**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a Recertification and Complaint survey (NY00347992) from 11/13/2024 to 11/20/2024 the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident for 1 (Resident #177) of 1 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, a Nurse's Progress Note dated 07/05/2024 documented that Resident #177 was noted with a bruise on their nose and the charge nurse and supervisor were informed, however family was not informed about the bruise until 3 days later on 07/08/2024. The findings are: The facility policy titled Notification of Changes for Residents revised 03/04/2024 documented that the facility shall promptly notify the resident and/or designated representative and physician of changes in the resident's condition in order to obtain orders for appropriate treatment and monitoring, promote resident's right to make choices about treatment and care preferences and to keep resident and designated representative informed. Resident #177 was admitted to the facility with diagnoses including Hypertension, Anxiety Disorder, and Diabetes Mellitus. On 11/15/2024 at 1:12 PM, Resident #177's Representative was interviewed and stated that they were not informed of the bruise to Resident #177's nose until days after it occurred. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #177 had moderately impaired cognition. A Nurse's Progress Note dated 07/05/2024 documented Resident #177 was noted with bruising to their nose and the Charge nurse and supervisor were informed immediately. A Medical Doctor's Note dated 07/05/2024 documented Resident #177 was seen for follow up for ecchymosis on their nose. Resident #177 denied any recent fall but was unable to say how the bruise occurred. X-ray ordered. No other concerns from the staff. Medications were reviewed and deemed appropriate. A Nurse's Note dated 07/08/2024 documented Resident #177 denied pain and skin was intact with superficial redness. The Physician Assistant was notified on the findings for verbal order of a facial bone x-ray. Resident #177's family were updated. There was no documented evidence that Resident #177's representative was notified on 07/05/2024 when the bruise on nose was first observed. During an interview on 11/19/20224 at 12:29 PM, Registered Nurse Supervisor #2 stated that the redness on Resident #177's nose was observed on 07/05/2024 and they called the family and notified them but did not document this in Resident #177's chart. Registered Nurse Supervisor #2 also stated that on 07/08/2024 they spoke to Resident #177's family to follow up and update them on the facility's investigation for the redness to the resident's nose. During an interview on 11/19/2024 at 11:47 AM, the Assistant Director of Nursing stated they did not report the discoloration to the family and that the nurse who discovered the discoloration reported to the family the same day. The Assistant Director of Nursing also stated that they met with the family after they conducted their investigation to update them on the conclusion. 10 NYCRR 415.3(f)(2)(ii)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #76) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required. The findings are: The facility policy titled Serving of Notice of Medicare Non-Coverage and Advanced Beneficiary Notice revised 10/30/2024, documented that it is the policy of this facility to serve Advance Beneficiary Notice and Notice of Non-Medicare Coverage within 48 hours before providing a service that Medicare will likely to deny coverage. Resident #76 was discharged from Medicare Part A services on 08/22/2024 with 71 days remaining. The Notice of Medicare Non-Coverage form documented that skilled services would end on August 22, 2024. The notice was signed by Resident #76 and dated 8-21-24. Review of medical record revealed no documentation that Resident #76 had requested discharge from the nursing home prior to notification being given that skilled services would be ending. A Nursing progress note dated 08/23/2024 documented Resident #76 was discharged home. During an interview on 11/20/2024 at 10:43 AM, the Minimum Data Set Assessor stated that the beneficiary notification letter should be submitted 2 days before the end of service to allow residents the right to appeal the decision. The Minimum Data Set Assessor also stated that they did not know why Resident #76 was given their notice only one day before discharge from skilled services. During an interview on 11/20/2024 at 10:56 AM, the Minimum Data Set Director stated the beneficiary form should be served within 48 hours to give the resident the opportunity to appeal the decision. The Minimum Data Set Director also stated a utilization review meeting was held with Resident #76 on 08/21/2024 at which time Resident #76 requested to be discharged from the facility. The Minimum Data Set Director further stated that the discussion at the meeting was not documented in Resident #76's chart, and Resident #76 was discharged home on [DATE]. 10 NYCRR 415.3(g)(2)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification conducted from 11/13/2024 to 11/20/2024, the facility did not ensure a person-centered Comprehensive Care Plan was developed and implemented to address the resident's needs. This was evident for 1 (Resident #150) of 5 residents reviewed for Unnecessary Medication out of 38 total sampled residents. Specifically, a Comprehensive Care Plan related to Resident #150's use of anticoagulant medication was not developed and implemented. The findings are: The facility policy on Comprehensive Care Plan effective on 1/2020 and last reviewed 6/2024 documented the interdisciplinary team will utilize the Comprehensive Person-Centered Care Planning process to address resident strengths, needs and or problems as identified on the admission discharge summary as well as other professional assessment and orders from the physician, dietary team, therapy, social services and PASARR and MDS. The policy also documented that a Person-Centered Care Plan is developed to include information necessary to properly care for the resident and will address the resident's preferences, goals, desired outcomes, and plan for discharge. Resident #150 was admitted with diagnoses that included Unspecified Atrial Fibrillation, Cerebrovascular Accident, and Heart Failure. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #150 had severely cognitive impairment and required maximal assistance to complete activities of daily living. Section N of the Minimum Data Set assessment also documented that Resident #150 was taking an anticoagulant. On 11/13/24 at 03:06 PM, Resident #150 was observed sitting in a wheelchair wearing medium length pants and was observed with scattered bluish skin discoloration on both lower legs. On 11/14/24 at 09:21 AM, Resident #150 was observed in bed with scattered light bluish discoloration on both lower legs. The Physician order initiated on 01/06/2023 and renewed on 11/15/2024 documented that Resident #120 was prescribed Eliquis 2.5 mg tablet by oral route two times per day. There was no evidence a Comprehensive Care Plan for anticoagulant medication use was developed and implemented. On 11/15/24 at 09:34 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #150 was observed at times with reddish discoloration in their legs, but the skin was not broken, and the discoloration disappears. Certified Nursing Assistant #2 also stated that Resident #150 had not complained of any pain nor discomfort. On 11/15/24 at 10:04 AM Registered Nurse #1 was interviewed and stated that they are responsible for doing care plans. Registered Nurse #1 also stated that Resident #150 had been receiving anticoagulant medication and it was an oversight that a care plan for anticoagulant medication use was not developed. On 11/20/24 at 10:10 AM, the Director of Nursing was interviewed and stated that the Registered Nurses on the unit initiate care plans and update them as necessary. The Director of Nursing also stated that they were not aware that a care plan for Resident #150's anticoagulant medication use was not developed. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility policy and procedure titled Pain Management reviewed 1/10/2024 documented that the nurse will initiate a care plan for pain and will collaborate with the health care team to revise the current care plan as needed. The Interdisciplinary Care Team will review and revise plan of care for pain with input of resident, designated representative at care planning meetings. Resident #145 was admitted to the facility with diagnoses which included Renal Osteodystrophy, Low Back Pain Unspecified, and End Stage Renal Disease. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #145 had intact cognition, required supervision to partial/moderate assistance with activity of daily living, and received scheduled and as needed pain medication. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #145 was had intact cognition, was independent and required supervision with activity of daily living and received scheduled pain medication. The Physician's orders dated 8/12/2024 documented Resident #145 was prescribed Oxycodone 5 mg 1 tablet every 8 hours as needed for low back pain, and on 8/23/2024 Lidocaine patch relief 4 percent topical patch (apply 1 patch daily to lower back and remove at bedtime for pain unspecified) and Icy hot max hydrochloride menthol 4 percent - 1 percent topical cream (apply topically 3 times a week to left upper AVF for pain unspecified were added. There was no documented evidence that Resident #145's comprehensive care plans related to Pain was reviewed or revised after the Minimum Data Set assessments were completed on 6/25/2024 and 9/25/2024. The pain scale for Resident #145 from 8/30/2024 to 11/19/2024 documented pain level of 0-6 range and sites of pain documented included back and headache. The Medication Administration Records were reviewed from June 2024 to November 2024 and Resident #145 was prescribed the following pain medication acetaminophen 325 milligram 2 tablets administer 30 minutes before dressing change, 2 orally every 6 hours as needed for low back pain unspecified. Oxycodone 5 milligram tablet (give 1 tablet every 12 hours as needed for low back pain unspecified or 1 tablet every 8 hours as needed for low back pain unspecified, cyclobenzaprine 10 milligram tablet - 1 tablet twice a day for muscle spasms of back, Lidocaine 4 percent topical patch once daily to lower back, remove at bedtime for pain unspecified. On 11/13/24 at 02:46 PM, Resident #145 was interviewed and state that they have pain in both legs which started 2 months ago, and they get pain meds when they are in their wheelchair. Resident #145 also stated that they are on pain medications which include Tylenol and oxycodone. On 11/20/2024 at 01:10 PM, Licensed Practical Nurse #2 was interviewed and stated Resident #145 gets Tylenol for low back pain or knee pain and a patch on their back and oxycodone was discontinued. On 11/20/2024 at 01:20 PM, Registered Nurse Supervisor #2 was interviewed and stated that they forgot to activate Resident #145's care plan for pain. Resident #145 receives Tylenol before dressing changes, gets icy hot patch, and oxycodone was discontinued because Resident #145 was not taking it. Registered Nurse Supervisor #2 further stated that Resident #145 was readmitted in August 2024 after hospitalization, and they did not activate Resident #145's pain care plan after readmission, and this was an oversight. Registered Nurse Supervisor #2 stated that they did attend the last care planning meeting for Resident #145, and they missed activating the resident's pain care plan. On 11/20/2024 at 01:29 PM, the Director of Nursing was interviewed and stated that they do rounds in the morning and 12 PM and 3-11 shift comes in. The Director of Nursing stated that they do check care plans for new admissions, and they contact staff and let them know care plans are due and need to be updated. 10 NYCRR 415.11(c)(2)(i-iii) Based on record review and interview conducted during the Recertification survey between 11/13/2024 and 11/20/2024, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for 1 (Resident #109) of 5 resident reviewed for Unnecessary Medications and 1 (Resident #145) of 3 Residents reviewed for Pain Management out of 38 sampled residents. Specifically, 1) the Comprehensive Care Plan for Psychotropic Medications were not updated and revised for Resident #109, and 2). the Comprehensive Care Plan for Pain Management was not reviewed and revised for Resident #145. The findings are: The facility policy and procedure titled Care Plan dated 01/2020, last revised 06/2024, documented that the Comprehensive Person-Centered Care Plan will be periodically reviewed and revised by a team of qualified persons after each assessment. The policy also documented that the Comprehensive Person-Centered Care plan will be reviewed and revised quarterly following Minimum Data Set completion, at the time of hospital readmission to ensure that the plan reflects the resident current status. The Comprehensive Person-Centered Care plan will be kept current by all disciplines on an ongoing basis. 1. Resident #109 was admitted to the facility with diagnoses that included Anxiety Disorder, Depression and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #109 had severely impaired cognition and was receiving Antianxiety and Antidepressant medications. The Physician's order dated 11/09/2024 documented that Resident #109 was to receive Alprazolam 0.5 mg tablet by oral route every 12 hours for adjustment disorder with anxiety (started 7/2/24), and Sertraline 50 mg tablet by oral route once daily for Major depressive disorder, recurrent. The Comprehensive Care Plan titled Psychotropic Drug Use: Anxiety dated 08/03/2023 last updated 3/26/2024 documented that resident has potential for adverse drug reaction/side effects, with the goals that Resident will remain free of accidents. Interventions included observe for any signs of decline in function or cognitive status, monitor for changes in behavior and mood, evaluate for dose adjustment or reduction. The Comprehensive Care Plan titled Psychotropic Drug Use: Depression dated 08/09/2023 last updated 4/01/2024 documented that Resident is on an antidepressant related to diagnosis of Depression, with the goals that Resident will have reduced incidents of mood or behavior change. Interventions included assess behavioral pattern daily, assess effectiveness of medication, assess need for psychotherapeutic medication, and monitor for increased signs and symptoms of Depression with medication change such as change in sleep pattern, change in appetite, suicidal ideations, etc. The Quarterly Minimum Data Set Assessments were completed on 07/05/2024 and 09/30/2024. There was no documented evidence that the care plans were reviewed and revised after each assessment. On 11/18/24 at 02:15 PM, an interview was conducted with Registered Nurse Supervisor #1 who stated that a resident's care plan is initiated by the Registered Nurse Supervisor upon admission or re-admission. Registered Nurse Supervisor #1 also stated they review the resident's chart during quarterly, significant change and annual assessment meetings to ensure that all care plans are in place and up to date. Registered Nurse Supervisor #1 further stated that they were on vacation when Resident #109 was re-admitted , and the Registered Nurse Supervisor that admitted the resident did not reactivate the care plan when Resident #109 was re-admitted on [DATE]. Registered Nurse Supervisor #1 stated that the interdisciplinary team members also missed updating Resident #109's care plans during the quarterly assessment review period in October 2024. On 11/19/24 at 08:22 AM, the Director of Nursing was interviewed and stated that the Registered Nurse Supervisors are responsible for initiating, review and updating residents' care plans. The Director of Nursing also stated that they have interdisciplinary team meetings every morning to check that all the care plans for the new admissions are in place, and to make sure that all necessary care plans are reviewed and updated during quarterly assessments. The Corporate Director and the Minimum Data Set Director are also involved in reviewing residents' care plans to see that everything is done and up to date. The Director of Nursing further stated that the Registered Nurse Supervisor that admitted the resident omitted the initiation of Resident #109's Psychotropic medications, and it was unfortunate that none of the team members were able to catch the omission during the chart review conducted for Resident 109's quarterly assessments. On 11/19/24 at 09:07 AM, the Minimum Data Set Director was interviewed and stated that if the resident is newly admitted , the admission Registered Nurse will initiate the care plan, and the unit Registered Nurse Supervisor will review resident's chart to check for any missing care plans, or care plans that needed to be updated during the assessment review. The Minimum Data Set Director also stated that their department does not usually check the resident's care plans for omission or update during the quarterly review assessment periods, and they did not know if any of Resident #109's care plans were missing or needed to be updated.

2. An observation of the medication cart on the 3rd floor on 11/19/2024 at 10:59 AM, revealed a vial of Levemir dated as opened on 10/17/2024. In addition, Insulin Lispro, Lantus pens and Basaglar were observed opened. There were no dates of when the medication was opened on the label of the medication itself. Items were contained in individual Ziplock bags which had dates on them with the exception of Basaglar which had no date on the bag or medication label. A vial of Vyzulta 0.024% eye drops was also observed opened but there was no open date on the medication label. During an interview on 11/19/2024 at 10:59 AM, Licensed Practical Nurse #5 stated every nurse is responsible for checking the medication cart. Licensed Practical Nurse #5 also stated that they did not date the medications because the bag it was in was dated. Licensed Practical Nurse #5 further stated that insulin and eye drops are discarded after 30 day, but they could not explain why the insulins were not dated. During an interview on 11/19/2024 at 11:23 AM, Registered Nurse #2 stated that after pharmacy delivers medication, they only label the box and educate staff to place medication in the respective box after use. Registered Nurse #2 stated moving forward, they will label the medication in the event the box is lost. Registered Nurse #2 stated all the nurses are responsible for discarding expired medication and they do random checks on the cart to ensure that the medication and insulin are labeled. During an interview on 11/20/2024 at 12:28 PM, the Assistant Director of Nursing stated staff are educated that expired medication should not be in the refrigerator, medication cart and/or unit. The Assistant Director of Nursing also stated that the labeling of medication should be done as soon as they are opened. The Assistant Director of Nursing further stated that the box the medication are kept in should be labeled and if the box is missing the medication should be discarded. 10 NYCRR 415.18(e)(1-4) Based on observation, interview, and record review conducted during the recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure drugs and biologicals were labeled in accordance with professional standards of practice. This was evident on 2 (Unit 5 and Unit 3) of 8 resident units. Specifically, 1). an opened and undated individual vial of insulin and eye drops was observed on the medication cart in the 5th Floor medication cart, and 2). A vial of insulin was not discarded 28 days after opening and open vials of insulin and a vial of eye drops did not contain dates of when the medication was opened on the label was observed on one of the 3rd Floor medication cart. This was evident for the Medication Storage and Labeling task. The findings are: The facility policy and procedure titled Medication Storage effective 1/10/2024 documented medications must be stored in accordance with manufacturer specifications and secured in locked areas in compliance with State and Federal requirements and accepted professional standards of practice. Storage areas may include, but not limited to drawers, cabinet, medication rooms, refrigerators, and carts. 1. On 11/15/2024 between 2:26 PM and 2:55 PM, the 5th Floor medication room and medication cart were observed. An Insulin Lispro vial, an Admelog Lantus Solostar pen, and a bottle of Brimonidine/Timolol Solution 0.2/0.5% eye drops were observed opened, and there was no date on the medication label. Dates were observed on the bags that the medications were contained in. During an interview on 11/15/2024 at 2:41 PM, Registered Nurse #3 was interviewed and stated that they are a floating staff, and they have to check the chart every week and they do it 2 to 3 times a week. Registered Nurse #3 also stated that they checked the cart before they started this morning, and all the medications were there, and they focused on the outside plastic bag that the medication was in. Once they saw the label inside, and it matched the medication, they did not look to see if the medication itself had the opened date on it. During an interview on 11/15/2024 at 3:08 PM, Registered Nurse Supervisor #2 stated they checked the medication carts daily for expired medications to include eye drops. Registered Nurse Supervisor #2 also stated that the pharmacy comes to check and did not tell them that they had to label the outside of the medications. Registered Nurse Supervisor #2 further stated that the insulin vials should be labeled and the last time they checked the insulin with the charge nurse was yesterday. Registered Nurse Supervisor #2 stated that they were instructed to look at the expiration date, when the insulin is opened and that it is labeled for the resident they are using it for.

Based on observations, record review, and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure menus were followed. This was evident for 4 residents (Resident # 70, Resident # 77, Resident #156, and Resident #201) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes. The findings include: The policy and procedure titled Food Preferences effective 8/14/2024 documented information will be gathered upon admission to obtain residents preferences, allergies, intolerances, cultural preferences, and diet history. Food preferences will be updated periodically as needed or upon reassessment. Menus are provided as per resident request for meal selections. The policy and procedure titled Dining Room Service reviewed on 8/21/2024 documented that staff should check the residents name and diet on the meal ticket to verify that the meal is served to the correct resident and check items on the plate/tray to assure accuracy for food preferences and for the therapeutic or modified consistency diets. 1. Resident #70 had diagnoses which included Chronic Obstructive Pulmonary Disorder and Parkinson's disease. The Quarterly Minimum Data Set 3.0 dated 9/25/2024 documented Resident #70 was cognitively intact. On 11/18/2024 at 12:42 PM, Resident #70 lunch tray was observed and contained regular French fries, veggie burger, soup, coleslaw, and milk. The tray ticket listed sweet potato fries, veggie burger, coleslaw, milk, soup, cookie. There was no cookie or sweet potato fries on Resident #70's tray. On 11/18/2024 at 12:45 PM, Resident #70 stated that they do not like sweet potato fries and sometimes they do not get any dessert and they like some desserts such as peaches, pears, applesauce, chocolate pudding and cookies. 2. Resident #77 had diagnoses which included Hyperlipidemia, Malnutrition, and Dementia. The Minimum Data Set Assessment 3.0 dated 09/19/2024 documented Resident #77 was moderately impaired cognition. On 11/14/2024 at 12:50 PM -12:58 PM lunch was observed on the 5th floor. Resident #77 was served a tray which contained carrots, steak, mashed potato, soup. The ticket on the tray listed 4-ounce applesauce, 6-ounce cream of potato soup, 5-ounce Salisbury steak with mushroom and onion gravy, 1/2 cup broccoli and 4-ounce milk. Resident #77 did not receive the 1/2 cup of broccoli on their tray and no changes were noted on their tray ticket. On 11/14/2024 at 12:54 PM, Resident #77 stated that they like broccoli a little bit. 3. Resident #156 had diagnoses of Anemia, Deficiency of other vitamins and Hyperlipidemia. The Quarterly Minimum Data Set 3.0 dated 9/29/2024 documented Resident #156 was moderately impaired cognition. On 11/14/2024 at 12:50 PM -12:58 PM lunch was observed on the 5th floor. Resident #156 was served a tray which contained mashed potato, cream of potato soup, applesauce, carrots, 4 ounces whole milk. The ticket on the tray listed 4 ounces applesauce, 6-ounce cream of potato soup, 5-ounce Salisbury steak with mushroom and onion gravy, 1/2 cup of broccoli and 4-ounce milk. Resident #156 received carrots and mashed potato which were not on their tray ticket and did not receive 1/2 cup of broccoli as listed. There were no changes made to the Resident #156's tray ticket for the substitution on their tray. On 11/18/2024 from 12:55 -1:01 PM, lunch was observed on the 5th floor. Resident #156 was served a tray which contained breaded fish, soup, Jello, mashed sweet potato, cookie. The ticket on the tray listed 2 chocolate chip cookies, 6-ounce regular cream of carrot soup, 4-ounce fried fish, 4-ounce coleslaw, 4-ounce milk, coffee, and sweet potato fries. Resident #156 was not served sweet potato fries on their tray and no menu changes were noted on Resident #156's tray ticket. On 11/18/2024 at 12:53 PM, Resident #156 was asked if they liked sweet potato fries, but they did not respond to surveyor when asked. 4. Resident #201 was admitted to the facility with diagnoses that included Hypertension, Diabetes Mellitus and Dementia. The Minimum Data Set Assessment documented that Resident #201 had short- and long-term memory impairment and had moderately impaired skills for decision-making. On 11/18/2024 at 12:52 PM, Resident #201 was served a tray that contained regular fries, mixed vegetables, fried fish, cookie, and soup. The ticket on the tray listed 2 chocolate chip cookies, 6 ounces of cream of carrot soup, 4 ounces of fried fish, 4 ounces of soft carrots, 4 ounces sweet potato fries, 8 ounces soy milk, 6-ounce hot water. Resident #201 was served mixed vegetables and regular potato fries which were not on their tray ticket, and no menu changes were noted on Resident #201's tray ticket. On 11/18/2024 at 12:54 PM, Resident #201 was asked if they liked sweet potato fries but continued to eat their lunch and did not respond to the surveyor. On 11/18/2024 at 01:01 PM, Registered Nurse Supervisor #2 was interviewed and stated that they look at the resident's trays when they arrive on the unit along with the Certified Nursing assistants before they are given to the residents. Registered Nurse Supervisor #2 also stated that they were not informed of a menu change and all residents got regular French fries and mixed vegetables instead of sweet potato fries and carrots on their tray ticket today and they will contact the dietitian. On 11/18/2024 at 2:54 PM, an interview was conducted with Dietitian #1 who stated they did tray audits on the 7th floor today and they did not notice anything different about the trays. Dietitian #1 also stated that if a substitution is made, the residents tray ticket would be updated, and there were no menu substitutions made that they are aware of. On 11/18/2024 at 02:59 PM, an interview was conducted with the Registered Dietitian who stated that they did not do any tray audits. If a substitution is done, an alternate food is offered, and they call the kitchen to have the item sent to the unit. The Registered Dietitian also stated that the residents should have received the food items that were on their tray tickets. On 11/18/2024 at 3:26 PM, an interview was conducted with the Director of Nutrition who stated today they did not have enough carrot, so they gave zucchini. The kitchen will substitute with something they have for renal or other diets, and most of the time they inform them of any substitutions are made. If they speak to the food service supervisor, they will let the Director of Nutrition know if they ran out of a food item. The Director of Nutrition also stated that the dietitian would be notified by phone of any changes and would inform the other dietician of the change. The Director of Nutrition further stated that they were informed that another vegetable would be used since they did not have enough carrots, and the Food Service Supervisor would usually cross out the food item and write the substitute item on the ticket. The Director of Nutrition also stated that if they know in advance, they will let the residents know and if they are doing meal rounds at the time they will let the residents know of the substitutions. On 11/19/2024 at 3:16 PM. an interview was conducted with the Food Service Supervisor who stated that the only substitution they are aware of is salad for vegetable item and there is no other food substitution they are aware of. The Food Service Supervisor also stated that they ran out of sweet potato fries, and they used mashed sweet potato instead, and the units were notified yesterday. The floor to be served was the 5th floor and residents there received sweet potato and regular fries. The Food Service Supervisor stated that the Director of Food Services and the manager make sure the trays are correct. On 11/20/2024 at 11:08 AM, an interview was conducted with the Director of Food Services who stated that they made a minor change to the menu. If a delivery does not come in, and there is not enough food they reach out to the dietitian. The Director of Food Services also stated that they are always on the unit and let residents know of any changes. The Director of Food Services further stated that there was only one change earlier in the week with carrots and mixed vegetables as there was not enough to give residents a compete serving so they informed the dietitian and changed the vegetable to Capri blend. The tray line checkers check the tray tickets for residents with concerns they will ensure when the residents tray comes by that the ticket on the tray is checked and signed off by the kitchen, so they receive everything they are supposed to get. The Director of Food Services stated they would try to locate communication between themselves and the Dietitian in relation to menu changes and no copy of the communication was provided at the time of the survey exit. 10 NYCRR 415.14(c)(1-3)

3. On 11/13/2024 at 10:28 AM, 11/14/2024 at 10:45AM and 11/15/2024 at 10: 20AM, the following were observed on the 4th floor: a. Center hallway window sills with chipped unpainted areas. b. Cement walls near the center hallway windows with mismatched paint. c. Heating system near the center hallway with dirty and dusty top, dried foods and small paper remnants observed on top of heating system. d. Center hallway floor with ripped broken tiles On 11/15/24 at 11:02 AM, the Director of Housekeeping was interviewed and stated that the heating system was dusty and dirty, and they would coordinate with the Maintenance staff to clean the heating system. On 11/15/24 at 11:27 AM, the Director of Maintenance was interviewed and stated they were working on painting walls but unfortunately had missed those areas in the window sills and will paint them immediately and will repair broken floor tiles. On 11/20/24 at 10:52 AM, the Administrator was interviewed and stated the Housekeeping and Maintenance staff are working to fix the unpainted walls, to clean the heating system and repair broken floor tiles. The Administrator also stated Housekeeping and Maintenance staff do make frequent rounds and check all areas that needs attention and do repairs, and those findings were maybe an oversight. 10 NYCRR 415.5(h)(2) 2. During observations made from 11/13/2024 at 3:10PM through 11/19/2024 at 12:28 PM, the following was observed on the 5th Floor Unit: a. on 11/13/2024 at 3:10 PM, 11/15/2024 at 09:48 AM, 11/18/2024 at 09:52 AM, 11/18/2024 at 01:10 PM, 11/18/2024 and 11/15/2024 at 03:21 PM, Resident #87 was observed sitting in a wheelchair which was observed with white colored stains on the wheels metal frame, brown colored debris on wheels and on wheelchair locks and white colored stains on the arm rest area. b. on 11/14/24 at 04:31 PM to 11/14/24 at 04:37 PM, 11/18/2024 at 10:05 AM and 11/18/2024 at 11:44 AM, in the 5th Floor Dining Room multiple wheelchairs for residents (Resident #47, #160, #68, #25, #121) were noted with white, cream, or brown colored debris on the wheel metal frame, grimy brown colored stained wheel locks and wheelchair frames on the bottom area. Resident #25's wheelchair was also noted with duct tape attached to the connector area of wheelchair. c. on 11/19/2024 from 10:46 AM to 12:28 PM, and 11/19/2024 from 03:08 PM to 03:11 PM multiple resident wheelchairs (Resident # 121, 77, 47, 60, 162, 25, 201) were noted with white colored debris on wheel wells, brown colored debris on bottom rails (frame) for wheelchairs, dusty locking mechanisms for wheelchair. On 11/19/2024 at 05:00 PM, Certified Nursing Assistant #9 was interviewed and stated that they look at the wheelchairs for their residents to make sure that the wheelchair is clean, and sometimes they report to the housekeeper and put in to have the wheelchair cleaned. Certified Nursing Assistant #9 also stated that they cannot recall the last time the wheelchair for Resident # 87 was cleaned. On 11/19/2024 at 05:02 PM, Certified Nursing Assistant #10 was interviewed and stated there are many residents who use wheelchairs on this unit, and they make sure the wheelchairs are in good condition and clean. Certified Nursing Assistant #10 also stated that there are residents who are confused on the unit, and they may eat and throw food and the wheelchairs get dirty. Certified Nursing Assistant #10 further stated that the wheelchairs are cleaned at night and were cleaned this month. When the wheelchairs are to be cleaned, they are informed by the supervisor and the chairs would be endorsed to the 11PM -7AM shift for cleaning. On 11/19/2024 at 05:06 PM, Certified Nursing Assistant #11 was interviewed and stated they look at the wheelchairs before use to make sure they are in good condition, can lock properly and are not damaged. Certified Nursing Assistant #11 also stated that they make sure the chair is clean with no fecal matter or vomit on it. Certified Nursing Assistant #11 further stated that the 3 PM-11PM shift staff clean the wheelchairs, and they usually clean them at night. On 11/19/2024 at 05:11 PM, Licensed Practical Nurse #5 was interviewed and stated that they looked at the resident's wheelchairs last Wednesday and they noticed that they were dusty. Licensed Practical Nurse #5 also stated that they used to use bleach wipes to wipe the wheelchair and the Certified Nursing Assistants clean the wheelchairs. On 11/19/2024 at 05:17 PM, Registered Nurse Supervisor #2 was interviewed and stated that the wheelchairs are washed once a week, and they are not sure the last time it was done. Registered Nurse Supervisor #2 also stated that they saw the wheelchairs this morning and they let the Director of Housekeeping/Housekeeping supervisor know that they needed to be cleaned. On 11/19/2024 at 05:32 PM, Housekeeper #2 was interviewed and stated there is a special person assigned to clean the wheelchairs at night at 11 PM and there is no cleaning of wheelchairs done on the 3 PM-11PM shift. On 11/19/2024 at 05:36 PM, Housekeeper #3 was interviewed and stated that they report to the supervisor when wheelchair need to be cleaned. Housekeeper #3 also stated that they are not sure when last time the wheelchairs were cleaned but the last time Housekeeper #3 cleaned wheelchairs was in early October 2024. Housekeeper #3 further stated that there is no schedule for cleaning wheelchair. On 11/19/2024 at 05:39 PM, the Director of Housekeeping was interviewed and stated the dirty wheelchairs was reported to them. The Director of Housekeeping also stated the wheelchairs were cleaned last week Tuesday. The Director of Housekeeping further stated that they check to make sure wheelchairs are cleaned correctly when they make rounds. The Director of Housekeeping stated that currently there is no cleaning schedule for wheelchairs. Based on observations, interviews, and record review conducted during the recertification survey from on 11/13/24 to 11/20/24, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 3 (Unit 8, Unit 5, and Unit 4) of 9 resident units. Specifically, Unit 8 and Unit 5 were observed with multiple wheelchairs embedded and heavily layered with dirt and debris and Unit 4 was observed with dirty, dusty heating system. The facility policy and procedure titled Resident Environment dated 01/02/2023 documented that it is the policy of the facility to provide a safe clean comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The findings are: 1. On 11/13/24 at 10:37 AM, and on 11/14/24 at 11:54 AM, the following was observed in the 8th floor Dining Room Area: a. Resident #19 was observed sitting in a high back wheel chair, with metal wheelchair frame and spokes layered with encrusted dirt, debris, and dried food particles. b. Resident #135 was observed sitting in a recliner chair and the base and bottom frame was noted with brownish encrusted residue. c. Resident #193 was observed in a high back wheelchair with dirt and dust and layered with encrusted dried food particles. d. Resident #83 was observed sitting in a wheelchair and the wheelchair spokes and metal frames were encrusted and layered with dirt, debris, and dried food particles. On 11/20/24 at 11:46 AM, the Director of Housekeeping Services was interviewed and stated that they are newly hired and are currently restructuring the work assignment for staff. The Director of Housekeeping Services also stated that staff are updated on a daily basis during daily huddles, and wheelchairs are cleaned, and power washed in the lower level area of the building by one night shift housekeeper whose shift is from 11:00 PM to 7:00 AM shift. the Director of Housekeeping Services further stated that they have noticed during their daily environmental rounds that they needed to also direct their attention to wheelchair cleaning and is working on a daily wheelchair cleaning schedule to ensure that residents equipment is clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility policy and procedure titled Medication Administration and Documentation revised 01/02/2024, stated that it is the policy of this facility that infection control protocols be maintained at all times. The policy further stated that the licensed nurse should wash their hands at the beginning of medication pass and in between each resident, using soap and water or alcohol-based cleanser. The facility policy and procedure titled Handwashing revised 09/16/2024, stated that is the policy of this facility that employees wash their hands as frequently as needed throughout the day using proper hand washing procedures. The policy further stated to wash hands before donning disposable gloves. The facility policy and procedure titled Infection Prevention and Control program revised 12/2023, stated that staff should use appropriate hand hygiene prior to and after procedure and ensure that re-usable equipment is appropriately cleaned and disinfected. On 11/14/2024 at 9:14 AM, Licensed Practical Nurse #3 was observed using the blood pressure machine on Resident #199 and then applied the blood pressure cuff on Resident #276 at 9:30 AM. Licensed Practical Nurse #3 was not observed cleaning the blood pressure cuff between residents. On 11/14/2024 at 5:00 PM, Registered Nurse #4 was observed cleaning the blood pressure machine and cuff with gloved hands. Registered Nurse #4 removed their gloves, did not perform hand hygiene, and donned clean gloves. Registered Nurse #4 then applied the blood pressure cuff on Resident #234's left arm. After obtaining the blood pressure reading, Registered Nurse #4 was observed retrieving a glucometer from their pocket with a gloved hand and performed a fingerstick for Resident #234. On 11/14/2024 at 5:10 PM, Registered Nurse #4 was observed dispensing medication without first performing hand hygiene and the used ungloved hands to open an Acidophilus medication capsule. On 11/14/2024 at 5:27 PM, Registered Nurse #4 was observed administering medication via Resident #101's gastrostomy tube, removed gloves without performing hand hygiene and proceeded to don clean gloves and administer eye drops to Resident #101. On 11/20/2024 at 8:18 AM, Licensed Practical Nurse #2 was observed using the blood pressure machine on Resident #142 and then applied the blood pressure cuff on Resident #30 without cleaning the blood pressure cuff between residents. During an interview on 11/14/24 at 06:32 PM, Registered Nurse Supervisor #3 stated they make rounds frequently on the unit and do spot checks to ensure that the staff are administering medications properly. Registered Nurse Supervisor #3 also stated that after administering medication via a gastrostomy tube, hand hygiene or sanitization should be done. Registered Nurse Supervisor #3 further stated that the glucometer should be carried on a tray ideally, and it should not be carried in the nurse's pocket. During an interview on 11/19/2024 at 11:37 AM, Licensed Practical Nurse #3 stated they are supposed to sanitize the blood pressure machine before going to the next resident because the machine comes into contact with the resident's skin. Licensed Practical Nurse #3 also stated they did not sanitize the machine because they were nervous. During an interview on 11/20/2024 at 9:02 AM, Licensed Practical Nurse #2 stated they are supposed to clean the blood pressure machine in between residents. Licensed Practical Nurse #2 also stated that they did not clean the machine because they were nervous, but they know they are supposed to clean it. During an interview on 11/20/2024 at 9:04 AM, Registered Nurse Supervisor #2 stated the nurses are responsible for cleaning the blood pressure machines between each resident. Registered Nurse Supervisor #2 stated that they do rounds and spot checks to ensure that the staff are cleaning the machine between residents. During an interview on 11/20/2024 at 12:28 PM, the Assistant Director of Nursing stated the staff are taught to wash hands with soap and water and may use sanitizer before and after medication administration, contact precautions, and donning, and doffing personal protective equipment. The Assistant Director of Nursing also stated that surveillance and competency assessments are done for each staff. The Assistant Director of Nursing further stated that the staff are taught to wipe the equipment after each use, and they and the supervisors are responsible to ensure that staff are following infection control protocol. 10 NYCRR 415.19 (a)(1-3), (b)(4) Based on observation, record review, and interviews conducted during the Recertification survey from 11/13/2024 to 11/20/2024, 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, (1) a housekeeper did not don the required personal protective equipment when cleaning the room of a resident on contact and droplet precautions, (2) Certified Nursing Assistant (Certified Nursing Assistant #8) was assisting multiple residents to perform hand hygiene in the dining room and did not clean their hands in between residents, and 3) nurses (Licensed Practcal Nurse #3, Registered Nurse #4 and Licensed Practical Nurse #2 did not perform hand hygiene appropriately during tasks or clean blood pressure cuffs between residents. This was evident during Infection Control, Dining Observation and Medication Administration tasks. The findings are: The facility policy and procedure titled Contact and Droplet Precaution reviewed 9/11/2024 documented the facility will initiate transmission -based precaution when a resident is suspected or confirmed with contagious or infectious disease symptoms, to prevent the transmission of disease. Contact Precautions/ personal Protective Equipment- gloves and gown are the correct personal equipment to be worn when a resident is on contact precautions. Staff is to don personal protective equipment before entering room. Droplet precautions/personal protective equipment- mask, gloves and gown are the correct personal protective equipment to be work when a resident is on droplet precautions and staff is to to don before entering room. The facility policy and procedure titled Donning Personal Protective Equipment reviewed 9/11/2024 documented to prevent the transmission of infection using proper donning, use of and removal of gloves, gown, mask and eye protection and face shield. The facility policy and procedure titled Hand washing reviewed 9/16/2024 documented hand washing is the single most effective method of preventing the spread of infection. All staff must wash their hands to remove microorganisms and prevent infection. 1. On 11/13/2024 between 11:03 AM and 11:20 AM, Housekeeper #4 was observed wearing only a mask and gloves while cleaning room [ROOM NUMBER] which had a laminated sign on the door that stated STOP Report to Nurse Before Entering, Contact/Droplet Precaution Sign and Enhanced Barrier Precautions. Housekeeper #4 swept and mopped the floor, dusted the back of the television for the A bed, wiped the bathroom door and cleaned the resident bathroom, wiped the bed rails and chair for the B bed, wiped the air conditioner/radiator unit. During an interview on 11/13/2024 at 11:26 AM, Housekeeper #4 stated they were not sure what personal protective equipment they were supposed to wear. Housekeeper #4 also stated that they looked at the STOP sign on the door and knew they have to put on Personal Protective Equipment because the resident in the room has some sort of infection. Housekeeper #4 further stated that it was only their second time on this unit and the unit they normally work on does not have these signs. Housekeeper #4 stated they had in-service on personal protective equipment in the last two to three months and they know they have to look at the signs on the door. Housekeeper #4 also stated that they are not that knowledgeable about this and were told by their supervisor that they have to put on the personal protective equipment for every room before cleaning the resident's bathroom. During an interview on 11/13/2024 at 11:30 AM, the Director of Housekeeping was interviewed and stated that if Personal Protective Equipment is outside the room staff should be utilizing it, and any room where residents are on isolation staff should be donning the mask, gown, and gloves before they get into the room. During an interview on 11/20/2024 at 12:53 PM, the Infection Preventionist stated they do rounds daily in the morning to make sure staff are sanitizing their hands, wearing Personal Protective Equipment and all infection control is done daily. The Infection Preventionist also stated no concerns were noted, staff are always being monitored, and that they do not recall any incidents. The Infection Preventionist further stated that staff should be wearing gown, gloves, mask to prevent the spread of infection in rooms where residents are on contact or droplet precautions. 2. On 11/13/2024 from 11:59 AM to 12:14 PM, during the dining observation on the 5th floor, Certified Nursing Assistant #8 was observed assisting residents with hand hygiene with bare hands in preparation for dining by passing out hand sanitizing wipes for the residents. Certified Nursing Assistant #8 assisted Resident #121 and took the used hand wipe and placed it in a plastic bag, assisted Resident #134 to clean their hands, did not perform hand hygiene before assisting Resident #156 to clean their hands. Certified Nursing Assistant #8 then assisted Resident #140 took the used hand wipe and placed it in the plastic bag, assisted Resident #28, Resident #77, and Resident #68 to clean their hands. Certified Nursing Assistant #8 then cleaned their hands with the hand sanitizing wipe after assisting Resident #68. During an interview on 11/13/2024 at 12:15 PM, Certified Nursing Assistant #8 stated that they use the hands wipes for residents and they did not clean their hands between residents. Certified Nursing Assistant #8 also stated that each resident may have a different type of bacteria on their hands, food debris on their hands and their hands need to be clean so bacteria/germs are not transferred from one resident to another resident since residents touch different things. Certified Nursing Assistant #8 further stated that they did not touch the resident's hands and that they use hand sanitizer wipes and did pick up the used hand wipes from the residents. During an interview on 11/13/2024 at 12:21 PM, Registered Nurse Supervisor #2 was interviewed and stated that they make sure that they tell the unit staff before residents eat staff are to wipe their hands. Resident's hands need to be cleaned staff have to make sure residents hands are not dirty. Registered Nurse Supervisor #2 also stated that staff should wipe their hands before they go assist another resident to prevent cross contamination from one resident to another. During an interview on 11/20/2024 at 12:59 PM, the Infection Preventionist stated that once a week they do infection control surveillance, and they also do daily monitoring during their rounds and if any concerns are observed they are checked and addressed. The Infection Preventionist also stated that during dining they do rounds on the unit, and at mealtime sometimes they do rounds to make sure staff are wiping residents hands prior to eating, offering to assist residents to clean their hands and that nothing is shared between residents.

Based on record review and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024 , the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility was not able to provide a policy related to facility staffing. The Payroll Based Journal Staffing Data Report for the 3rd quarter of 2024 (04/01/2024 - 06/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment last updated in 10/2024 documented a facility capacity of 302 residents with a weekend staffing plan by shift distributed as follows: Day shift: 2 Registered Nurse Supervisors 2nd floor: 4 Licensed Practical Nurses and 6 Certified Nursing Assistants 3rd floor : 2 Licensed Practical Nurses and 5 Certified Nursing Assistants 4th, 5th & 6th floor: 1 Licensed Practical Nurse and 5 Certified Nursing Assistants 7th & 8th floor: 2 Licensed Practical Nurses and 5 Certified Nursing Assistants 9th floor :1 Licensed Practical Nurses and 3 Certified Nursing Assistants Total=2 Registered Nurse Supervisors, 14 Licensed Practical Nurses and 39 Certified Nursing Assistants Evening shift: 2 Registered Nurse Supervisors 2nd floor: 4 Licensed Practical Nurses and 6 Certified Nursing Assistants 3rd floor: 2 Licensed Practical Nurses and 6 Certified Nursing Assistants 4th floor: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants 5th & 6th floor: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants 7th floor: 2 Licensed Practical Nurses and 4 Certified Nursing Assistants 8th floor: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants 9th floor :1 Licensed Practical Nurse and 3 Certified Nursing Assistants Total=2 Registered Nurse Supervisors, 13 Licensed Practical Nurses and 33 Certified Nursing Assistants Night shift: 2 Registered Nurse Supervisors 2nd floor: 3 Licensed Practical Nurses and 4 Certified Nursing Assistants 3rd floor: 3 Licensed Practical Nurses and 4 Certified Nursing Assistants 4th, 5th & 6th floor: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants 7th & 8th floor: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants 9th floor :1 Licensed Practical Nurse and 2 Certified Nursing Assistants Total=2 Registered Nurse Supervisors, 12 Licensed Practical Nurses and 22 Certified Nursing Assistants Review of the actual weekend facility staffing schedule from 04/06/2024 to 04/28/2024 documented the following: On 04/06/2024 on the 7 AM-3 PM shift there was a shortage of 2 Licensed Practical Nurses on the 2nd floor and 1 Certified Nursing Assistant on the 5th, 6th and 7th floor. On 04/06/2024 on the 3 PM-11 PM shift there was a shortage of 1 Licensed Practical Nurse and 3 Certified Nursing Assistants for the 2nd and 3rd floor. On 04/06/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse Supervisor, 2 Licensed Practical Nurses and 1 Certified Nursing Assistant. Total staff shortage in a 24-hour period was 1 Registered Nurse Supervisor, 5 Licensed Practical Nurses, and 7 Certified Nursing Assistants with no replacement of staff. On 04/07/2024 on the 7 AM-3 PM shift there was a shortage of 1 Licensed Practical Nurse for the 2nd floor, and 2 Certified Nursing Assistants for the 2nd and 3rd floor. On 04/07/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 2 Certified Nursing Assistants for the 3rd floor. On 04/07/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse Supervisor, and 3 Licensed Practical Nurses for the 2nd floor, 2 Licensed Practical Nurses and 1 Certified Nursing Assistant for the 3rd floor. Total staff shortage in a 24-hour period was 1 Registered Nurse Supervisor, 8 Licensed Practical Nurses, and 5 Certified Nursing Assistants with no replacement of staff. On 04/13/2024 on the 7 AM-3 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 1 Certified Nursing Assistant for the 5th floor. On 04/13/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 2 Certified Nursing Assistants for the 3rd floor. On 04/13/2024 on the 11 PM-7 AM shift there was a shortage of 1 Licensed Practical Nurse on the 3rd floor and 2 Certified Nursing Assistants on the 3rd and 8th floor. Total staff shortage in a 24-hour period 5 Licensed Practical Nurses and 5 Certified Nursing Assistants with no replacement of staff. On 04/13/2024 on the 7 AM-3 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 1 Certified Nursing Assistant for the 5th floor. On 04/13/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 2 Certified Nursing Assistants for the 3rd floor. On 04/13/2024 on the 11 PM-7 AM shift there was a shortage of 1 Licensed Practical Nurse on the 3rd floor and 2 Certified Nursing Assistants on the 3rd and 8th floor. Total staff shortage in a 24-hour period 5 Licensed Practical Nurses and 5 Certified Nursing Assistants with no replacement of staff. On 04/20/2024 on the 7 AM-3 PM shift there was a shortage of 1 Licensed Practical Nurse for the 2nd floor. On 04/20/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 2 Certified Nursing Assistants for the 3rd floor. On 04/20/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse Supervisor and 2 Certified Nursing Assistants for the 3rd and 4th floor. Total staff shortage in a 24-hour period was 1 RN Supervisor, 3 Licensed Practical Nurses, and 4 Certified Nursing Assistants with no replacement of staff. On 04/21/2024 on the 7 AM-3 PM shift there was a shortage of 1 Licensed Practical Nurse for the 2nd floor, 9 Certified Nursing Assistants covering the 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, and 9th floor. On 04/21/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses and 2 Certified Nursing Assistants for the 2nd floor, and 3 Certified Nursing Assistants for the 3rd floor. On 04/21/2024 on the 11 PM-7 AM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd and 3rd floor and 1 Certified Nursing Assistant for the 3rd floor. Total staff shortage in a 24-hour period was 5 Licensed Practical Nurse and 15 Certified Nursing Assistants with no replacement of staff. On 04/27/2024 on the 7 AM-3 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor, 1 Licensed Practical Nurse for the 3rd floor and 1 Certified Nursing Assistant for the 2nd floor. On 04/27/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor,1 Licensed Practical Nurse for the 3rd floor and 2 Certified Nursing Assistants for the 2nd floor and 3rd floor. On 04/27/2024 on the 11 PM-7 AM shift, there was a shortage of 1 Registered Nurse Supervisor, 1 Licensed Practical Nurse for the 2nd and 3rd floor and 2 Certified Nursing Assistants for the 3rd and 9th floor. Total staff shortage in a 24-hour period 1 Registered Nurse Supervisor, 7 Licensed Practical Nurses and 9 Certified Nursing Assistants with no replacement of staff. On 04/28/2024 on the 7 AM-3 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 1 Licensed Practical Nurse for the 3rd floor. On 04/28/2024 on the 3 PM-11 PM shift there was a shortage of 2 Licensed Practical Nurses for the 2nd floor and 2 Certified Nursing Assistants for the 3rd floor. On 04/28/2024 on the 11 PM-7 AM shift, there was a shortage of 1 Registered Nurse Supervisor, 2 Licensed Practical Nurses for the 2nd and 3rd floor and 1 Certified Nursing Assistant for the 3rd Floor. Total staff shortage in a 24-hour period was 1 Registered Nurse Supervisor, 5 Licensed Practical Nurses, and 1 Certified Nursing Assistant with no replacement of staff. Review of the actual weekend facility staffing schedule from 04/06/2024 to 06/30/2024 revealed that the facility had an ongoing shortage of staff for both Licensed Professional Nurses and Certified Nursing Assistants specifically on the 2nd floor unit which is the designated Ventilator unit. There was also persistent shortage of a Registered Nursing Supervisor specifically on the 11 PM- 7 AM shift. On 11/19/2024 at 10:27 AM, the Director of Nursing was interviewed and stated when there is a need and no one is covering, I come in and cover on the weekend. The Director of Nursing also stated that they are meeting the staffing requirements as per the Payroll Based Journal guidelines. On 11/19/2024 at 10:30 AM, the Staffing Coordinator was interviewed and stated that the staffing is augmented with the use of nursing staffing agencies. The Staffing Coordinator also stated that they are currently using two nursing agencies that provides them with Licensed Practical Nurses, Registered Nurses and Certified Nursing Assistants, and they also utilizes per diem and overtime as the needs arises. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, interviews, and record review conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure food was served and dishware was handled in accordance with professional standards for food service safety. Specifically, 1). numerous kitchen staff were observed not wearing beard restraints while preparing and assembling food, and 2). the Food Service Director did not wash their hands after contact with a garbage can while checking food temperatures on the tray line. This was evident during the Kitchen Observation task. The findings are: The facility policy titled Food Safety and Sanitation dated 3/25/2024 documented hair restraints are required and should cover all hair on the head, beard nets are required when facial hair is visible. Employees will wash their hands before start of work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes and touching face, hair, other people or surfaces or items with potential for contamination. The facility policy titled Employee Sanitary Practices Policy dated 3/25/2024 documented all employees wear hair restraints (hairnet a, hat and/or beard restraint) to prevent hair from contaminating exposed food. Wash hands before handling food using posted hand washing procedures. Disposable gloves are a single use item and should be discarded after each use. Hand must be washed prior to using gloves and after removing gloves. 1. On 11/15/2024 between 11:33 AM and 11:52 AM, the kitchen tray line temperature was observed. Dietary Aide #3 was observed placing French fries on resident's plates, [NAME] #3 was scooping the mashed potatoes, Dietary Aide #1 was at the head of the tray line loading trays onto the lunch cart for the units, [NAME] #1 was observed taking cooked burgers from the oven and placing them into a pan with spatula with [NAME] #2 in the same area by the ovens and Dietary Aide #2 was at the end of the tray line loading trays onto the cart for lunch meal. None of the staff observed were wearing beard guards while preparing and assembling foods. During an interview on 11/15/2024 at 11:59 AM, Dietary Aide #1 stated they forgot to wear their beard net and they should be wearing it so hair does not get into the resident's food. On 11/15/2024 at 12:01 PM, [NAME] #1 was interviewed and stated that they normally wear a beard net, but they got busy, and it slipped their mind to wear it. [NAME] #1 also stated that they should be wearing a beard net just in case hair falls into the resident's food. During an interview on 11/15/2024 at 12:03 PM, Dietary Aide #2 stated they forgot their beard net in their other uniform. Dietary Aide #2 also stated that they usually put the beard net on before they come into the kitchen. On 11/15/2024 at 11:55 AM, [NAME] #2 was interviewed and stated that they were not told they had to wear a beard net. [NAME] #2 also stated that they should wear a beard net, so nothing gets into the food while they are cooking. [NAME] #2 further stated that they have worn beard nets in the past and they do not have a good answer are to why they are not wearing the beard net today. During an interview on 11/15/2024 at 11:57 AM, [NAME] #3 stated that they forgot to shave this morning due to getting up late and they were busy with work and forgot to wear the beard net. [NAME] #3 also stated they should wear the beard net because if they do not shave their beard, hair can fall into the food. On 11/15/2024 at 12:17 PM, Dietary Aide #3 was interviewed and stated they have issues with acne, and they normally wear a beard net but after their break they forgot to put the beard net back on. During an interview on 11/15/2024 at 12:06 PM, the Director of Food Service was interviewed and stated they do a daily kitchen tour to make sure staff are in the proper attire which includes personal hygiene, cleanliness, jewelry, fingernails, proper uniform, gloves, hairnets, and beard nets. The Director of Food Service also stated that they have noticed staff are missing proper attire such as not having beard nets and this issue is with the union employees. The Director of Food Service further stated that before the tray line starts the staff do a huddle at each meal and they personally make sure that each staff has utensils, hairnets, beard nets and gloves. During an interview on 11/20/2024 at 12:54 PM, the Infection Preventionist stated they do not do regular rounds of the kitchen and the last time they did rounds was prior to the beginning of the survey. The Infection Preventionist also stated that when they do rounds, they check to make sure dietary staff are wearing their uniform, wearing hair and beard nets, and sanitizing their hands. The Infection Preventionist further stated that staff should be wearing hair nets and beard nets to prevent anything from falling into prepared foods or supplies for the food for residents. 2. On 11/15/2024 between 11:33 AM and 11:42 AM, the tray line food temperatures were observed with the Food Service Director. The Food Service Director donned gloves after retrieving alcohol preps and a thermometer. After taking the temperature of the mushroom Swiss burger, the Food Service Director cleaned the thermometer probe with an alcohol prep pad and touched the lid of the trash can with their gloved hands while disposing of the used alcohol pad. The Food Service Director did not remove gloves or perform hand hygiene and continued to take temperatures of other food items on the tray line. During an interview on 11/15/2024 at 12:10 PM, the Director of Food Service stated that they normally wash hands, and they did not recall touching the trash can with their gloved hand. The Director of Food Service also stated that the garbage dirty and they are supposed to clean their hands, so everything maintains its cleanliness. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a Recertification survey from 11/7/22 to 11/15/22, the facility did not ensure residents' rooms were maintained in a clean, comfortable, and homelike environment. Specifically, two rooms on the second floor were noted with enteral feeding poles with dried cream brown colored stain and oxygen ventilator unit tank base stand and oxygen tank straps were noted to have gray colored dust buildup. This was evident for 1 out of 7 floors observed for the Environment. The findings are: The facility policy and procedure titled Terminal Cleaning Policy revised September 2022 documented that maintaining a high standard of hygiene is essential in preventing the spread of infection in a nursing home setting. Clean and disinfect all reusable equipment as per cleaning and decontamination of the environment and patient equipment procedure and manufacturers instruction and remove from the room. Under the Controlling CDI Environmental Services Environmental Services Cleaning Guidebook (1) Basic cleaning concepts documented cleaning is the physical removal of dust, soil, blood, and body fluids. Cleaning physically removes germs. It is accomplished with water, detergents, and mechanical action. The key to cleaning is the use of friction to remove germs and debris. On 11/07/2022 at 11:04 AM, and 02:29 PM, 11/08/2022 at 11:00 AM, 11/09/2022 at 10:59 AM, 11/10/22 at 03:15 PM and on 11/14/22 at 10:59 AM, room [ROOM NUMBER] was observed with dried cream-colored stains at the base of the two enteral feeding poles and the immediate floor area around the poles. There were two individual oxygen tanks attached to the ventilator for each resident that had gray colored dust buildup on the ventilator stand legs and on the straps for the oxygen tank attached to ventilation devices at both bedsides in the room. On 11/07/22 at 11:20 AM, 11/09/22 at 11:05 AM, 11/10/22 at 10:44 AM, and 11/14/2022 at 02:49 PM, dried cream-colored stains noted on the base of the feeding pole in room [ROOM NUMBER]. On 11/09/22 at 11:06 AM, and 11/14/22 at 10:52 AM, the oxygen tank stand base in room [ROOM NUMBER]. was observed with brown colored stain in multiple areas and dust build-up in multiple areas on the oxygen tanks located in the room. On 11/09/22 at 11:07 AM, 11/09/22 at 03:48 PM, 11/10/22 at 10:43 AM, 11/10/22 at 03:09 PM, 11/14/22 at 10:52 AM and 11/14/22 at 02:48 PM the other enteral feeding pole in room [ROOM NUMBER] was observed with dried brown creamed colored stain 4-inch x 2 inch at the base of the enteral feeding pole. On 11/14/2022 at 02:41PM, an interview was conducted with the Director of Maintenance (DOM), who stated oxygen tanks are exchanged as needed when the oxygen tanks are empty or upon staff request. The DOM looks to see if they are dusty and need to have the outside cleaned and if that needs to be done is done before the tanks are taken to the unit. On 11/14/2022 at 2:57 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) # 1 who stated that they looked at the resident's room this morning during rounds. They stated they had not noticed the dust before and equipment should be clean to prevent infection. An interview was conducted with Housekeeper (HK) #1 on 11/14/2022 at 02:50 PM who stated all equipment is brought down to the garage and washed when residents are discharged , and terminal cleaning is done. HK #1 also stated that if they come upon dirty equipment, they stop and clean the equipment. They were also not sure the last time the feeding poles or oxygen tanks were cleaned, and they are floating on the unit today. HK #1 further stated that housekeeping is in charge of the enteral feeding poles and they are cleaned when the residents are discharged only. If they see anything such as vomit on the equipment, it is taken care of right away. An interview was conducted with the Director of Housekeeping (DOHK) on 11/14/2022 at 3:11 PM, who stated they do random rounds 4-5 times per floor daily. The DOHK also stated that only when equipment is taken off the unit following a resident's discharge is terminal cleaning done for the equipment. The DOHK further stated that if an item needs to be cleaned they are informed by nursing, however, the oxygen tanks should always be clean. On 11/14/2022 at 03:23 PM, an interview was conducted with the Respiratory Therapist (RT) who stated that they look at the respiratory equipment daily and check once a week but did not notice if base was dirty or dusty. The RT also stated that dust could affect the ventilator and inner filter so it is important that the equipment is free of dust. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during a Recertification survey from 11/7/22 to 11/15/22, the facility did not ensure that a portion of the Minimum Data Assessment (MDS) accurately reflected the resident's status. Specifically, the behavioral symptoms of a resident who refused medications daily were not captured on the Minimum Data Set (MDS). This was evident for 1 of 2 residents reviewed for Activities of Daily Living (ADL) out of 38 sampled residents. (Resident # 64). The findings are: The facility policy and procedure titled Minimum Data Set revised 9/1/2022 documented: all members of the Interdisciplinary Care (IDCP) Team participate in completion of their assigned MDS section (s). The facility policy further documented all MDS 3.0 assessments are scheduled, completed, and transmitted according to the Resident Assessment Instrument (RAI) guidelines. The facility policy contained no reference to accuracy of the MDS assessments. Resident #64 was admitted with diagnoses that included Heart Failure, Hypertension, Peripheral Vascular Disease (PVD), Cerebrovascular Accident (CVA), and Chronic atrial fibrillation. The Annual MDS assessment dated [DATE] documented the resident was cognitively intact and in Section E 0200 Behavior Symptom-Presence and Frequency, Section E 0300 Overall Presence of Behavioral Symptom, and Section E 0800 Rejection of Care-Presence and Frequency documented that the resident exhibited no behavioral symptoms. The Comprehensive Care Plan (CCP) for Behavioral Symptoms: Resist Care, updated on the following dates: 9/2/2022, 10/13/2022 and 11/2/2022, included a nursing note on above dates which documented: Resident continues to refuse taking medication. Spoke to resident again at bedside, re-explained and re-educated resident on the importance of taking medication regularly and the risk of not taking medication for a while. Resident verbalize understanding but insisted on refusing medication. The Physician Orders last renewed on 11/6/2022 documented orders for Amiodarone 200 mg tablet give 1 tablet (200 mg) by oral route once daily for Atrial Fibrillation, Furosemide 20 mg tablet give 1 tablet (20 mg) by oral route once daily for Atrial Fibrillation, Metoprolol Succinate ER 100 mg tablet, extended release 24 hour give 1 tablet (100 mg) by oral route once daily for Hypertension and Xarelto 20 mg tablet give 1 tablet (20 mg) by oral route once daily with the evening meal for Atrial Fibrillation. The Medication Administration Record (MAR) dated September 2022 documented the following: Amiodarone 200 mg tablet give 1 tablet (200 mg) by oral route once daily was not administered 9/1/2022 to 9/29/2022 and documented refused from 9/1/2022 to 9/24/2022, and 9/26/2022 to 9/29/2022. Furosemide 20 mg tablet give 1 tablet (20 mg) by oral route once daily was not administered 9/1/2022 to 9/29/2022 and documented refused from 9/1/2022 to 9/12/2022 and 9/14/2022 to 9/29/2022. Metoprolol Succinate ER 100 mg tablet, extended release 24 hour give 1 tablet (100 mg) by oral route once daily was not administered 9/1/2022 to 9/29/2022 and documented refused from 9/1/2022 to 9/29/2022. Xarelto 20 mg tablet give 1 tablet (20 mg) by oral route once daily with the evening meal was not administered 9/1/2022 to 9/29/2022 and was documented as refused from 9/1/2022 to 9/29/2022. The MAR revealed Resident #64 did not receive any medications for the month of September, mostly due to refusals and on two occasions (9/13/22 and 9/25/2022) due to medical appointments. The MDS did not accurately capture the resident's behavioral symptoms. On 11/10/22 at 02:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated Resident #64 is alert and able to verbalize needs. LPN #1 stated the resident refuses all medication even if re-offered at different times of the day and evening. LPN #1 also stated the facility has held Care Planning meetings with the resident, the resident family, the doctor, and the entire team but the resident continues to refuse medications stating they do not need medication. LPN #1 stated the resident behaviors are documented in monthly progress notes and refusal of medication is documented daily in the resident MAR. On 11/10/22 at 03:32 PM, an interview was conducted with the MDS Assessor (MDSA). The MDSA stated when completing the MDS, they interview the resident if alert, interview the staff and look at the progress notes, the MAR/TAR, physician notes and the entire medical record of the resident. The MDSA also stated that in Section E of the MDS all the residents' behaviors including the refusal of medication and lab work is documented. When asked if Resident #64 exhibited behaviors, the MDSA terminated the interview and later returned to state that they were only responsible for coding of Potential Indicators of Psychosis in Section E, and the Social Worker is responsible for the rest of the documentation in Section E. On 11/14/22 at 11:53 AM, an interview was conducted with the Social Worker (SW) who stated that Resident #64 is alert with some periods of confusion but is verbal and able to make needs known. SW stated Resident #64 refuses all medications daily despite multiple interventions. The SW also stated that the MDS department as well as Social work have a shared responsibility for completing Section E of the MDS. The SW further stated section E 0200 was coded incorrectly because the resident refuses medications daily, so it should have been answered yes and not no. SW stated it was an error because they are aware that the resident has behaviors. The SW also stated that no one verifies that the information completed in the MDS is correct. On 11/14/22 at 11:59 AM, an interview was conducted with the Director of Minimum Data Set (DMDS). The DMDS stated MDS assessors as well as the Social Work department is responsible for completing Section E - Behaviors. The DMDS also stated when certifying the MDS, they do not check for accuracy but check for completion of the sections of the MDS. Once the sections are completed, they submit the MDS. The DMDS further stated every staff member who completes the Section in the MDS is responsible for the accuracy of that section. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification survey from 11/07/22 to 11/15/22, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 of 2 residents reviewed for Mobility out of 38 sampled residents. (Resident #151) Specifically, Resident #151 was observed on multiple occasions without a right handroll in accordance with a physician's order. The findings are: The facility policy titled Orthotic Management dated January 2022, documented that it is the responsibility of the nurse to schedule the orthosis wear time in the Certified Nursing Assistant Accountability when they pick up the orthotic order. Resident #151 was admitted to the facility with diagnoses that include Cerebrovascular Accident and Non-Alzheimer's Dementia. On 11/08/22 at 12:38 PM, Resident #151 was observed with a hand roll (gauze roll) in resident's lap. On 11/10/22 at 10:01 AM, Resident #151 was observed in the dining room sitting in the wheelchair asleep. There was no hand roll observed in the resident's right hand. On 11/15/22 at 08:01 AM, Resident #151 was observed asleep in bed with the hand roll on the bedside table; no hand roll was observed in the resident's right hand. The Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that resident had severely impaired cognition, required extensive assistance of 2 persons for bed mobility, transfer, and toilet use, and had impairment on both sides of the lower extremities. The Physician's order dated 10/21/22 documented to apply Right handroll at all times, remove for skin check, range of motion (ROM) and hygiene daily. The Resident CNA (Certified Nursing Assistant) Documentation Record for Resident #151 displayed documentation for Nursing Rehab Splint/Brace on the 7:00a-3:00p, 3:00p -11:00p, and 11:00p-7:00a shifts on 11/08/22 and 11/10/22. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) all task created on 08/31/18, documented ADL all task, self-care deficit needs assist in ADL's secondary to weakness. Goals included maintain ADL and functional mobility x 90 days. Interventions included always apply Right handroll, remove for skin check, ROM, and hygiene daily. There was no documented evidence that the resident was able to remove or did remove or refused the hand roll. On 11/15/22 at 09:47 AM, Licensed Practical Nurse (LPN) #2 was interviewed at resident's bedside and stated that the resident usually wears the handroll in the daytime and that sometimes the resident makes a tight fist with their hands, so a handroll is placed so that the resident doesn't cut themselves with their nails. LPN #2 also stated that the resident wears the hand roll during the day but is not aware if it is worn at night. LPN #2 further stated that they would check the orders and verified and that the order does say handroll is to be worn always. On 11/15/22 at 09:33 AM, Certified Nursing Assistant (CNA) #2 was interviewed at the resident's bedside and said that since they work on the 3-11 shift, they usually see the resident with the handroll on during the day but did not recall them wearing the handroll during the evening shift. CNA #2 stated that the day shift puts it on for the resident but they were not aware that it has to be worn at all times. On 11/15/22 at 10:33 AM, the Registered Nurse Manager (RNM) was interviewed and stated that the hand rolls were ordered by the Physical Therapist (PT) and then it is placed on the CNA Accountability Record (CNAAR). The RNM also stated that Resident #151 can remove the hand roll and is not sure that the order is for it to be applied at all times. The RNM further stated that Resident #151 can remove the handroll and throw it on the floor as they sometimes see it on the floor, however this was not documented in the record. On 11/15/22 at 3:00 PM, the Director of Nursing (DON) was interviewed and stated that in-services are given to the CNA's on splints, handrolls and other devices. During morning report, staff is made aware of resident with new devices, and this information is then passed on to staff on the units. The DON also stated that they were not sure of the usage time for Resident #151, but that the staff would remove the hand roll for hygiene and to check the skin. The DON further stated that the resident does move her left hand and may take off the handroll. The DON could not provide documented evidence that Resident #151 had been non-compliant with handroll use. 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey 11/7/22 to 11/15/22, the facility did not ensure that food was stored, prepared, distribute and served in accordance with professional standards for food service safety. Specifically, an unopened container of expired cottage cheese was noted in the refrigerator. This was evident during the initial tour and follow up tour conducted during the Kitchen facility task. The findings are: The facility policy and procedure titled General Food Preparation and Handling reviewed 11/2022 documented under Food Storage item (a). Foods will be received, checked, and stored properly as soon as they are delivered. The policy did not contain any information for checking the delivered foods for the use by, best by or manufacturer expiration dates upon delivery to the facility. On 11/07/2022 from 10:10 AM to 10:30 AM, the initial tour of the kitchen was conducted with the Cook. One sealed 5-pound plastic container of 4% milk minimum cottage cheese was noted in the dairy and produce refrigerator. A stamp in black lettering was observed on the container as follows: 50-19 [DATE] x EH 12:44. The facility did not ensure that food items were removed from the active refrigerator supply stock by the pull by date. On 11/07/2022 at 10:40 AM, an interview was conducted with the [NAME] who stated they are in charge of stocking received supplies. The [NAME] also stated they put items away and inventory is done on Thursday and Sunday. The [NAME] further stated they did not notice the date on the cottage cheese and it is important to not have expired items as this can affect the resident so it should not be in the kitchen. On 11/07/2022 at 10:42 AM, the Food Service Director (FSD) was interviewed and stated that they look at the expiration date of items daily. The FSD stated that the date written in with magic marker threw them off. The FSD further stated that the item had not been opened and was not old, but to avoid harming the residents the item should be discarded. 415.14 (h)

Based on observations, record review, and staff interviews during the re-certification survey, the facility did not store food properly to prevent foodborne illness. Specifically, (1) raw tilapia fish was observed stored above pre-cooked corned beef on a multi-tiered metal rack in the walk in refrigerator, (2) raw frozen tilapia fish was observed stored above pre-cooked frozen onion rings and potato pancakes, and frozen vegetables in the walk in freezer, and (3) raw sole fish rolled with scallops and crab meat was observed stored over pre-cooked frozen vegetable lasagna in the walk in freezer. This was evident for the Kitchen reviewed during the Kitchen facility task. The finding is: The Food Storage Policy and Procedure, revised on 4/10/19, documented the following: Procedure #13 Refrigerated Food Storage, line E. documented cooked foods must be stored above raw foods to prevent contamination. Raw animal foods will be stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. Procedure #14 Frozen Food Storage line F. documented meat, fish, poultry should be stored on lowers shelves, while fruits, vegetables, juices and breads should be stored on higher shelves. On 01/15/20 at 09:34 AM, the walk-in Refrigerator was observed with sheet pans with raw tilapia stored above precooked corned beef in a multi-tiered metal rack in the walk in refrigerator. During the same tour, the walk-in freezer was observed with raw tilapia on a shelf above a shelf that contained onion rings, potato pancakes, and frozen vegetables. On a follow up visit on 1/16/20 at 9:35AM, the same walk-in freezer was observed with raw frozen sole rolled with scallops and crab meat stored over vegetable lasagna. No shelf was between the items, the cardboard boxes were stacked on top of each other. On 01/16/20 at 09:41 AM, an interview was conducted with the Food Service Director (FSD). The FSD stated that they do their best to separate poultry from raw meat and other items. She stated that staff usually designates the right hand side of the fridge for poultry. In regards to proper food storage, the FSD stated that all raw foods should go on the bottom. An 01/16/20 at 09:53 AM, an interview was conducted with [NAME] #1. The cook stated that pre-cooked foods should be on top and raw foods underneath. When asked why raw tilapia was stored above precooked corned beef on 1/15/20, he stated that it must have been something that was done very quickly. He stated that all foods, whether they are being cooked or reheated, reach a temperature of 180 degrees. [NAME] #1 also stated that he remembers receiving training on the food hierarchy although he can't remember specifically when. 415.14(h)