23 to 11/20/23, the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to ensure that all residents were free from significant medication errors, did not have the Infection Preventionist (IP) working at least part time in the facility, and did not have the IP attend Quality Assurance and Performance Improvement (QAPI) meetings. Refer to the following tags: F760: Residents are Free of Significant Medication Errors F868: QAA Meetings F882: Infection Preventionist Qualifications/Role The Facility assessment dated [DATE], documented that the facility would provide the care needed so that all resident's medications would be administered and in a timely manner. The Facility Assessment also listed staff members that the facility would employ to provide care to the residents, including an Infection Preventionist. For nine residents reviewed residing on Neighborhood 3E on 9/2/23, there was no evidence in the residents' medical records that multiple scheduled medications had been administered to the nine residents as ordered by the physician at the scheduled times. Additionally, there was no documented evidence that the medical provider was notified of the late or missing medications which included but not limited to high-risk medications such as anticoagulant (blood-thinner) medications, insulin, and multiple medications for blood pressure. In an interview 11/20/23 at 12:37 PM, the Acting Administrator stated that they recalled on 9/2/23, there was a nursing shortage and that the current DON (prior to hire date) came in and administered medications to some residents. The Acting Administration was unsure if the medications were administered on time or late or if the covering provider had been notified of the issue. The facility could not provide evidence that the Infection Preventionist had attended the last two Quality Assurance Improvement Performance (QAPI) meetings reviewed for past six months. The facility failed to ensure that the Infection Preventionist worked at least part time in the facility. When interviewed on 11/16/23 at 11:17 AM the IP stated they are a full-time employee at another facility and only comes into the facility as needed. During a follow up interview on 11/16/23 at 2:07 PM the IP stated they have not been in the facility since August of 2023. During an interview on 11/20/23 at 12:45 PM, the Administrator of Record (AoR) stated they were made aware after the fact that a nurse not employed by the facility at the time came in to pass medications and they cannot verify one way or another if the medications were given. The AoR stated it is not common practice to have a nurse come give medications if they are not employed by the facility. During an interview on 11/20/23 at 3:36 PM the AoR stated they were not aware of the regulation to have an Infection preventionist in the building at least part time and stated they were aware the Infection Preventionist was supposed to attend QAPI meetings and that the Infection Preventionist had not attended the past few QAPI meetings. 10 NYCRR 415.26

Based on interviews and record review conducted during a Recertification Survey 11/13/23 to 11/20/23, the facility did not maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role, and the infection preventionist (IP). Specifically, the facility could not provide evidence that the IP attended the last two Quality Assurance Improvement Performance (QAPI) meetings. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 7/28/23 and 11/13/23 did not include the presence of the IP. Review of an undated facility QAPI Attendee Sheet provided by the facility did not include the IP. When interviewed on 11/16/23 at 11:17 AM and at 2:07 PM the IP stated they are a full-time employee at another facility and come into this facility as needed. The IP stated they have not been in this facility since August 2023. During an interview on 11/17/23 at 1:03 PM, the Director of Human Resources stated the previous IP nurse left the faciity on 6/16/23, and the current IP works from home. During an interview on 11/20/23 at 3:37 PM the Covering Administrator of Record stated the IP does not work in the building, works from home, and does not attend QAPI meetings. 10 NYCRR: 415.27(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey from 11/13/23 to 11/20/23, it was determined that for two (Resident # 21 and #23) of two residents reviewed for infection control, the facility did not ensure compliance with infection prevention and control national standards such as transmission-based precautions (TBP). Specifically, staff did not follow the guidelines for appropriately applying and removing Personal Protective Equipment (PPE) when encountering transmission-based precautions (TBP) residents and their environment or isolate a resident (Resident #23) with a communicable disease from a resident (Resident #21) who did not have a communicable disease. This is evidenced by the following: The facility policy, Surveillance for Infections when it pertains to PPE for contact precautions, directed staff to apply gloves and isolation gowns prior to any resident care to protect themselves against infectious agents. To prevent cross- contamination, staff should remove PPE when cares are completed and before touching any other non- contaminated items. PPE should be removed prior to leaving the resident care area and hand washing with soap and water should be performed. A cohort is the quarantine of a household to prevent the spread of an infection or disease to other households. No resident will travel to or from the cohorted household with the exception of medically necessary interventions. The cohort will remain in effect until all effected residents have recovered. 1.Resident #23 had diagnoses including dementia, diabetes and Clostridium difficile (C-diff: inflammation of the colon caused by a bacterium, leading to diarrhea which is contagious to others). The Minimum Data Set (MDS) Assessments dated 8/20/23 and 11/10/23, revealed the resident had severely impaired cognition, was always incontinent of bowel and required extensive assist of staff for bathing, toileting, and personal hygiene. Review of medical provider orders for Resident #23 included C-Diff precautions from 11/9/23- 11/23/23 and vancomycin (antibiotic) every six hours for C-diff for 14 days (11/9/23-11/23/23). Review of the current Comprehensive Care Plan (CCP) documented that Resident #23 was at risk for incontinence and included staff checking and changing the resident every two to four hours as needed and providing medications and treatments as ordered by the medical team. 2.Resident #21 had diagnoses including dementia, diabetes, and chronic kidney disease. The MDS assessment dated [DATE], revealed the resident had severely impaired cognition and required extensive assistance of staff for toileting, transferring and personal hygiene. The MDS Assessment also included that the resident was always incontinent of stool. Review of the current CCP documented that Resident #21 was at risk for incontinence and included staff interventions for cleansing after each incontinence episode and providing the resident with incontinence briefs. During an observation and interview on 11/13/23 at 10:33 AM, signage was observed on Residents' #21 and #23 semi- private room door that indicated Contact Precautions, see nurse prior to entering. In addition to the signage, a cart was positioned outside the residents' door containing gloves, gowns, face masks, and bleach wipes. When interviewed at this time Registered Nurse Manager (RNM)#1 stated that Resident #23 had tested positive for C-diff approximately one week prior and was currently receiving antibiotic therapy. Additionally, RNM #1 said the resident's roommate (Resident #21) had been tested (day prior 11/12/23) and was negative for C-diff but could not be moved to a different room due to lack of available rooms. During unit tours by the survey team on 11/13/23 and 11/14/23 day shifts there were multiple empty (clean) resident rooms observed in the facility. During an observation and interview on 11/14/23 at 2:10 PM, RNM #1 said the Infection Preventionist (IP) had instructed staff to have Resident #23 use the bathroom and Resident #21 use a bedside commode. RNM#1 said the interdisciplinary team had discussed moving Resident #23 but did not have anywhere to move them to. RNM#1 said the bedside commode (visible at this time in the resident's room from the hallway) should not be visible from the hall and the dining area and at this time donned gloves and a gown and moved the bedside commode out of visibility then came out of the room into the hall still wearing the gown and gloves without removing any of the PPE or performing hand hygiene. During an interview on 11/15/23 at 9:43 AM and again at 3:27 PM, RNM#1 stated that Resident #23 had a history of chronic diarrhea before they were admitted and that the plan was to separate the residents once an available room was cleaned. Review of resident's bowel log at this time revealed Resident #23 last had a loose stool on 11/14/23. During an interview on 11/16/23 at 12:58 PM, the Assistant Director of Nursing (ADON) said that when they learned that Resident #23 had tested positive for C-diff, they notified the IP and were told that both residents could remain in the same room together as long as they did not share the same bathroom. During an interview on 11/16/23 at 2:07 PM, the IP said that if there are available rooms, the resident who is positive for C-diff should move to a private room. During an interview on 11/17/23 at 2:05 PM the Director of Nursing stated that staff should discard their PPE appropriately and wash hands or use hand sanitizer before leaving the residents room. 10 NYCRR 415.19(b)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey, it was determined that the facility failed to ensure they had an Infection Preventionist (IP) who was responsible for the facility's Infection Control Program. Specifically, the facility failed to ensure that the IP worked at least part time in the facility. This is evidenced by the following: Review of the Facility assessment dated [DATE] listed an IP as a key staff member for the facility to provide support and care to the residents. During an interview on 11/16/23 at 11:17 AM the IP stated they are a full-time employee at another facility and only comes into the facility as needed. During a follow up interview on 11/16/23 at 2:07 PM the IP stated they have not been in the facility since August of 2023. During an interview on 11/17/23 at 1:03 PM the Director of Human Resources stated the IP works per diem remotely from home and was last full time in the facility 8/26/22. During an interview on 11/17/23 at 2:05 PM the Director of Nursing stated they would expect the IP to be readily available to staff for questions and concerns and to be available to provide education to staff. During an interview on 11/20/23 at 3:36 PM the Administrator stated they were not aware that they had to have an IP in the building at least part time. 10 NYCRR 415.9(a)

Based on observations, interviews, and record review conducted during the Standard Recertification Survey completed 11/13/23 to 11/20/23, it was determined that for one of one main kitchen the facility did not prepare, store, distribute, and serve food in accordance with professional standards for food service safety. Specifically: the dish machine in the main kitchen had two leaks, there was a significant buildup of ice on the walk-in freezer floor, a refrigerator gasket was in disrepair, and floors were soiled with standing water and food. The findings are: On 11/13/23 at 9:01 AM a buildup of ice on the pipe to the condenser in the walk-in freezer was observed in the main kitchen. Further observations included a significant build up of ice on the floor below this condenser, with masses of ice between approximately two and eight inches high. In an interview at this time, the Food Service Director (FSD) stated that this issue has been going on for over a year and that a vendor comes in to chip the ice off every few weeks but has not done anything to fix the issue. On 11/13/23 at 9:05 AM the floor under the shelves in the walk-in produce cooler were observed to be soiled with a mold-covered cucumber, apples, and food particles. On 11/13/23 at 9:08 AM the mechanical dish machine in the main kitchen was observed to have a significant leak, and when the machine was operated water flowed from the underside of the dish machine onto the dish room floor. Further observations included a significant amount of standing water present on the dish room floor. In an interview at this time, the FSD stated that the dish machine was leaking, they were looking into getting a new one, and they were told that this was an issue with the gasket. On 11/13/23 at 10:54 AM the upper portion of the door gasket on the residential-style refrigerator located in the second floor H-unit kitchen was observed to be torn, and there were food particles inside the area of the tear. On 11/15/23 at 10:49 AM vendor invoices related to the main kitchen dish machine were provided by the FSD included the following: a) A note on an invoice dated 5/26/23 which included 'Found dishwasher leaking from where to parts of unit meet together. Found loose bolts. Tightened down bolts but did not stop leak. Tried to seal with plumbers putty and that did not work either. Will provide an estimate to re seal and put back together.' b) A note on an invoice dated 10/26/23 included 'on arrival found the leak is originating from the center of the machine. Will provide estimate for repairs.' During an interview on 11/15/23 at 11:28 AM and 11:44 AM, the FSD stated that the current dish machine leak (from under the rinse side) started about two weeks ago. The FSD said that a vendor came to look at the ice buildup in the walk-in freezer, was told that it can be fixed, and that the condenser needed to be resealed with silicone. On 11/15/23 at 11:45 AM the floor under the shelves in the walk-in produce cooler were observed to be soiled with apples and food particles. On 11/15/23 at 11:47 AM the mechanical dish machine in the main kitchen was operated and a significant amount of water flowed from the underside of the dish machine (on the rinse side) onto the dish room floor. Further observations included standing water present on the dish room floor. In an interview at this time, the FSD stated that the water on the floor was just from this morning, and when staff walked through the water on the dish room floor, they then bring that water throughout the kitchen. On 11/15/23 at 1:58 PM there was an additional leak observed in the main kitchen dish washer and when the machine was operated, water dripped from the underside of the piece of metal that connected the wash and rinse sides of the machine onto the dish room floor. Additional observations included that the leak from the underside of the dish machine on the rinse side was being diverted into a black bucket below, which was overflowing water onto the dish room floor and standing water was present throughout the floor. In an interview at this time, a Food Service Worker stated that the leak from the section that connects the wash and rinse sides of the machine had been going on for about three to four months, it gets water all over the floor, and they have to walk through that water. During an interview on 11/16/23 at 10:19 AM, the FSD stated that they reached out to their vendor regarding the invoice dated 5/26/23 to see if there was follow-up and provided the surveyor with a print-out of the email communication with the vendor. The FSD further stated that the repair was expensive, and the nursing home did not want to pay so the issue was not fixed. Review of the email communication provided at this time included the statement: 'We did not complete the work that we estimated for that particular work order. 10 NYCRR: 415.14(h), Subpart 14-1.95, 14-1.110(d), 14-1.113(a), 14-1.140(a), 14-1.170

Based on observations, interviews and record reviews conducted during a Recertification Survey completed on 2/17/22, it was determined that for one (Resident #2) of five residents reviewed, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet their preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, Residents #2 's CCP did not address diagnoses of depression or insomnia and did not address use of a psychotropic medication (medications that that affect behavior, mood, thoughts and/or perceptions that may have severe side effects). This was evidenced by: Resident #2 was admitted to the facility with diagnoses that included corticobasil degeneration (a rare progressive neurological disorder characterized by deterioration of specific areas of the brain), Parkinson's disease, and diabetes. The Minimum Data Set (MDS) Assessment, dated 11/1/21, revealed that Resident #2 had no speech (absence of spoken words), was sometimes understood by others, and was sometimes able to understand others. The MDS Assessment also included that the resident had a diagnosis of depression and received an antidepressant medication daily. The Care Area Assessment Summary or CAAS (provides guidance to the facility about specific areas of concern for a resident that may need interventions as identified on the MDS Assessment) revealed the use of a psychotropic medications and recommended to proceed to completing the care plan. Review of the current physician orders and a physician progress note, dated 1/24/22, revealed that Resident #2 was on Remeron (an antidepressant medication that is also considered a psychotropic medication) for depression and on melatonin at bedtime for insomnia. Review of the CCP, dated 10/26/21, included a risk for change in Resident #2's mood related to visitation limitations due to Covid-19. The CCP did not address the resident's depression, insomnia or the use of a psychotropic medication, any measurable goals or person-centered nonpharmacological approaches to use. During random observations on 2/14/22 and 2/15/22 during the day shift, Resident#2 was observed sitting up in a tilt back wheelchair in front of a television in the common area and always with their eyes closed. During an interview 2/16/22 at 8:57 a.m., the Registered Nurse Manager (RNM) stated that psychotropic medications should be addressed by social work and nursing. The RNM stated psychotropic medications were usually added into one of the CCP areas but if a resident had multiple psychotropic medications, then they may break it down. The RNM stated Resident #2 did not have mood or behavior issues that they were aware of but that they would expect the use Remeron and Melatonin to be addressed on the resident's care plan in addition to a diagnosis of depression. During an interview on 2/17/22 at 9:06 a.m., the Director of Nursing (DON) stated the primary nurses and managers usually work together on the development of the CCP and that the RNMs' audit the CCPs weekly. The DON stated the MDS nurse, who is a Licensed Practical Nurse, completed the care plan for areas that triggered during the MDS Assessment and that the DON signed it as the Registered Nurse (per the regulations). The DON stated that they expected that if the CAAS indicated to proceed to the care plan then the triggered area should be addressed on the CCP and would include the clinical indication for the medication, measurable goals, and non-pharmacological interventions but that this had not been done. 10NYCRR 415.11 (c)(1)

Based on observations conducted during the Standard Recertification Survey completed on 2/17/22, it was determined that for two (second and third floors) of four resident use floors the facility did not properly equip corridors with handrails on each side. Specifically, there were sections of corridor wall that lacked handrails. The findings are: 1. On 2/14/22 at 10:16 a.m. it was observed that there were no handrails along corridor walls at the following locations on the second floor: outside A2-07; approximately 2-foot long and 5-foot sections, outside A2-06; an approximately 2-foot section. 2. On 2/15/22 at 8:49 a.m. it was observed that the was no handrail along an approximately 3-foot section of corridor wall between A3-21 (training bathroom) and resident room A3-19. 3. On 2/16/22 from 10:10 a.m. to 10:23 a.m. it was observed that there were no handrails along corridor walls at the following locations on the second floor: across from A2-21 next to the stairwell door; an approximately 4-foot section, between A2-21 and A2-19; an approximately 3-foot section, and next to A2-07 (housekeeping closet); an approximately 4-foot section. 10NYCRR: 415.29, 713-1.8(a), 713-2.18(17)