Based on observations, interviews, and record review conducted during the Recertification Survey from 04/17/2024 to 04/24/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident in 1 of 6 pantries observed for food storage. Specifically, the 6th floor residents' pantry refrigerator had a temperature of 44 degrees Fahrenheit and contained an undated staff's food. The findings are: The facility policy and procedure titled Pantry Policy with an effective date of March 2024 documented that it is the policy of the facility to provide safe and clean pantry including a refrigerator on each unit to store resident's food and nourishments. Refrigerator temperatures are to be maintained between 32-40 degrees Fahrenheit. Items kept in the refrigerator must be dated and labeled with name and room number. Items will be disposed of after 3 days and any unlabeled and undated items will be disposed of as well. The Facility policy and procedure on Use and Storage of Food Brought to Residents from the Outside which was last revised 10/2023, documented that food must be covered, labelled, and dated. Any item found not labelled will be discarded. Leftovers must be consumed within 3 days and then discarded. An observation was conducted on 04/18/2024 at 10:11 AM with Licensed Practical Nurse #1. It The 6th floor pantry refrigerator was observed with a temperature of 44 degrees Fahrenheit. There was an undated plastic bowl of soup labeled with a staff's name. During an interview on 04/18/2024 at 10:11 AM, Licensed Practical Nurse #1, who was managing the unit, stated the undated plastic bowl of soup belonged to a Certified Nursing Assistant working at the facility. They stated residents' and staff's food should not be in the same refrigerator. Licensed Practical Nurse #1 stated the staff was supposed to put their food items in the refrigerator in the staff lounge. During an interview on 04/18/2024 at 10:38 AM, Registered Nurse #1 stated staff's food should not be stored with residents' food to avoid cross contamination as it relates to the infection control policy. They stated residents' food kept in the refrigerator must by labeled with the resident's name and date and must be discarded after 48 hours. Registered Nurse #1 stated that the refrigerator temperature must be 40 degrees Fahrenheit. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification survey from 04/17/2024 to 04/24/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Enhanced Barrier Precautions were not implemented in the facility. The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection Prevention and Control. The facility policy and procedure titled Enhanced Barrier Precautions, with effective date of 04/2024, documented that it was the policy of the facility to adhere to the Centers for Disease Control and Prevention guidelines as related to Enhanced Barrier Precautions to prevent the transmission of Multidrug Resistant Organisms while promoting resident quality of life. The policy documented that enhanced barrier precautions will be used for residents in the facility who have a Centers for Disease Control and Prevention targeted multi-drug resistant organism (germs that are resistant to many antibiotics and can cause infections) and / or have a chronic wound or indwelling device. On 04/22/2024 at 10:37 AM, Registered Nurse #2 was observed performing wound care and treatment for Resident #91, who had a pressure ulcer, without wearing a gown. An undated facility document with a list of residents with wounds and indwelling medical device for Enhanced Barrier Precautions documented that Resident #91 had wounds, tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe), percutaneous endoscopic gastrostomy tube (a tube that allows you to receive nutrition directly through your stomach), and Foley catheter (a tube that goes into the bladder through the urethra that carries urine out of a person's body). A form titled Pre-Implementation Tool -Enhanced Barrier Precautions for Use in Skilled Nursing Facilities/Nursing Homes dated 04/19/2024 documented that the facility developed a timeline for implementation of enhanced barrier precautions and that implementation was expected to begin in 3 - 4 weeks. During an interview on 04/22/2024 at 2:38 PM, the Infection Preventionist stated the Enhanced Barrier Precautions will be implemented for residents with chronic wounds and indwelling medical devices. They stated gowns and gloves will be required during high contact care which include personal care, wound care, and activities during rehabilitative therapy. They stated they did a facility assessment on 04/19/2024 and completed a pre-implementation tool for enhanced barrier precautions. The Infection Preventionist stated they started giving in-service education to the staff on 04/22/2024 and will be completed on 04/26/2024. The Infection Preventionist stated that the enhanced barrier precautions will be implemented on 04/29/2024 once all staff received the in-service education. During an interview on 04/22/2024 at 2:57 PM, the Director of Nursing stated they have not implemented the enhanced barrier precautions in the facility. They stated they were still developing an agenda and preparing things they need, such as inventory of personal protective equipment and providing in-service to the staff. The Director of Nursing stated they were informed by their regional office about the Centers for Medicare and Medicaid Services memorandum on enhanced barrier precautions but does not recall ever seeing the memorandum. The Director of Nursing stated they had a planned discussion with the staff about enhanced barrier precautions, but the meeting was cancelled. During an interview on 04/24/2024 at 1:51 PM, the Administrator stated they were unaware of the effective date of the Enhanced Barrier Precautions. The Administrator stated they were getting the policy and the staff education together and that their corporate team were in the process of getting all the signages for posting. 10 NYCRR 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification survey from 3/23/22-3/30/22 the facility did not ensure that a resident remained free from physical restraints. Specifically, a resident was observed with a left-hand mitten which was not identified as a restraint. This was evident for 1 of 2 residents reviewed for Physical Restraints out of a sample of 38 residents. (Resident #32) The findings are: The facility policy titled Physical Restraints revised July 3, 2019, documented it is the policy of the facility that before application of a restraint, all other alternatives will have been explored and/or tried. Only after documentation as to why these measures are ineffective or inappropriate will the least restrictive restraint be ordered and utilized. The resident has the right to make an informed choice regarding the use of restraints. In the case of a resident who is incapable of making a decision, the designated representative may exercise the right based on the same information that would have been provided to the resident. Resident #32 was admitted to the facility on [DATE] with diagnoses that included Seizure Disorder, Traumatic Brain Injury, and Respiratory Failure. The admission Minimum Data Set (MDS) dated [DATE] documented Resident #32 was rarely/never understood and was moderately impaired in cognitive skills for daily decision making. The MDS also documented that Resident #32 required total dependent, two persons assist with bed mobility, transfer, and toilet use. The MDS did not document use of physical restraints. On 03/23/22 at 09:58 AM, 03/24/22 at 11:31 AM, and 03/25/22 at 09:09 AM, Resident #32 observed alert in bed and a hand mitten was observed on the resident's left hand. The Nursing admission assessment dated [DATE] documented under the Restraint Assessment that resident had a fall within last 3 months, requires assist with all ambulation, has poor trunk control and no desire expressed for resident to have side rail. No restraints were indicated on the initial nursing assessment. Physician orders dated 1/14/22 through 3/24/22 revealed no orders for a left-hand mitten. Active and discontinued care plans dated 1/14/22 through 3/24/22 revealed no care plan in place for a left-hand mitten restraint. There was no documented evidence that an evaluation for the mitten use had been initiated or that mitten use was being documented in the CNA Accountability Record. Physician's orders was placed for mitten use on 3/25/22 at 10:45am and documented Left hand mitten safety, remove every 2 hrs for 15 minutes for skin check, ROM, and hygiene. On 03/29/22 at 10:18 AM, the Registered Nurse (RN) #1who functioned as the charge nurse was interviewed. RN #1? stated that the mitten was ordered because Resident #32 pulled on the G-tube and the trach. RN #1 stated that there is a form that gets completed and they would tell the supervisor first, then the family and if they approve of the restraint, they will get an order from the MD and consent from the family. RN #1 also stated that this form was kept in the hard copy chart and was not part of the Electronic Medical Record. RN #1 further stated that all the residents with mittens have an order as the mitten cannot be used without an order and they were not sure why there was no order in for Resident #32. On 03/29/22 at 11:14 AM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA #1 stated Resident #32 had been wearing a mitten because the resident would pull at their tubes. CNA #1 also stated they remove the mittens to wash the resident's hands at least once each shift. CNA #1 further stated that they documented this in the accountability book at the end of the shift. On 03/29/22 at 11:57 AM, CNA #2 was interviewed. CNA #2 stated that they remove the mitten when giving care to wash and moisturize the resident's hands. CNA #2 also stated that from time to time they remove the mitten to check on the resident's hand. CNA #2 further stated that since Resident #32 was admitted they had started pulling on their tubes. On 03/30/22 at 10:50 AM, the Respiratory Therapist (RT) was interviewed. The RT stated they are always in contact with the family and the hand mitten had been on the resident's hand for a while. The RT also stated that the resident had a TBI patient and so touches things and this prevents the resident from injuring themselves. The RT could not recall whether Resident 32 had the mitten on admission. On 03/30/22 at 12:44 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that they were notified by one of the nurses on 3/25/22 that Resident #32 had a mitten. The ADON also stated they did not know who placed the hand mitten for the resident. The ADON further stated that the facility procedures permit use of an emergency restraint, and it is possible that a nursing supervisor put it on, possibly as an emergency restraint. The ADON also stated that an emergency restraint must be addressed within 24 hours. 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey 3/23/2022 to 3/30/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives participated in the development of a Comprehensive Care Plan (CCP). Specifically, there was no evidence cognitively intact residents were afforded the opportunity to participate in the care plan meetings or documentation explaining why they could not participate. This was evident for 3 of 4 residents reviewed for Care Plan out of a sample of 38 residents. (Resident #145 and #66) The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP) and Resident/Patient Meeting with effective date February 2022, supersedes:12/1/2019; 3/30/2017 documented under Policy/Procedures and Information 1) A CCP meeting (with the inclusion by invitation to the resident and/or family) will be conducted with 21 days from admission 2) The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan face to face meeting, teleconference, written communication is at the discretion of the facility. 3)Within 14 days of the resident admission, a comprehensive assessment of the resident needs will be prepared, and developed by interdisciplinary team, including, LPN, CNA, attending Physician, RN, food/nutrition team and resident/resident 4) The facility department of Social Services will notify the patient and/or designated representative via phone and letter of the date and time of CCP meeting. Teleconference will be offered if and/or when requested or if the family/representative is unable to physically attend. 1) Resident #145 was admitted to the facility with diagnoses that included Hypertension, Diabetes Mellitus, Renal Insufficiency and Peripheral Vascular Disease. The admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #145 was cognitively intact, did not have any behaviors or reject care. The MDS also documented that resident participated in the assessment and family or significant other did not. On 3/24/2022 at 9:48 AM, Resident # 145 they had not attended any meetings with staff members here. The Social Service note dated 3/9/2022 documented case note: CCP invitation mailed to resident daughter. There was no documented evidence in the medical record that Resident #145 was invited to a care plan meeting. There was no documented evidence regarding why the resident did not attend the care plan meeting. On 3/29/2022 at 4:05PM, the Social Worker (SW #1) was interviewed. SW #1 stated that Resident #145 was invited to the care plan meeting verbally and declined to attend. A care plan meeting invitation letter was mailed to their family even though resident was cognitively intact and made their own decisions. 2.) Resident #66 was admitted to the facility with diagnoses that included Cerebral Vascular Accident, Transient Ischemic Attack and Hypertension. The admission MDS dated [DATE] documented Resident #66 was cognitively intact, had no behavior and did not reject care. The MDs also documented that resident required extensive 2 person assist with bed mobility and dependent 2 person assist with transfer. The MDS further documented that resident and significant other participated in the assessment. On 3/23/2022 at 11:36 AM, Resident #66 was interviewed and stated that baseline care plan was provided but they had not been invited to attend the care planning meeting. Resident #66 also stated that they make choices for themselves and would have attended the meeting if invited. Social services progress note dated 2/7/2022 documented a care plan invitation was mailed to the resident's daughter. Social worker will follow up as needed. There was no documented evidence within progress notes or comprehensive care plan that Resident #66 was invited to the care plan meeting since and no documented evidence that resident declined to attend the care plan meeting held on 1/31/2022. On 3/29/2022 at 3:41PM, an interview was conducted with Licensed Practical Nurse (LPN) #6. LPN #6 stated they did not attend care plan meetings, as the Minimum Data Set (MDS) Nurse attends the meetings. LPN #6 also stated that the Social Worker arranges care plan meetings and sometimes they invite the residents. On 03/30/22 at 11:15 AM, a subsequent interview was conducted with SW #1 who stated that Resident #66 declined to attend the care plan meeting. SW #1 also stated that the Resident/Family Invitation to Care Plan meeting letter was sent to the resident's family member and they reminded the daughter to attend the meeting but did not remind the resident to attend even though the resident is cognitively intact. 415.11(c)(2) (i-iii)

Based on observation, record review and staff interviews during the Recertification survey conducted 3/23/22 to 3/30/22, the facility did not ensure that care and services are provided according to accepted standards of clinical practice. Specifically, the facility did not ensure that a resident with intravenous (IV) Midline access site for antibiotic therapy was provided with proper administration of the initial dose by a Registered Nurse (RN) and assessment of the resident by an RN for symptoms and reactions to prevent further infection, and complications of IV therapy when administered by a Licensed Practical Nurse (LPN). This was evident for 1 of 10 residents observed for Medication Administration. (Resident #57). The findings are: The undated facility policy on Job Description: - Licensed Practical Nurse documented: The Licensed Practical Nurse, under the supervision of the RN Supervisor, renders professional nursing care to residents in support of medical care as ordered by the physician and pursuant to objectives and policies of Long Island Care Center. The New York State Education Board for Nursing on Practice Information: - The Practice of IV Therapy by Licensed Practical Nurses in Long Term Care Settings last updated April 16, 2021, documented the role of the LPN in providing intravenous therapy is determined by a number of factors including the complexity of the procedure, the degree of direction, the setting, as well as the skill and competence of the licensee. A Registered Professional Nurse (RN) may delegate select activities associated with the administration of intravenous therapy to an appropriately competent LPN .Regardless of the degree of delegation, however, the RN retains the ultimate responsibility for the administration and clinical management of intravenous therapy, including assessment of the patient for symptoms and reactions. In addition, Education Law does not permit LPNs to make any patient assessments and an LPN may not Administer the first dose of any medicated IV solution through any venous access device. Resident #57 was admitted to the facility with diagnoses that included Hypertension, Ulcerative Colitis, and Seizure Disorder. The Physician's order dated 3/18/2022 documented: Ceftriaxone 2-gram solution for injection every Day at 10:00 am for 6 Weeks (First Became Standing: 02/19/2022 9:01 am) for Cellulitis of left upper limb. Physician's order dated 02/19/2022, (order changed 3/9/22), documented Vancomycin 1,000 mg by IV daily for 6 weeks. Physician's order dated 3/18/2022 documented Vancomycin 1,000 mg intravenous injection, infuse 1 gram by intravenous route every 12 hours for 6 weeks for Cellulitis of left upper limb (start date: 3/09/2022 12:38 pm). The Medication Administration Record (MAR) dated February 2022 documented that the first dose of Vancomycin 1 gm by IV Midline ordered 2/19/22 was administered to the resident by Licensed Practical Nurse #1 on 2/19/22 at 9pm, and administered subsequent daily dose at 9 pm on 2/20/22, and 2/25/22. LPN #1 also documented the resident's condition while receiving intravenous therapy during this period. LPN #2 administered the Vancomycin 9pm dose and documented the resident's condition while receiving intravenous therapy from 2/21/22, to 2/24/22, and 2/26/22, to 2/28/22. There was no documented evidence that an assessment of the resident's condition related to the administration of the intravenous therapy was conducted during this period by a Registered Nurse. The MAR dated 03/01/22 and 03/28/22 documented that LPN #1 administered the 10 AM dose of Vancomycin 1,000 mg IV to the resident and documented the resident's condition while receiving intravenous therapy on March 11, 14, 15, 17, 20, 21, 24, 25, and 10pm dose on March 16, 19, 20, 25. LPN #1 also administered the 10 am dose of Ceftriaxone 2 gram solution by IV Midline to the resident on 12 occasions and LPN #2 administered the 10 pm dose of Vancomycin on 13 occasions. There was no documented evidence that an assessment of the resident's condition related to the administration of the intravenous therapy was conducted during this period by a Registered Nurse. Observations and record reviews were made on the unit between 3/24/2022 and 03/28/2022 from 9:00 am to 12:00 pm when LPN #1 was passing medications to the residents, including the IV medication to Resident #57. No RN was observed performing assessment of the resident, or documenting resident's condition related to the administration of the IV therapy. On 03/24/22 at 09:50 AM, LPN #1 was interviewed. LPN #1 stated that Resident #57 was started on IV antibiotics on 02/29/2022 and they have been administering the medication during the day shift since the medication was started. LPN #1 also stated that they are responsible for documentation of the progress notes related to resident's IV meds as no other Registered Nurse is assigned to the unit most of the time. On 03/24/22 at 04:38 PM, an interview was conducted with LPN #2. LPN #2 stated that Resident #57 is on Rocephin IV daily and Vancomycin every 12 hours, and they have been administering the PM dose of Vancomycin IV medication to the resident between 9 and 10 pm every day during the evening shift. LPN #2 also stated that they are the only nurse on the unit on evening shift, responsible for administration of the medication and for documentation on the resident's use of the medication. LPN #2 further stated that the RN Supervisor is called to the unit if there is any issue or concern, or sometimes, if there is new order from the doctor, or any new lab results to be documented. On 03/28/22 at 12:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility has 2 RNS during the day covering all the units, plus a RN in charge on certain units. The DON also stated that the RN covering is expected to check, assess, and document on the residents being administered IV antibiotics. The DON further stated that they were not aware that this was not being done. 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0755, Regulation FF11 [NAME], Daneya C. Based on interviews, observations and record reviews conducted during a Recertification survey from 3/23/2022 to 3/30/22, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the medication room cabinet on (4th floor) The findings are: The facility's policy and procedure entitled Medication Storage Of effective date 6/1/2009, documented that medication are stored according to procedures established and in compliance with State and Federal regulations, as well as manufacturer's recommendations, to ensure the integrity of all medications. On 3/29/2022 at 4:40 PM, the medication storage room was observed. One unopened botte of Bisacodyl 5mg 100 tablets was observed with an expiry date of 1/2022 in the stock medication cabinet. On 3/29/2022 at 4:40 PM, Licensed Practical Nurse (LPN) #2 was interviewed. LPN #2 stated that all nurses are responsible for checking medications when the supply comes in. LPN #2 also stated that stock medications are not really being used and would only be used if there is a new order for a resident. LPN #2 further stated that all nurses are supposed to be checking in the event that there is a new order. On 03/30/22 at 1:08 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the LPN on the unit is responsible for checking expiry dates on medication and this should be done on all shifts. The ADON also stated that the charge nurse is responsible for doing routine and spot checks of medication. On 03/30/22 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated all nurses on the units should be checking medication. The DON also stated that medication should also be checked every time the nurse interacts with the medication and they should be checking for expiration dates. The DON further stated once a week, nurses should be checking dates and all supervisors should be making rounds to check on nursing staff. 415.18(a)

Based on observation, record review and staff interviews during the Recertification survey conducted 3/23/22 to 3/30/22, the facility did not ensure that resident on intravenous therapy received adequate monitoring. Specifically, a resident's antibiotics medication was not adequately monitored every shift by a Registered Nurse for the indication for its use and/or for the possible presence of adverse consequences when administered by a Licensed Practical Nurse (LPN). This was evident for 1 of 10 residents observed for Medication Administration. (Resident #57). The findings are: The New York State Education Board for Nursing on Practice Information: - The Practice of IV Therapy by Licensed Practical Nurses in Long Term Care Settings last updated April 16, 2021, documented the role of the LPN in providing intravenous therapy is determined by a number of factors including the complexity of the procedure, the degree of direction, the setting, as well as the skill and competence of the licensee. A Registered Professional Nurse (RN) may delegate select activities associated with the administration of intravenous therapy to an appropriately competent LPN .Regardless of the degree of delegation, however, the RN retains the ultimate responsibility for the administration and clinical management of intravenous therapy, including assessment of the patient for symptoms and reactions. Education Law does not permit LPNs to make any patient assessments The RN must document, at least every shift, assessment of the patient's condition relative to the intravenous therapy. Resident #57 was admitted to the facility with diagnoses that included Hypertension, Ulcerative Colitis, and Seizure Disorder. The Physician's order dated 3/18/2022 documented: Ceftriaxone 2-gram solution for injection every Day at 10:00 am for 6 Weeks (First Became Standing: 02/19/2022 9:01 am) for Cellulitis of left upper limb. Physician's order dated 02/19/2022, (order changed 3/9/22), documented Vancomycin 1,000 mg by IV daily for 6 weeks. Physician's order dated 3/18/2022 documented Vancomycin 1,000 mg intravenous injection, infuse 1 gram by intravenous route every 12 hours for 6 weeks for Cellulitis of left upper limb (start date: 3/09/2022 12:38 pm). The Medication Administration Record (MAR) dated February 2022 documented that Vancomycin 1 gm by IV Midline ordered 2/19/22 was administered to the resident by Licensed Practical Nurse #1 on 2/19/22, 2/20/22 and 2/25/22. LPN #1 also documented the resident's condition while receiving intravenous therapy during this period. LPN #2 administered the Vancomycin 9pm dose and documented the resident's condition while receiving intravenous therapy from 2/21/22, to 2/24/22, and 2/26/22, to 2/28/22. There was no documented evidence that an assessment of the resident's condition related to the administration of the intravenous therapy was conducted during this period by a Registered Nurse. The MAR dated 03/01/22 and 03/28/22 documented that LPN #1 administered the 10 AM dose of Vancomycin 1,000 mg IV and Ceftriaxone 2 gram solution by IV via on 12 occasions and LPN #2 administered the 10 pm dose of Vancomycin on 13 occasions. There was no documented evidence that an assessment of the resident's condition related to the administration of the intravenous therapy was conducted during this period by a Registered Nurse. Observations and record reviews were made on the unit between 3/24/2022 and 03/28/2022 from 9:00 am to 12:00 pm when LPN #1 was passing medications to the residents, including the IV medication to Resident #57. No RN was observed performing assessment of the resident, or documenting resident's condition related to the administration of the IV therapy. On 03/24/22 at 09:50 AM, LPN #1 was interviewed. LPN #1 stated that Resident #57 was started on IV antibiotics on 02/29/2022 and they have been administering the medication during the day shift since the medication was started. LPN #1 also stated that they are responsible for documentation of the progress notes related to resident's IV meds as no other Registered Nurse is assigned to the unit most of the time. On 03/24/22 at 04:38 PM, an interview was conducted with LPN #2. LPN #2 stated that Resident #57 is on Rocephin IV daily and Vancomycin every 12 hours, and they have been administering the PM dose of Vancomycin IV medication to the resident between 9 and 10 pm every day during the evening shift. LPN #2 also stated that they are the only nurse on the unit on evening shift, responsible for administration of the medication and for documentation on the resident's use of the medication. LPN #2 further stated that the RN Supervisor is called to the unit if there is any issue or concern, or sometimes, if there is new order from the doctor, or any new lab results to be documented. On 03/28/22 at 12:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility has 2 RNS during the day covering all the units, plus a RN in charge on certain units. The DON also stated that the RN covering is expected to check, assess, and document on the residents being administered IV antibiotics. The DON further stated that they were not aware that this was not being done. 415.12(l)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews conducted during a Recertification survey from 3/23/22 to 3/30/22, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, a resident with a Dementia diagnosis was maintained on an antipsychotic medication with no documented behaviors to support the ongoing use of the medication. This was evident for 1 of 6 residents reviewed for the Unnecessary Medication out of a sample of 38 residents. (Resident # 67). The findings include. The facility policy, procedure, and information titled Medication: Psychoactive Medication Use revised 01/2022 documented that the facility will monitor all residents on psychoactive medications as mandated by the State and Federal Guidelines. Resident #67 was admitted to facility on 12/23/2021 diagnoses that included Non-Alzheimer's Dementia and Depression. The admission Minimum Data Set (MDS) dated [DATE] documented resident as severely cognitively impaired with no behaviors and no rejection of care. The MDS also documented that the resident received an antipsychotic on 3 of 7 days and a GDR had not been attempted. On 03/24/22 at 02:59 PM, Resident #67 was observed in the day room sitting alone calmly at a table watching television and using a phone. Resident #67 engaged in conversation with the surveyor and showed the surveyor a photograph of their parent on a personal cell phone. On 03/25/22 at 09:34 AM, an interview was conducted an interview with Resident #67. Resident was calm, and frequently conversed about feeling sorry for themself. Resident #67 stated that they are usually sitting in the hallway or dayroom but wanted to lie down in bed this morning to relax. On 03/29/22 at 03:29 PM, Resident #67 was observed in the Day room engaging in activities. Resident was seated calmly in a wheelchair listening and watching musical activity performance. The Physician order dated 12/23/21 renewed 3/7/22 documented Mirtazapine 15 mg tablet give 1 tablet by oral route one time before bedtime for Major Depressive Disorder and Quetiapine 25 mg tablet give 1 tablet by oral route 2 times per day for Unspecified Psychosis not due to a substance or known physiological condition. The Comprehensive Care Plan (CCP) titled Psychotropic Meds-Psychoactive Drug Use dated 12/23/2021 revised 1/31/2022 documented a goal of resident will not experience side effect/ adverse reaction to medication. Interventions included to assess need to taper medication; monitor appetite, monitor for changes in behavior, mood, and mental status. The Medication Regimen Review (MRR) conducted on 12/27/2021 documented resident has order of Seroquel (quetiapine) with an indication of psychosis since their recent admission. Recommendation: Taper and discontinuation of order. Physician response: No, continue with the current indication because low dose Seroquel has proven to be effective at alleviating the behavioral symptoms that can present a risk of harm to either the resident or others. The behavioral symptoms targeted for the use of Seroquel for this resident include. No behavioral symptoms were checked off on the MRR. Psychiatric consult dated 1/4/2022 documented [AGE] year old resident with Unspecified Dementia receiving Remeron 15mg at bedtime and Seroquel 25 mg twice a day. Resident had appropriate affect, neutral mood, polite, clear voice and was oriented to person only. The consult also documented that resident was resident was not aware of current place and had no recollection of amputation surgery. Diagnosis included Dementia and Delirium and Care Plan was to taper Seroquel to 25mg and follow up 3 months. Physician note dated 2/11/22 documented that physician was asked to follow up on resident with chronic cognitive impairment secondary to suspected Alzheimer's Dementia who was taking Seroquel. The note also documented that the resident has had no exacerbation of mood and had no recollection of who the doctor was and why they were in their room. The assessment and plan documented psychiatric disorder unclear diagnosis and continue Seroquel 25mg twice daily. There was no documented evidence that Seroquel was tapered as per the Psychiatrist recommendation. There was no documented evidence in the clinical record of monitoring of resident's behavior or the presence of behaviors to support ongoing use of Seroquel with a resident with a diagnosis of Dementia. On 03/29/22 at 03:33 PM, an interview conducted with CNA #6. CNA #6 stated that resident is usually in chair during the day and evening unless resident wants to relax in bed, is alert and likes to talk but may get agitated at times. CNA #6 also stated that resident has been observed being verbally abusive to staff but verbal abuse does not happen often or last long. CNA #6 further stated they will engage in conversation with resident if verbal abuse occurs and resident will calm down and has had no serious behavior issues beside the verbal abuse. On 03/30/22 at 12:14 PM, an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 says if a resident has behaviors such as throwing food or screaming, they are redirected and notes would be written. If interventions are not effective the Nursing Supervisor would be informed. LPN #5 also stated that notes are not written for Resident #67 because the resident is on behavior meds and has not had any behaviors. On 03/30/22 at 12:23 PM, an interview was conducted with Unit Manager/Assistant Director of Nursing (ADN). The ADN stated nurses would write behavior notes if the resident has behaviors. The ADN also stated that positive or negative changes in resident are documented and there is no scheduled frequency for documentation of behavior notes. The ADN stated they had not reviewed the psychiatrist recommendation for tapering of medication and did not know why this had not been done. The ADN stated that the only behavior they are aware that Resident #67 exhibited was calling/shouting out on occasion. On 03/30/22 at 01:26 PM, a telephone interview was conducted with the Medical Doctor (MD). The MD stated that resident was admitted to the facility on this medication in December for an unspecified psychiatric disorder. The MD also stated that the resident's moods are mostly stable, resident is almost always confused and has hallucinations about having bowel movements and is redirectable. The MD further stated that the resident's preoccupation with bowel movements may be confusion but they will insist that something is in their underwear even though they were just told a few minutes ago that nothing is there. The MD stated that they were afraid resident would become agitated if taken off the medication as the resident has underlying anxiety and they were concerned about rebound symptoms so did not attempt to taper the medication. 415.18(c)(1)

Based on observations and staff interviews conducted during a Recertification survey from 3/23/2022 to 3/30/2022, the facility did not ensure 1). that controlled drugs were stored appropriately in locked compartments and 2). that medication and biologicals were labeled and dated appropriately when opened. Specifically, one of the two double locked narcotics cabinet door was unlocked and multi-use insulin vials were not labeled when opened. This was observed on 1 of 5 units during the Medication Storage Task. (Unit 2). The findings are: The facility policy titled Medication: Storage of effective date 6/1/2009 documented Medications are stored according to procedures established and in compliance with State and Federal regulations, as well as manufacturer's recommendations, to ensure the integrity of all medications. On 03/29/22 at 12:50 PM, the Medication cart was observed on the 2nd Floor in the hallway near the elevator bank. One Lantus insulin pen and one Novolog Flex pen were observed opened and there was no discard date on the label. On 03/29/22 at 01:02 PM, the narcotics cabinet in the nursing station down the hallway was observed with the first door unlocked. Licensed Practical Nurse #7 was interviewed immediately and stated that they had just opened the narcotics cabinet prior to the surveyors coming on to the unit. LPN #7 also stated that they know both doors should be locked at all times and could not explained why one door was left unlocked. LPN #7 further stated that they and the night shift staff, maybe, usually check medication for dates but they had not gotten to this task yet today. On 03/30/22 at 01:15 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that the narcotics cabinet should be always double locked and they usually check every time they pass by the cabinet to ensure that it is locked and it usually is locked. RN #1 also stated that multidose vials come in a Ziplock bag and the sticker should be placed on the bag and not on the vial once the vial is opened. RN #1 also stated tape can be placed on the insulin pen and the date can be placed on this. RN #1 further stated that it is usually the night shift nurses that check nightly to ensure that things are labelled. On 03/30/22 at 02:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that Insulin pens and vials should be labelled on the actual device once opened and a duscard date placed on each device. The DON also stated that narcotics cabinets should be double-locked at all times. The DON further stated that all supervisors are responsible for ensuring that all these things are done and they do make rounds on the unit. 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/23/22 from 10:04AM to 10:52 AM, the following was observed on the 5h Floor: room [ROOM NUMBER]-string for light broken. room [ROOM NUMBER]-rusted vent, peeling paint in bathroom, dust in bathroom, peeling paint above window. room [ROOM NUMBER]- rusted vent and peeling paint above window. room [ROOM NUMBER]A- a hole in ceiling in bathroom and dirty/dusty windowpane. room [ROOM NUMBER]-peeling/rusted paint in room along with rusted vent. room [ROOM NUMBER]- peeling paint on wall by 520. Bathroom had paint chipped. Dusty vent room [ROOM NUMBER]- rusted vent, chipped paint on window sill, chipped paint in bathroom by window, dusty windowpane, and dust around toilet corner floors. On 03/25/22 at 12:06 PM, a cracked wall was observed by the window next to television in the dining room along with chipped paint on lower sections of wall, peeling wallpaper, and a rusted vent. On 03/30/22 at 11:04 AM, Maintenance work order book was reviewed beginning from July 2021. Last entry in log book was dated 3/13/2022 and there was no documentation of any of the environmental concerns observed by the surveyor. On 03/30/22 at 11:06 AM, an interview was conducted with Housekeeping [NAME] (HP) #2. HP #2 stated they work on the 5th Floor and their duties include cleaning resident rooms, staff bathrooms, and terminal cleaning done if a resident passes away or is discharged . HP #2 also stated they report to supervisor if something breaks or leaks on the floor. HP #2 further stated they let their supervisor know about peeling paint. HP #2 stated that the vents and window ledges on the unit are cleaned as part of a special assignment which was recently completed. Peeling paint, cracks in wall in dining, and hole in room are all handled by the maintenance department. On 3/23/22 at 10:15 AM and 3/24/22 at 12:39 PM, missing bottom wardrobe drawer for closet A, missing top wardrobe closet knobs for closet B, missing top wardrobe closet knob for closet C, missing top wardrobe closet knobs for closet D, and broken baseboard were observed in room [ROOM NUMBER]. On 3/23/22 at 10:20 AM and 3/24/22 at 12:45 PM, missing main wardrobe closet handle for closet A, missing main closet handle for closet B, missing top wardrobe closet knob for closet C, missing main wardrobe closet handle, and missing top wardrobe closet knob for closet D and broken baseboard were observed in room [ROOM NUMBER]. On 3/29/22 at 12:27 PM, missing top left wardrobe closet door for closet B was observed in room [ROOM NUMBER]B. The Maintenance Logbook on Unit 2 contained no documentation regarding missing wardrobe closet knob and handle, broken baseboard, broken wardrobe closet door in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. On 3/29/22 at 10:34 AM, Certified Nursing Assistant (CNA #1) was interviewed. CNA #1 stated that if there are any issues with furniture or equipment in resident's rooms, they inform charge nurse on duty and write it down in the Maintenance logbook. CNA #1 also stated a verbal report was made to Maintenance staff regarding the broken wardrobe drawer for room [ROOM NUMBER]A. CNA #1 further stated that they did not notice missing knobs/handles in room [ROOM NUMBER] and room [ROOM NUMBER]. On 3/30/22 at 10:05 AM, Certified Nursing Assistant (CNA #2) was interviewed. CNA #2 stated that they noticed the closet B wardrobe door missing in room [ROOM NUMBER]B when they returned to work after having a day off. CNA #2 also stated they reported verbally to Maintenance staff about a week and half ago. CNA #2 further stated they did not report it to a nurse nor logged the issue in the Maintenance logbook. On 3/30/22 at 10:24 AM, Registered Nurse (RN #1) was interviewed. RN #1 stated that if staff notices any broken furniture or equipment in the resident's room, staff is to notify charge nurse and document in the Maintenance logbook located in the nursing station. Charge nurse will submit work order electronically via TELS. On 03/23/22 at 11:00 AM, in room [ROOM NUMBER]B, Radiator cover was noted rusted, the top panel observed with dirty, red and brown stains, peeling paints noted on the walls by the window. On 03/23/22 at 11:15 AM, in room [ROOM NUMBER]B, wall by the window was observed with peeling paints, Radiator cover rusted, top panel noted with brown stains. Resident's nightstand observed with broken handle. On 03/23/22 at 11:33 AM, in room [ROOM NUMBER]A, Mismatch paints observed on right side of the wall, widow frame rusted, and radiator cover noted with brownish stains on top. The Unit Maintenance Work Order started on 2/28/21 was reviewed, the last date a report was documented is 11/29/2021. There is no documented evidence of the above identified concerns in the book. On 03/28/22 at 03:46 PM, an interview was conducted with the Licensed Practical Nurse, LPN #2. The LPN stated that there is an electronic system that staff can report any issue or repair to be carried out on the unit, which is not in use at present, the staff are currently using the paper documentation - Maintenance Work Order to report any repairs to be carried out by the housekeeping/maintenance staff. LPN #2 stated that they are not sure if the identified concerns have been reported in the book, but the stains on top of radiators' covers are supposed to have been seen and cleaned up by the housekeeping, and the peeling paint is supposed to be done by the maintenance. LPN #2 further stated that the facility has just started some renovation works on the unit, with replacement of the new handrails by the hallways. On 03/29/22 at 08:52 AM, an interview was conducted with the Housekeeping [NAME], (HP#1). HP #1 stated that every room is cleaned every morning, garbage picked up in the rooms, and the floor mopped daily. HP #1 stated that if any floor or wall is noted to need repair or to be repainted, it is reported to the maintenance, and sometimes it is documented in the book for the maintenance to check and carry out the necessary repair. HP #1 further stated that they did not work on Monday and has not noticed the dirty spots on the radiator cover that needed to be cleaned. On 03/29/22 at 12:04 PM, an interview was conducted with the Assistant Director of Nursing, ADON. ADON stated that any issue or concern to be repaired or fixed is logged in to the computer, or in the Maintenance Book on the unit, the Maintenance Staff checks daily and assigns the job to their staff to be carried out. ADON stated that they are not aware of the concerns identified by the surveyor but will let the maintenance know immediately to get them fixed. On 03/29/22 at 04:01 PM, an interview was conducted with the Director of Facility Operations, (DFO). DFO stated there is one (1) housekeeping staff during day tour assigned on each unit, and 2 staff assigned on the evening tour to cover the entire units to ensure that residents' areas are properly cleaned and maintained. The DFO also stated that a computer is placed by every unit nursing station installed with a program called TELS-Direct Supply. All nursing staff have been trained on how to add work order in the computer if they noticed any work to be done, and a Maintenance Book on each unit to log in a work order if anything is to be fixed on the unit. A maintenance staff goes round every day to check the maintenance book if anything is documented, for the maintenance to fix. The computer is checked daily to see any work order generated and assign the work to the maintenance staff to carry out. The DFO further stated that rounds are personally made daily to check if there is an issue and get it fixed right away. The DFO stated that they have not been made aware of the identified concerns but they will be addressed immediately. The DFO further stated that they are aware that there are a number of issues in the building but they have been having dificulty retaining maintenance staff. 415.5(h)(2) Based on observations, record reviews and interviews during the Recertification survey conducted from 3/23/22 to 3/30/22, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, broken heating unit, dirty windowsill, rusted radiator cover/vent unit, dusty and corroded window frame, missing wardrobe closet drawer and door, missing wardrobe closet handles/knobs/door, unpainted and peeling wall paints were observed in resident's rooms, hallways, and the common areas. This was evident in multiple area on 4 of 5 units (Units 6, 2, 5 and 4). The findings are: The facility policy and procedure titled Terminal Housekeeping Cleaning - Sanitizing and Disinfecting dated 3/20 documented it is facility's responsibility to maintain a hygienically clean environment by routine cleaning and infection control practice. It further documented that minor repair by maintenance worker will be completed. During observations of the environment conducted on Unit 6 on 3/23/2022 from 2:17 PM to 2: 43 PM and on 3/25/2022 at 3:33 PM, the following was observed: -room [ROOM NUMBER] was noted with a very loud sound emanating from the radiator. In addition, peeling wall paper was observed near the window sill. -room [ROOM NUMBER], several unpainted areas were noted on the wall around the resident's closet. -room [ROOM NUMBER] window sill was observed with dirt and several unpainted areas. -The window sill in the hallway by the fire door, west side, and the hallway walls were noted with unpainted areas. On 3/29/2022 at 12:38 PM, Housekeeping [NAME] (HP) # 1was interviewed. HP #1 stated that their mission is to keep the rooms cleaned. HP #1 further stated that they understand that there are areas of concern but they are not on the floor every day, but when on the floor they make sure they do a good job.