**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during an Abbreviated survey (Complaint # NY00348153) completed on 10/9/24, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, floor tiles in resident rooms were discolored and had a sticky residue and carpeting in common areas were soiled and stained. This affected three (First, Second, and Third Floors) of three resident use floors. The findings are: 1a. Observation on 10/7/24 at 3:17 PM revealed Resident room [ROOM NUMBER] had floors that were white/tan vinyl composite tile (VCT, a type of flooring made from a combination of limestone, fillers, and thermoplastics). The flooring had a brownish-gray blotchy coating in the center of the room, including the entranceway. On 10/8/24 at 10:21 AM, the floor of Resident room [ROOM NUMBER] appeared the same. There were two floor mats near the bed that had adhered to the floor. The bathroom floor was white sheet vinyl that appeared gray in front of and to the right of the toilet. The bathroom floor and the entryway vinyl composite tile had a sticky residue underfoot. 1b. Observation on 10/7/24 at 3:25 PM revealed the vinyl composite tile in Resident room [ROOM NUMBER] had a sticky residue underfoot in the center of the room. 1c. Observation on 10/7/24 at 3:29 PM revealed the white sheet vinyl flooring in the bathroom of Resident room [ROOM NUMBER] had yellow and brown discoloration in a two-foot area in front of the toilet and had a sticky residue underfoot. The vinyl composite tile in the center of the room had a sticky residue underfoot. 1d. Observation on 10/8/24 at 8:24 AM revealed the white sheet vinyl flooring in the bathroom of Resident room [ROOM NUMBER] and the vinyl composite tile in the center of the room had a sticky residue underfoot. During an interview on 10/8/24 at 8:30 AM, Housekeeper #1 stated they swept and mopped resident room floors every day. They stated when a resident was discharged , the room got deep cleaned, and for a long-term resident, the room was deep cleaned, but they did not know the frequency. They stated they did not personally strip and wax floors. Housekeeper #1 stated they had noticed stickiness on some resident room floors, but the floors were clean. The stickiness was possibly caused by the chemical that was used and watering down the chemical a bit helped with the stickiness. During an interview on 10/8/24 at 8:45 AM, Housekeeper #2 stated every morning they cleaned each resident room floor by dry mopping then wet mopping with two sets of chemicals. One chemical was a regular cleaner, and the other was a sanitizer, both chemicals were automatically diluted with water at a set concentration and both chemicals were no rinse. Housekeeper #2 stated when the floor appeared gray and dull, it usually meant a strip and wax was needed. After floors were stripped and waxed, they were shiny and white. Additionally, floor mats could leave black discoloration on the floors and Housekeepers were not allowed to pick up mats when the resident was in bed, for safety reasons. Housekeeper #2 stated resident room floors were stripped and waxed when residents changed rooms, but if they saw a resident room that was bad, they would report it to their supervisor. They stated the stickiness of the tile could be due to humidity and type of shoes worn, and when a floor was noticeably sticky, they would get a bucket of hot water from the kitchen and mop with plain hot water. This would reduce the stickiness for a little while, but it could mean that another strip and wax was due. During an interview on 10/8/24 at 8:50 AM, the Housekeeper/Garbage Technician stated they just started last weekend with stripping and waxing resident rooms and they had completed the floors of two rooms, both of which were vacant rooms on the Second Floor. They stated the Maintenance Operations Manager and the Environmental Services Operations Manager decided which rooms they would strip and wax. During an interview on 10/8/24 at 12:50 PM, Housekeeper #3 stated they dry and wet mopped the resident room floors every day. They stated the cleaning solution made the floors sticky and they reduced the stickiness by mopping with very hot water. During a second interview on 10/8/24 at 1:00 PM, Housekeeper #1 stated the floor of Resident room [ROOM NUMBER] needed a strip and wax. They stated they did their daily routine on this floor, but it did not get out the gray color. During an interview on 10/8/24 at 1:28 PM, the Environmental Services Operations Manager stated they personally walked the resident units to see what needed to be done and anything they found, would be assigned on housekeepers' daily worksheets. They stated daily cleaning of resident rooms included high dust, damp wipe surfaces, general bathroom cleaning, dust mop, vacuum, and damp mop. The facility had one person on the second shift who could strip and wax floors, and recently hired a second person. They stated recently, some vacant rooms on the Second Floor were stripped and waxed. These vacant rooms were identified as the highest priority because those rooms were previously occupied by residents who did not want to move out overnight for the strip and wax. They stated the procedure for stripping and waxing of an occupied room involved the resident sleeping elsewhere for the night because of the chemical odor. The Environmental Services Operations Manager stated the plan was to finish stripping and waxing more vacant resident rooms on the Second Floor, use those rooms for the overnight stay of residents who get their rooms done next, then move on the highest priority occupied resident rooms. They stated they were not aware of any issue in Resident room [ROOM NUMBER]. Additionally, gray tone with dull, no sheen flooring meant it needed to be stripped and wax. Housekeeping staff could not move floor mats when the resident was in bed for safety reasons, and some floor mats left a black residue, which had to be scraped with a putty knife. The Environmental Services Operations Manager stated in the summer months, the floors could get sticky. They recently had the floor chemical provider come in to re-calibrate the strength of the chemicals, as repeated application of the chemicals might be the cause. A beverage spill that embedded into the tile could cause stickiness. When floors get sticky, we get very hot water from the kitchen and mop again with just the hot water alone, and this usually cuts the stickiness. During an interview on 10/9/24 at 11:00 AM, the Maintenance Operations Manager stated floors should be stripped and waxed at a frequency that is based on the usage of the room, but a good routine would be to strip and wax each resident room quarterly. During an interview on 10/9/24 at 11:38 AM, the Administrator stated the facility did not have a policy and procedure on housekeeping services or floor care. They stated one employee had the task of stripping and waxing floors and there was no existing schedule for this task. The decision for which rooms got stripped and waxed seemed to be based on staff input and concerns and comments. The Administrator stated the First Floor had frequent turnover with frequent new admissions, with more opportunities for staff to identify any issue with the room at the time of each turnover. The Third Floor did not get that frequent of attention with more residents that stayed in their rooms long term. They stated the sticky residue on some floors could be caused by using too many coats of wax, the frequency of mopping, or the kind of chemical used, and education of staff was needed. 2a. Observation on the Third Floor on 10/8/24 between 9:05 AM and 10:18 AM revealed the corridor floors were carpeted and the carpets were green and tan [NAME]. Observation in the 3D corridor revealed several large stains in the carpet that appeared dark gray, on average eight inches in diameter, with several larger areas of what appeared to be water stain ring of lighter gray, on average two feet in diameter. There were several small dark brown spots, and water stain areas near the Dining Room. In the lounge area, there were several dark and light gray areas of discoloration and darker green worn area four inches in diameter near the hall bathroom. Observation in the 3C corridor revealed whitish discolored areas in the carpet near the Dining Room in an area that was ten feet long by two feet wide. There were areas of dark gray blotches, small to large, throughout the corridor and widespread areas of slight light gray discoloration. Additional observation revealed a trail of white drops, about eight feet long, outside of Resident room [ROOM NUMBER]. There were many light and dark gray spots at the table area outside of Resident room [ROOM NUMBER] with a resident sitting at table. In the lounge area, there were several brownish/gray spots, and a darker green worn area eight inches in diameter. Observation in the 3A corridor revealed several medium to large spots that were dark grayish brown in the carpet between the nurses' desk and the Dining Room, on average about one foot in diameter. There was a trail of white spots outside of the Dining Room that was eighteen inches long. The carpeting had whitish splotches outside of Resident room [ROOM NUMBER]. In the lounge area, there were some darker green worn areas, a whitish area, and an area of small dark gray splatters. At this time, one resident was sitting in the lounge area. Observation in the 3B corridor revealed the carpet had dark gray spots between the entrance and the Dining Room. Also, large perimeter rings of medium gray were observed outside of the Dining Room. There were several medium gray large spots and one white spot outside of Resident room [ROOM NUMBER]. The carpet also had a large area of water stain in the table area outside of Resident room [ROOM NUMBER]. In the lounge area, there were several small dark gray spots. Five residents were sitting in the lounge at this time. 2b. Observation on the First Floor on 10/8/24 between 11:26 AM and 12:03 PM revealed the corridor floors were carpeted and the carpets were green and tan [NAME]. Observation in the 1A corridor revealed an area of dark gray on the carpet outside of the Dining Room. Continued observation revealed several light areas outside of Resident Rooms #101 and #115. Outside of Resident room [ROOM NUMBER], there were several small white and dark gray splotches. Several medium gray areas were observed on the carpet in the table area outside of Resident room [ROOM NUMBER] that ranged from two to eighteen inches in diameter. Observation in the 1B corridor revealed a large spot with a medium gray perimeter on the carpet, that was two feet long by eight inches wide near the Dining Room. There was a large blotchy gray area outside of Resident room [ROOM NUMBER]. There were gray and white spots in the table area outside of Resident Rooms #116 and #119. In the lounge area, the carpet had a gray discolored area two feet in diameter plus many small dark brown spots in front of the television. Additional observation revealed various brown streaks and splotches were at the end of the hallway. Observation in the 1C corridor revealed the carpet had a large slightly gray area between the entrance and the Dining Room, also at the Dining Room, there were many small and medium stains of dark gray and whitish observed, which ranged from one inch to eight inches in diameter. The carpet had dark gray splotches all along the corridor. There were large areas of discoloration outside of Resident Rooms #142 and #141 and a few smaller dark brown marks at end of corridor. Observation in the 1D corridor revealed there was a dark brown streak in the carpet in front of the nurses' desk that was eighteen inches long. There were gray splotches in the carpet at the Dining Room entry. Continued observation revealed a dark spot six inches in diameter outside Resident room [ROOM NUMBER] and a whitish spot outside of Resident room [ROOM NUMBER]. There was an area where the carpet's pile was pulled outside of Resident room [ROOM NUMBER]. Multiple gray marks were observed in the lounge area and at the end of the corridor. 2c. Observation on the Second Floor on 10/9/24 between 8:20 AM and 8:45 AM revealed the corridor floors were carpeted and the carpets were green and tan [NAME]. Observation in the 2A corridor revealed at least twenty dark gray spots around the nurses' desk. An area of various sized dark gray stains was observed between the entrance and the Dining Room. There was a large area of discoloration at the Dining Room that was five feet in diameter. Trails of medium gray splotches were on the carpet in the table area outside Resident room [ROOM NUMBER]. Observation in the lounge area revealed the carpet had several areas of darker green and light brown, each about eight inches in diameter, plus a light brown discoloration of the carpet in front of the television. Observation in the 2B corridor revealed multiple dark gray spots in the carpet in the area between the entrance and the Dining Room that ranged from one inch to six inches in diameter. There were two large areas of whitish stain at the Dining Room that were eight inches and eighteen inches in diameter. Additional observation revealed various black areas at the Dining Room that ranged from one half of an inch to three inches in diameter. There were whitish and dark gray splotches in the table area outside of Resident Rooms #217 and #219, and multiple gray stains in the lounge area. During interviews on 10/8/24 and 10/9/24: Resident #22 stated they had lived in their room for two years and in that time, their floor had never been stripped and waxed. They stated the facility did not vacuum the carpet in their hall too often and they did not steam clean the carpets often either, it had not been done in their hallway in at least six months. Resident #22 stated the carpets in the hallways were stained, especially near the Dining Room, and needed to be replaced. Resident #23 stated the carpet in the hall was stained. Resident #24 stated staff cleaned the floor in their room every day, but it got dirty right away, and their daughter cleaned it when they came to visit. They stated their daughter discussed the situation with staff. Resident #24 stated the carpets were stained at the area where they entered the Dining Room. Resident #25 stated the floor was dirty in the corner of bathroom behind toilet and needed to be cleaned better. They stated the floors could get sticky, especially near toilet area. Resident #25 stated carpeting in hallways was always dirty and stained. Staff had cleaned the carpets in the past, put they had not noticed it recently. A visitor on the Third Floor stated the carpet in the hall was stained and needed to be cleaned. A visitor on the First Floor stated they had noticed the carpets had water marks. During an interview on 10/8/24 at 8:50 AM, the Housekeeper/Garbage Technician stated the carpets in the hallways needed steam or shampoo treatment to bring them back. During an interview on 10/8/24 at 9:20 AM, Licensed Practical Nurse #1 stated in the past, the facility kept up with the carpets, but now the carpets appeared dirty and stained. They stated they had not recently seen any signs that carpets were being maintained, such as workers cleaning carpets, wet floor signs, or improvement in their condition. During an interview on 10/8/24 at 10:15 AM, Certified Nurse Aide #1 stated the carpets in the hallways needed help. They stated they had seen a large carpet shampooer come through at night, and set up fans afterward, and they most recently observed it about one month ago. Certified Nurse Aide #1 stated carpets can only be washed so much, and they've reached the point where the shampooer doesn't help anymore. The carpets were in the worst shape in the front of the unit by the Dining Room. During an interview on 10/8/24 at 12:50 PM, Housekeeper #3 stated they were not sure if carpet cleaning machines were used on these carpets, as Housekeepers only vacuumed carpets. They had not seen any improvement in the condition of the carpets. Housekeeper #3 stated residents spilled stuff, and accidents happened with these carpets, and they needed to be shampooed. During an interview on 10/8/24 at 12:56 PM, Certified Nurse Aide #2 stated the carpets were dirty and disgusting and occasionally someone came through to clean them. During an interview on 10/8/24 at 1:00 PM, Housekeeper #1 stated the carpet in the halls had been there for at least 25 years and it used to be shampooed regularly, but it was not done regularly anymore. They stated they were not sure when it was shampooed last. Housekeeper #1 stated the stains were food spills and the carpet needed to be pulled up as shampooing was not going to work anymore. During an interview on 10/8/24 at 1:28 PM, the Environmental Services Operations Manager stated the facility used to have a machine called the Chariot that would clean the carpets and they were immaculate. They stated the machine went out of service about three years ago and for the last three years, they have used various machines and extractors to clean the carpets. The extractor left streaks behind, and the shampooing machine was no longer effective, and the carpets were not looking how they wanted them to look. They stated they needed upgraded equipment for the job. Additionally, the Environmental Services Operations Manager stated about a month ago, the Administrator brought in a person to shampoo the carpets on the weekends with their own equipment. They stated once the carpets were in good shape, they should be shampooed once or twice per week to maintain them. During an interview on 10/9/24 at 8:55 AM, Licensed Practical Nurse #2 stated the stains on the carpet were likely food and beverage. They stated there used to be a worker who regularly cleaned the carpets, but that stopped over a year ago. They stated the carpets were shampooed one or two months ago, and there was improvement seen, the carpets did not look brand new, but they looked better and clean. Licensed Practical Nurse #2 stated the carpets needed to be cleaned again or just replaced. During an interview on 10/9/24 at 11:00 AM, the Maintenance Operations Manager stated carpets in the high traffic areas needed more attention than others. Most of the stains were food and drink, and if the spill wasn't addressed right away, the stain set in. One housekeeper had been cleaning the carpets with the facility's carpet cleaning machine, but the machine was not as effective as it could be for such a large area. They stated there had been slow progress made on cleaning the carpets, but it was difficult because new stains were being created in areas where shampooing was still ongoing. During an interview on 10/9/24 at 11:38 AM, the Administrator stated when they started working at the facility in August, the condition of the carpeting was not good. They stated about one month ago, they brought in two new per diem employees with floor care experience, to work on carpet cleaning. These individuals brought in their own equipment and chemicals. Prior to that, the facility did not have an experienced team, or the proper equipment needed for carpet cleaning. The Administrator stated the carpet in certain areas needed more attention, and they had been focusing on the elevator lobbies. The facility's carpet cleaning equipment was not enough for the level of carpet problems and some stains required a different type of chemical. They stated carpet was difficult to maintain in high traffic areas, the stains were mostly food stains, and they were significant. They stated some of the lighter stains appeared as if they were from water leaks, but they could have been caused by previous improper cleaning. The Administrator stated it will take some time, and the speed of progress will depend on the carpet's current condition in each area. 10 NYCRR 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during an Abbreviated survey (Complaint # NY00354156) completed on 10/9/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (Main Kitchen) of one Kitchen and three (Units 1A/B, 1C/D, 3C/D) of five Unit Serveries. Specifically, flies were observed, there were water leaks and backups, handwash sinks were out of service, handwash sinks did not have single service towels available, surfaces of equipment were soiled, floors, walls, and ceilings were damaged and soiled, ceiling tiles were missing, there was ice buildup inside freezers, kitchen waste disposal machines were out of service, and there were unlabeled and undated food items. The findings are: The policy and procedure titled Cleaning Schedule, updated 10/2023, documented cleaning schedules are used to maintain high levels of sanitation in the Food and Nutrition Services department and serve to assign cleaning tasks to various kitchen staff members. Heavy cleaning such as under equipment, walls and floors and major equipment can be planned on a weekly basis. Review of the document titled [NAME] Main Kitchen Cleaning List/ Schedule, dated November 2023, revealed ovens, coolers, freezers, and walls were to be cleaned weekly, and hand sinks were to be cleaned three times per week. It did not list the responsible party for each task. The policy and procedure titled Labeling and Dating, updated 10/2023, documented all foods are labeled, dated, and securely covered and use-by dates are monitored and followed. The policy and procedure titled Unit Food Storage, reviewed 11/2023, documented in unit pantry refrigerators, non-personal food items such as juice, milk, canned fruit, etc. shall be dated once opened and unused portions will be discarded after three days. Also, unused foods will be discarded after three days, or less dependent on the food item. 1. Observation in the Main Kitchen on 10/7/24 from 8:50 AM until 10:40 AM revealed several live small flies in the garbage area, dishwash room, and paper products area, and one large fly in the nourishment area. There were also about 25 small dead insects observed in the unused handwash sink in the former bakery area. Continued observation revealed there were two insect light traps (an insect control method that uses a light source to attract insects, the insects fly toward the light and become trapped in a collection chamber, which is lined with sticky tape) in the Main Kitchen. One was in the garbage area, and one was in the dishwash room. The insect light trap in the garbage area was unplugged with a clean collection paper and the insect light trap in the dishwash room was operating and had a collection paper that was completely covered in dead flies. During the time of the observation on 10/7/24, the Food Service Supervisor #1 stated they were not aware of the dead insects in the former bakery area's handwash sink and it could be related to a drain backup that occurred last week, and it was concerning. They stated a licensed exterminator maintained the insect light traps. They stated there was at least a couple of hundred dead flies on the collection paper of the insect light trap in the dishwash room and the collection paper needed to be thrown out and replaced. Food Service Supervisor #1 stated the insect light trap in the garbage area was unplugged because staff kept knocking the plug with their carts. During an interview on 10/7/24 at 11:00 AM, the Director of Facilities observed the collection paper from the insect light trap in the dishwash room, in the garbage at this time, and stated they were unaware it was so full and changing the collection papers should be the responsibility of the exterminator. They stated they did not know when the collection paper was most recently changed, and the collection paper removed from the insect light trap earlier today was disgusting. Observation on the First Floor on 10/7/24 at 12:45 PM revealed one live fly was in the Unit 1 C/D Servery. There was a small insect light trap located in the servery and its collection paper had approximately 40 dead flies. Observation on the Third Floor on 10/7/24 at 1:00 PM revealed a small insect light trap was located in the Unit 3 C/D Servery and its collection paper had approximately 20 dead flies. During a second observation on 10/7/24 at 11:55 AM, several small live flies were present in the Main Kitchen's dishwash room. During a third observation on 10/9/24 at 9:50 AM, several small live flies were present in the Main Kitchen's dishwash room. During an interview on 10/8/24 at 2:15 PM, the Food Service Director stated the Main Kitchen had two insect light traps, but the insect light trap in the garbage storage area was unplugged. Insect light trap maintenance was the responsibility of the licensed exterminator, who visited the facility weekly. The Food Service Director stated the collection paper of the insect light trap in the dishwash room was pretty full. Review of the undated Commercial Pest Management Maintenance Agreement revealed it included weekly service of floor drains for small fly activity with special attention to kitchen, utility rooms, beverage stations, and service insect light traps, and spot treat for activity at time of service. Review of the most recent Summary of Service from the licensed exterminator, dated 10/3/24, revealed the comment, Insect light trap Kitchenette 3 C/D is not working properly. Please schedule service to ensure effective flying insect control, which was dated 7/18/24. Additional comments included, Insect light trap 2 is not working properly. Please schedule service to ensure effective flying insect control, which were dated 5/2/24, 12/29/22, and 11/17/22. The comment, Insect light trap 1 is not working properly. Please schedule service to ensure effective flying insect control, was dated 10/19/23. During an interview on 10/9/24 at 10:20 AM, the Director of Facilities stated a licensed exterminator visited the facility weekly and the written maintenance agreement stated the insect light trap maintenance was part of the services that they provided, which should include changing the collection papers when needed. They stated they were not aware of how many insect light traps were in the facility, and could not identify the numbering system the exterminator used to label the insect light traps. They did not know which insect light traps were reported as not working properly on the exterminator's reports. The Director of Facilities stated they did not know why the exterminator's reports indicated the insect light traps had no activity. 2a. Observation in the Main Kitchen on 10/7/24 from 8:50 AM to 10:40 AM revealed the following environmental conditions: -brown discoloration on the ceiling tile grid work in the garbage area -one ceiling tile missing between two walk-in freezers in the garbage area -one ceiling tile stained black near the walk-in dairy cooler in the garbage area -no single service towels available at the hand wash sink in the garbage area or the hand wash sink in the dry storage room -standing water on the floor inside the walk-in production cooler -brown liquid and black debris inside the collection pans under the floor grates at the grill -brown liquid drips formed along two conduit under the extinguishment hood at the grill area and on outer edge of the hood -water leak into bucket below the preparation sink located behind the grill -left side of griddle was grease laden -well at the front of griddle had a thick layer of solid grease and food debris -hand wash sink in nourishment area out of service -wall behind the cooler in the nourishment area was crumbled in an area that measured 24 inches high by six inches wide -shelf above unused stovetop was grease laden -three of three ovens in a row had doors that were grease laden with visible brown streaks and splatters -floor of walk-in egg and cheese cooler mostly rust-colored bare metal, small areas of black protective coating remained -walk-in dessert freezer had large chunks of ice on thermostat wiring on right and condenser on left, with a stainless steel pan below the condenser that was full of solid ice -three ceiling vents had visible dust above the lunch cook's area -visible dust on the one square foot vertical column at the lunch cook's area, along the top twelve inches closest to the ceiling -ceiling tile coating peeling near the vertical column at the lunch cook's area -portions of tile wall base missing at the outside corner near the beverage room, outside of the former bakery area, and near the ice machine -black and rust colored substances on ceiling vent, ceiling tile, and ceiling tile grid work inside the beverage room -gray substance on wall above windows inside the beverage room, in an area that measured three feet wide by two feet high -water damage along entire length of wall to the left in the beverage room, in a 45-degree corner that measured two feet wide on each side -floor under the three-bay sink had standing dirty liquid under the left side and dried food debris under the right side and around the chemical buckets stored at the right side -wall behind the grease trap in the former bakery area had grease splatter in an area that measured three feet wide by two feet high -four mounds of ice below the center of the condenser in the walk-in ice cream freezer, each about four inches high, plus one large chunk of ice surrounded the condenser on the left side -three-inch diameter floor drain in the center of the cart wash area had a visible layer of grime -three quarters of the ceiling tile grid work in the dishwash room had visible rust, dust, or peeling paint -multiple ceiling tiles in the dishwash room had a coating that was peeling -one ceiling tile was missing in the dishwash room -constant water drip from hose reel below the missing ceiling tile -circular ceiling speaker in dishwash room was coated in a brown and gray substance -ceiling vent in dishwash room had peeling paint -concrete block wall behind the dishwash machine had gray discoloration to the left of the machine and a black ceiling tile above the area -concrete block wall to the right of the dishwash machine, in the corner, had a pink and black speckled substance in an area that measured ten feet wide by four feet high -visible dust accumulation on the grate of the wall fan in the dishwash room -wall to the right of the dishwash machine had a black substance on the vinyl wall protectant that measured 18 inches wide by 18 inches high -standing water in the far corner of the dishwash room near the hallway door that appeared dark in color -one ceiling tile missing near combi-therm oven -liquid and food debris inside the collection pans under the floor grates at the tilt skillet Additional observation in the Main Kitchen on 10/9/24 from 9:50 AM to 10:10 AM revealed the following environmental conditions: -two of two kitchen waste disposal machines were out of service -floor drains in the dishwash room were backed up and wastewater had collected on the floor, which affected approximately 50 percent of the floor area of the dishwash room, floor drains in the center of the room were under water and the water in this area had black particles At the time of the observations on 10/7/24, Food Service Supervisor #1 stated the ceiling tile was missing between the two walk-in freezers in the garbage area due to an active condensation leak above. They stated the paper towel dispensers were battery operated and they needed new batteries at some of the hand wash sinks. The brown liquid drips under the hood were from daily grill usage and the area was cleaned twice per week, and as needed. The water leak at the preparation sink located behind the grill had been ongoing for about one month and they had put in a maintenance work order for it. Food Service Supervisor #1 stated the griddle was almost never used, but the grease on it was from the nearby deep fryer and the food debris in the well in front of the griddle was from staff members who used the griddle as a work surface to transfer food from the fryer baskets to pans. They stated the griddle needed to be cleaned. They stated high-reach areas in the kitchen needed dusting and cleaning, and there used to be a second shift maintenance staff member who helped with tasks in the kitchen, but that person was no longer available. They stated the grease trap was emptied by an outside contractor last Friday and the splatter on the wall behind it had not been cleaned. The substance on the ceiling speaker in the dishwash room was likely rust, dust, and peeling paint. The maintenance department was responsible for maintaining the ceiling and high areas in the dishwash room and they stated they were not sure when it was last addressed by maintenance. They stated about one year ago, there was a smoke incident in the dishwash room that caused an area of the wall and ceiling to be stained gray. They tried to clean the wall, but it did not come out, and the discolored ceiling tile needed to be replaced. Food Service Supervisor #1 stated they did not know what the black substance was on the vinyl wall protectant in the dishwash room, but it needed to be cleaned. At the time of the observations on 10/7/24, the Assistant Food Service Director stated the hand wash sink in the nourishment area had been out of service for three to four weeks and an outside plumber had recently come in to look at it. They stated the floor under the three-bay sink needed to be cleaned and cleaning the floor was part of the Porter's regular routine. There were usually two Porters each day, but yesterday and today, there was only one. The Assistant Food Service Director stated the standing water in the far corner of the dishwash room collected there because the floor was not level and that was the low spot. The water appeared dark because of the floor mats and the area needed to be mopped up. During an interview on 10/7/24 at 11:00 AM, the Director of Facilities stated they were not aware of any issues with ice accumulation in the walk-in dessert freezer or a water leak from the preparation sink located behind the grill. The water drip from the missing ceiling tile near the combi-therm oven was likely due to condensation from the freezer line above. The Director of Facilities stated they were aware of issues with the drain line of the hand wash sink in the nourishment area, an outside contractor had snaked the lines recently, but the problem persisted. They stated the ceiling tile grid work in the dishwash room had rust and peeling paint and needed to be replaced. The ceiling tiles in the dishwash room that had a coating that was peeling also needed to be replaced. The Director of Facilities stated maintaining the ceiling of the kitchen was the responsibility of the maintenance department and they had not assigned the task to any maintenance staff member. Cleaning any areas that were reachable was the responsibility of the dietary department, but if a ladder was needed to reach the area, it became the responsibility of the maintenance department. They stated they were not aware of the condition of the ceiling speaker and vent in the dishwash room. The walls above and behind the dishwash machine needed attention by maintenance staff because a ladder was needed, but the black substance on the wall near the dishwash machine should be addressed by dietary staff because it was reachable. The Director of Facilities stated they were not aware of the missing ceiling tile in the dishwash room or the constant water drip below, which they stated was likely due to leaking from the connection in the hose reel. 2b. Observation in the Unit 1 A/B Servery on 10/7/24 at 12:15 PM revealed a leftover container of noodle salad with a red lid and a white bag with a sandwich wrapped in white paper in the refrigerator with no name or date. Also at this time, the wall fan was operating and the outside grate on the front and back were coated with a layer of dust. During an interview on 10/7/24 at 1:05 PM, the Assistant Food Service Director stated the wall fan needed to be cleaned and maintenance staff were supposed to clean them. 2c. Observation in the Unit 1 C/D Servery on 10/7/24 at 12:35 PM with the Assistant Food Service Director and Food Service Supervisor #2 present, revealed an unopened five-ounce yogurt in the refrigerator that had a resident's name written on it, with the manufacturer's best by stamp dated 9/20/24. Also, a red bag contained grapes with no name or date. Stainless steel bins of egg salad, beets, garden salad, and tuna fish were undated in the refrigerator. There was sliced cheese wrapped in plastic cling wrap that was undated. During an interview on 10/7/24 at 12:35 PM, the Assistant Food Service Director stated the beets were served yesterday and should have been thrown out, and the egg salad and tuna fish were normally dated with today's date and brought up to the serveries from the Main Kitchen at lunchtime. They stated every day after dinner, someone from the dietary department went into each servery and looked for labels and dates on foods brought in from families. If food brought in from families was more than three days old, it would be brought to the attention of a nurse, who would inform the family. Foods from the Main Kitchen should be thrown out after three days. They stated they were not sure who the grapes belonged to or how long they had been in the servery refrigerator. During an interview on 10/7/24 at 12:35 PM, the Food Service Supervisor #2 stated one of their duties was to check serveries at the end of the evening. All prepared foods were to be discarded at the end of the evening, with the exception of egg salad and tuna fish, which needed to be labeled with a date because they could be kept for a three-day period. During an interview on 10/8/24 at 1:55 PM, the Director of Facilities stated there used to be a Maintenance Technician who worked second shift that helped with maintenance tasks in the kitchen, but that practice ended about one month ago. During an interview on 10/8/24 at 2:15 PM, the Food Service Director stated the extinguishment hood was cleaned by an outside contractor every two to three months, an outside contractor maintained the grease traps, and dietary staff cleaned out the collection pans under the floor grates on a weekly basis. They stated they were aware of the current condition of the ceiling in the dishwash room and had discussed it previously with the Director of Facilities, Maintenance Operations Manager, and former Administrator. The Food Service Director also stated the [NAME] job duties included washing dishes, pots and pans, mopping, and taking out the garbage and recycling nightly. Porters should mop under equipment in the kitchen every day. If high dusting required a ladder, it would be a maintenance staff task, but if the [NAME] could reach the area with a long broom handle, then the [NAME] should complete the task. During an interview on 10/9/24 at 9:25 AM, the Food Service Director stated tasks from the [NAME] Main Kitchen Cleaning List/Schedule were to be divided between the [NAME] and Porter. It was the Cook's responsibility to keep the kitchen equipment clean and the Porter's responsibility to keep the dishwash room clean. They stated all foods needed to be labeled and dated, including foods brought in from residents' family members. After three days, a Nurse or Food Service Supervisor should ask the resident or their family what they want done with the food. If a yogurt brought in by a resident's family had reached the best by date, it should have been brought to the resident's attention. They also stated tuna fish and egg salad should be brought to unit serveries daily and discarded nightly, but should still be labeled with the date. The Food Service Director also stated there were two kitchen waste disposal machines, one at the dishwash machine that needed a new motor and had not been used in the two years that they had worked at this facility, and one at the three-bay sink that needed new bearings. There was no power to the disposal at the dishwash machine, and the staff had to dispose of food scraps and liquids the old-fashioned way, by dumping it into bags, and special attention must be paid that the bags did not get too heavy and rip. These bags needed to be taken out three times per day. During a continued interview on 10/9/24 at 10:00 AM, the Food Service Director stated the floor drains in the dishwash room were backed up and water was collecting on the floor. They stated even though an outside contractor had cleared the lines less than one week ago, something was still an issue. The Food Service Director also stated the black particles in the water around the center floor drain were likely grease particles. During an interview on 10/9/24 at 10:00 AM, the Maintenance Operations Manager stated the floor drain in the dishwash room needed to be cleared again and if contractors cleared it last week, it should not be backing up again now. They stated floor drain backups happened occasionally and may be caused by items stuck in the drains, such as gloves, large chunks of food, or a towel. The Maintenance Operations Manager stated the facility had equipment to clear small areas of drain line but did not have the right equipment onsite to attempt to clear the main drain line. 10 NYCRR 415.14(h) SubPart 14-1 - Food Service Establishments 14-1.43, 14-1.95, 14-1.110(d), 14-1.140(a), 14-1.143, 14-1.160, 14-1.170, 14-1.171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00321782) the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs of each resident for one (Resident #2) of four residents reviewed. Specifically, medication, Adderall (central nervous system stimulant), prescribed to Resident #2 was not acquired from the pharmacy and administered as ordered, 7/16/24-7/19/24. The finding is: 1.Resident #2 had diagnosis that included attention-deficit hyperactivity disorder, joint replacement surgery and anxiety disorder. The hospital Discharge summary dated [DATE] documented Resident #2 was alert and oriented to person, place, time, and event. During an interview on 7/26/24 at 12:26 PM, Resident #2 stated they have had a terrible time with getting their medication at the facility. Resident #2 stated all they got were excuses, medication wasn't transcribed right, you're not supposed to get that, doctor hasn't approved it yet. Resident #2 stated they finally jut gave up, begging people, about their medication. Resident #2 stated they did eventually start getting their Adderall (Amphetamine-Dextroamphetamine 15 milligrams). Review of facility Order Summary Report for active orders as of 7/26/24 documented Resident #2 had active order status for Amphetamine-Dextroamphetamine (Adderall-central nervous system stimulant) 15 milligrams, 1 tablet by mouth every day for attention deficit hyperactivity disorder. The Amphetamine-Dextroamphetamine order date was 7/15/24, with a start date of 7/16/24. The July 2024 Medication Administration Record documented to administer Amphetamine-Dextroamphetamine 15 milligrams, 1 tablet by mouth every day at 9:00 AM with a start date of 7/16/24. The Amphetamine-Dextroamphetamine was not initialed as administered until 7/23/24. Between 7/16/24 through 7/22/24 the record was blank, without initials or chart/follow up codes indicated as to the rational the medication was not administered as ordered. Review of Resident #2's Controlled Substance Inventory Record dated 7/19/24 for Amphetamine-Dextroamphetamine 15 milligrams documented first dose being administered on 7/20/24 at 9:00 AM. There was no documented evidence that Resident #2 received ordered Amphetamine-Dextroamphetamine 15 milligrams from 7/16/24 through 7/19/24 (4 doses omitted). During an interview on 7/29/24 at 10:20 AM, Licensed Practical Nurse #1 stated if a medication wasn't available that was ordered they would contact the pharmacy and let the supervisor know. They stated if they didn't have Amphetamine-Dextroamphetamine 15 milligrams, Resident #2 wouldn't have received it. They stated the electronic medication administration record indicated signature pending for the availability of the Amphetamine-Dextroamphetamine 15 milligrams. They stated the pharmacy wouldn't sent the Amphetamine-Dextroamphetamine until it was confirmed with the medical provider and that they notified the Registered Nurse #5, Unit Manager. They stated that the Amphetamine-Dextroamphetamine 15 milligrams wasn't received from the pharmacy until 7/19/24. Additionally, they stated they notified Resident #2 that their Amphetamine-Dextroamphetamine wasn't available, and that Resident #2 stated they needed their medication. During an interview on 7/29/24 at 10:30 AM, Registered Nurse #5, Unit Manager, stated nobody informed them that Amphetamine-Dextroamphetamine 15 milligrams wasn't available to be given. They stated they were informed that a medical providers signature was needed by Licensed Practical Nurse #1. They stated there was a delay in communicating a signature was required to the proper medical provider and that was on them. They stated that Medical Doctor #1, the prescribing provider, wasn't notified until 7/18/24 that a signature was required by pharmacy. During an interview on 7/29/24 at 11:06 AM, Pharmacist #1 stated that an order for Amphetamine-Dextroamphetamine 15 milligrams was entered into their system for Resident #2 on 7/15/24 but the electronic script wasn't signed until 7/18/24 by a medical provider. Pharmacist #1 stated they didn't know how medical providers were notified that a signature was needed. They stated the pharmacy had to order the Amphetamine-Dextroamphetamine and that it was delivered to the facility on 7/19/24. During an interview on 7/29/24 at 11:30 AM, Medical Doctor #1 stated that if a medication isn't available, they would expect the nurse to call the pharmacy to determine why the medication isn't available, then contact, notify a medical provider to ask what could be done. They stated there needs to be communication if a controlled substance needs to be signed for. Medical Doctor #1 stated they cannot be constantly checking their application to see if a signature is needed. They stated there was a lag in being notified and there shouldn't have been. They were not informed until 7/18/24 at 10:50 AM via text that a signature for Resident #2 controlled substance was required. During an interview on 7/29/24 at 11:45 AM, Director of Nursing #1 stated they expected a Nursing Supervisor/Unit Manager to be notified if a medication isn't available so it can be investigated why it isn't available. They stated then the Primary Care Physician should be notified for instructions/orders and the conversation should be documented. 10 NYCRR 415.18(a)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00321782) the facility did not ensure that residents were free of any significant medication errors for 1 (Resident #1) of four residents reviewed. Specifically, on 5/4/24 Licensed Practical Nurse #2 erroneously administered Resident #1 another Resident's (#4) morning medications that resulted in a significant medication error. Additionally, there was no documented evidence Resident #1 was monitored per the medical providers recommendation as documented on the discrepancy form. The finding is: The policy and procedure titled Medication Administration Policy updated 9/21 documented Administration of Medication: identify resident using 2 resident identifiers (name, ID band, picture), follow five rights to medication administration. The policy and procedure titled Medication Discrepancy Form revised 12/04 documented purpose was to assure quality resident care and safe environment for all residents regarding distribution of medications and to expedite information to the nurse eliminating repeated medication errors. A medication discrepancy is defined as any deviation from established procedure for the administration of medication or acceptable standards of nursing practice. 1. Resident #1 had diagnosis including encephalopathy (disease that affects the brain), age related physical debility, and depression. The Minimum Data Set (a resident assessment tool) dated 4/26/24 documented Resident #1 had moderately impaired cognition, was usually understood, and usually understands. The comprehensive care plan initiated 4/21/24 documented Resident #1 had impaired cognitive function, and impaired long/short term memory. With an intervention that staff would anticipate needs. Review of facility Medication Discrepancy Form documented on 5/4/24 at 9:40 AM a medication error was made by Licensed Practical Nurse #2 involving Resident #1. The form documented Licensed Practical Nurse #2 got residents mixed up and gave Resident #1, Resident #4's medications. Licensed Practical Nurse #2 discovered medication error when they went to give Resident #4 their medications. No effect on Resident #1 at that time. The form documented the medical provider was notified and made recommendations to place Resident #1 on report to monitor for adverse reaction for 2 days. It was documented the responsible party was notified on 5/4/24 at 11:00 AM. Medication Discrepancy Form was signed by Licensed Practical Nurse #2 and Registered Nurse #3 Supervisor on 5/4/24. There were no additional signatures documented on the form that indicated the error was reviewed by Director of Nursing Service, Medical Doctor, or Administrator. Attached to the discrepancy form was Resident #4's medication record that highlighted which of the medications were given erroneously to Resident #1 which included Ferrous Sulfate, Senna, Clonazepam, Levetiracetam and Memantine. During an interview on 7/19/24 at 11:30 AM, Medical Doctor #1 stated they would expect to be notified immediately of medication discrepancies so the resident can be monitored for any detrimental medication interaction. Medical Doctor #1 stated they were not aware of the medication discrepancy with Resident #1 on 5/4/24. Medications given in error were reviewed at this time with Medical Doctor #1. Medical Doctor #1 stated the only significant medication given would have been the administration of the Clonazepam, cause sedation. They stated they would have monitored for lethargy and safety concerns (falls). During a telephone interview on 7/26/24 at 8:41 AM, the complainant stated they were notified by the facility around noon on 5/4/24 that Resident #1 had received the incorrect medications, that were ordered for another resident. Complainant stated they arrived about an hour later to see Resident #1, who was somnolent with altered mental status and slurred speech. Resident #1 the day after receiving incorrect medications was feeling weak, dizzy, and generally not well per the complainant. Complaint stated Resident #1 received Ferrous Sulfate (iron supplement) 325 milligrams, Senna Plus (stool softener and laxative) 8.6/50 milligrams, Clonazepam (benzodiazepine (scheduled 4 controlled substance-depressant) 0.5 milligrams, Levetiracetam (anticonvulsant-treat seizures) 250 milligrams and Memantine (used to slow progression of Alzheimer's disease) 5 milligrams. During an interview on 7/26/24 at 3:30 PM, Registered Nurse #5, Unit Manager, stated that a controlled substance given in error would be significant as you don't know how a resident was going to respond. During a telephone interview on 7/29/24 at 3:28 PM the On- Call provider stated they did not recall if they had been notified of the error and made recommendations or not. During a telephone interview on 8/1/24 at 9:00 AM, Licensed Practical Nurse #2 stated they didn't remember the whole incident but probably did give the wrong medication. They stated it would have been an honest mistake and they would have reported to it to the supervisor immediately. They stated it was important to report if the wrong medications were given in case something were to go wrong with the resident. They stated nobody followed up with them about the medication discrepancy after it occurred, and they weren't given any protocol to follow. Additionally, they stated that some nursing supervisors were more thorough than others but that they cover their butt and report any resident concerns to the nursing supervisor. b. Review of Progress Notes dated 5/4/24 at 11:56 AM, Registered Nurse #3 Supervisor documented Resident #1 was alert, drowsy, arouses easily. Verbal responses appropriate. Vital signs stable (VSS). Monitoring for adverse effects was given wrong medication. On call provider and resident representative notified. Resident #1 sitting in recliner. Frequent checks. Continued review of the progress notes revealed there was no additional documented evidence of frequent checks and monitoring completed until 5/6/24 at 9:49 PM. During an interview on 7/26/24 at 2:34 PM, the Assistant Director of Nursing stated the unit 24 Hour Report Log Sheet dated 5/4/24 was unable to be located. Review of the provided unit 24 Hour Report Log Sheets dated 5/5/24 through 5/8/24, revealed there was no documented evidence that Resident #1 was monitored for potential side effects/changes in condition and that a medication discrepancy occurred on 5/4/24. During an interview on 7/26/24 at 11:39 AM, Licensed Practical Nurse #1 stated if a medication error occurred, they would report to the supervisor, get the resident's vital signs, the medical provider and family would need to be notified. They stated recommendations given by the medical provider would be followed and they would place the resident on report. During an interview on 7/26/24 at 11:51 AM, Licensed Practical Nurse #7, Nursing Supervisor, stated it was important for the medical provider to be notified of medication discrepancy to keep communication open, so the nursing staff were properly monitoring the resident. Additionally, they stated they did not recall being notified or made aware of a medication discrepancy with Resident #1. During a telephone interview on 7/26/24 at 1:38 PM, Registered Nurse #3, Supervisor stated they recalled being notified of the medication discrepancy on 5/4/24. They stated Resident #1 was drowsy, but arousable when they assessed them. They stated they left a voicemail for the on call medical provider but didn't recall if they received a call back from the provider or if they received any new orders. They stated if they had received new orders from a medical provider, they would have placed them in Resident #1's electronic medical record. Registered Nurse #3, Supervisor, stated they discussed over the phone the medication discrepancy with Director of Nursing #2 and that all the forms/paperwork for the discrepancy were left for them to review. Additionally, they recalled speaking with the complainant and reassured them that they were monitoring Resident #1. They stated that it is important to monitor a resident after a medication discrepancy in case there was a reaction or change in a resident's condition. During an interview on 7/29/24 at 12:30 PM, the Director of Nursing #1 stated they would expect nursing staff to evaluate a resident for 48-72 hours for adverse reactions after administration of the wrong medications and for evaluations to be document in the resident's progress notes. They stated process was not followed and there was not documented evidence that Resident #1 was monitored. Attempts made on 7/29/24 at 8:51 AM and 8/1/24 at 9:27 AM to contact Director of Nursing #2 with no response or return call. 10 NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the standard survey completed on 10/27/23, the facility did not ensure that each resident had the right to choose aspects of their lives, in the facility, that are significant to them. Specifically, one (Resident #29) of four residents reviewed for choices was not given the choice to get out of bed when they wanted to. The finding is: Review of the undated document labeled Resident's [NAME] of Rights documented that each resident had the right to dignity, independent decision-making, and respect. 1.Resident #29 had diagnoses that included Multiple Sclerosis (MS- a chronic progressive disease whose symptoms may include numbness and impaired muscular coordination), generalized weakness and neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS- a resident assessment tool) dated 9/15/23 documented the resident understood and understands and was cognitively intact. The MDS also documented that Resident #29 was totally dependent for transfers and was a two-person physical assist. The [NAME] (guide used by staff to deliver care) as of 10/27/23, documented Resident #29 was independent in choosing when they get up or go to bed. The comprehensive care plan (CCP) initiated 4/29/22 documented that Resident #29 could make their needs and wants known without difficulty. Additionally, they were independent in choosing when they wanted to get up and go to bed. During an observation and interview on 10/23/23 at 11:17 AM, Resident #29 was in bed and stated they would prefer to be washed up in the morning, but the aides don't generally get them washed up until after lunch. The resident stated they had asked staff earlier that morning to get them up. During an observation on 10/25/23 at 8:30 AM Resident #29 was in bed having breakfast. During an interview on 10/25/23 at 9:35 AM, Certified Nursing Aide (CNA) #6 stated that the shortage of clean linen was an issue because it caused a delay in getting residents out of bed and prevented them from providing proper care. During an interview on 10/25/23 at 9:50 AM, Licensed Practical Nurse (LPN) #9 stated that the shortage of clean linen caused a delay in care for the residents. LPN #9 stated they often went to other units or the basement to obtain clean linens. During an observation and interview on 10/25/23 at 10:03 AM, Resident #29 was still in bed and stated they had not received their AM care yet because there wasn't any clean linen. During an observation and interview on 10/25/23 at 12:01 PM, Resident #29 was observed in their bed, wearing a nightgown. They stated that they would have preferred to have their shower in the morning, but the CNA told them they would have to wait until after lunch. During an interview on 10/26/23 at 9:55 AM, CNA #8 stated that it was undignified to make residents stay in bed when they want to get up, but they are not always able to get them up in the mornings because they don't have enough clean linen. During an interview on 10/26/23 at 10:26 AM LPN #10 Unit Manager (UM) 2nd floor stated that residents should be provided proper care, 24 hours a day, whenever they needed it. LPN #10 UM stated residents shouldn't have to wait to get out of bed. During an interview on 10/27/23 at 11:41 AM, Registered Nurse (RN) #3, Acting Director of Nursing (DON), stated that not providing proper care to residents was a dignity issue and should be provided upon the resident's request. During an interview on 10/27/23 at 12:00 PM, the Administrator stated that it wasn't ideal that residents should have to wait for care, but sometimes things happened. Additionally, the Administrator stated residents should be provided incontinent care, if needed, before being served breakfast. 415.5 (b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes reviewed for two (Resident #72, 140) of two residents reviewed for advanced directives. Specifically, the MOLST (Medical Orders for Life -Sustaining Treatment) in the resident's medical record (paper chart) did not coincide with the electronic medical record including (EMR, Medication Administration Record (eMAR), physician orders, care plans and closet care plans. The findings are: The policy and procedure (P&P) titled Advanced Directives revised 5/16 documented upon completion of a MOLST the original paperwork is placed in the medical record. The P&P titled CPR revised 11/21 documented CPR (cardiopulmonary resuscitation) will be initiated according to the resident's advanced directives on file. When a resident is identified as unresponsive, the resident's chart will be reviewed to determine the code status. 1. Resident #72 had diagnoses included anxiety, stage 4 (full thickness tissue injury exposing bone/muscle) pressure ulcer of sacral region, and muscle weakness. The Minimum Data Set-(MDS - a resident assessment tool) dated [DATE] documented Resident #72 was cognitively intact, was understood and was able to understand others. The comprehensive care plan dated [DATE], documented Resident #72's advanced directives as Do Not Resuscitate (DNR) with a revised date of [DATE]. Review of the physician's Order Summary dated [DATE], revealed Resident #72 had a DNR order. Review of the MOLST dated [DATE], documented an order for Cardio-Pulmonary Resuscitation (CPR, provision of emergency measures including artificial ventilation and chest compressions in the absence of breathing and/or heart rate) in section A. The interdisciplinary progress notes dated [DATE], Social Worker (SW) #1 documented Resident #72 remained with a DNR order. Review of the closet care plan (guide used by staff to provide care) dated [DATE], documented Resident #72's code status as DNR. During an interview on [DATE] at 8:45 AM, Licensed Practical Nurse (LPN) #5 stated they would look in the electronic medical record (EMR/eMAR) first, then the MOLST for a Resident's the code status. During interview on [DATE] at 8:49 AM, Registered Nurse (RN) #3 Acting Director of Nursing stated that Resident #72's MOLST form documented a CPR order, and the electronic medical record (EMR/eMAR) documented a DNR order. RN #3 stated that was a problem; they conflicted and could result in delayed care or go against the resident wishes. Additionally, they stated MOLST forms were updated every 3 months and signed by provider. During an interview on [DATE] at 8:59 AM, Nurse Practitioner (NP) #2 reviewed Resident #72's orders and the MOLST. NP #2 stated the Social Worker needed to update, they both should match, if an emergency occurred, care could be delayed. Additionally, NP #2 stated nurses show them the MOLST forms, and they just sign it. During an interview on [DATE] at 9:22 AM, SW #1 stated they usually go over the MOLST form with residents and inform the nurses so they can change the code status in electronic medical record (EMR, eMAR), and care plan. They were updated quarterly based on resident wishes. 2. Resident #140 had diagnoses which included dementia, congestive heart failure (CHF), and hypertension (HTN). The MDS dated [DATE] documented Resident #140 was moderately cognitively impaired, was usually understood and usually understands. The closet care plan dated [DATE] documented Resident #140 code status as a Full Code (requiring CPR). The comprehensive care plan revised on [DATE] documented Resident #140's advanced directives as having a MOLST, DNR/DNI (Do not intubate), and limited medical intervention. The Order Recap Report dated [DATE] through [DATE], revealed an active order dated [DATE] that documented Resident #140 had a MOLST with a Full Code status. Review of the electron Medication Administration Record (eMAR) dated 10/2023 documented Resident #140 had a MOLST with a Full Code status. Review of Resident #140's MOLST dated [DATE] witnessed by SW #1 and signed by NP #2 revealed a DNR status. The Social Work Progress Notes dated [DATE], the Director of Social Work documented they were aware of a new MOLST with DNR/DNI and limited medical intervention. The Social Work Plan of Care Note dated [DATE] revealed SW #1 documented an annual care plan meeting was held [DATE]. The plan was reviewed by the team. Resident #140 remained a Full Code with MOLST on file. During observation and interview on [DATE] at 2:36 PM, Licensed Practical Nurse (LPN) #12 stated when the eMAR differentiated from the MOLST it caused concern and delays treatment. LPN #12 verified Resident #140's eMAR documented MOLST-Full Code. During an interview on [DATE] at 9:22 AM, the Director of Social Work stated Resident's #140's MOLST and comprehensive care plan reflected a DNR status as of [DATE]. Unit Mangers were responsible to ensure the eMAR and the MOLST matched with the CCP and closet care plan. The Director of Social Work stated Resident #140's physicians orders and eMAR should have been updated to reflect DNR on [DATE], were not and could cause confusion during a medical emergency. During an interview on [DATE] at 11:02 AM, LPN #10 Unit Manager (UM) stated they were not aware of the change in advanced directives for Resident #140 on [DATE] therefore they did not enter the new DNR status into the computer system. During an interview on [DATE] at 11:09 AM, RN #3 Acting Director of Nursing stated during an emergency nurses verified with the MOLST form in the medical record. LPN #10 should have entered the DNR order into the computer based on Resident #140's wishes. At the end of the day we need a better process. During an interview on [DATE] at 1:55 PM, the Administrator stated nurses should check the MOLST and determine a resident's code status. The MOLST, comprehensive care plan, closet care plan, physicians' orders, the electronic medical record (EMAR and eMAR) and the dashboard were all expected to match to provide the appropriate treatment. 10 NYCRR 400.21

Based on observation, interview, and record review conducted during a Standard survey completed on 10/27/23, the facility did not ensure that all alleged violations involving abuse, including injuries of unknown source, are reported immediately, but not later than two hours after the allegation is made, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State Law through established procedures for one (Resident #466) of three residents reviewed for abuse. Specifically, an injury of unknown origin (a bruise to beneath their left eye) was not reported to the Administrator of the facility which resulted not being reported to the State Agency within the required time frames. The findings are: The policy and procedure (P&P), titled Abuse Prohibition: Screening/Training/prevention/Identification, Investigation, Reporting/protection of Resident/Employee/Coordination with QAPI, dated 8/2022 documented that facility staff identifying alleged abuse must report immediately to the nursing supervisor. The supervisor will then notify the Director of Nursing or designee immediately. Additionally, the policy documented that staff need to understand their responsibility in the reporting system. 1. Resident #466 had diagnoses of anxiety, depression, and dementia. The Minimum data Set (MDS-a resident assessment tool) dated 10/21/23 documented Resident #466 had severe cognitive impairments. The comprehensive care plan (CCP) dated 10/21/23 did not address the bruising/injury to Resident #466's face. Review of the 24- hour Nursing Report sheets dated 10/20/23 to 10/26/23, revealed there was no documented evidence addressing the bruising/injury to Resident #466's eye. Review of the interdisciplinary Progress Notes dated 10/20/23 to 10/26/23 revealed there was no documented evidence of bruising or injuries to the left side of Resident #466's face. Review of the Nursing Admission/Readmit Screener - VI signed 10/21/23 revealed no evidence of bruising/injury to Resident #466's face. Review of the physician's History and Physicals dated 10/23/23 and 10/24/23 revealed there was no documented evidence addressing the bruising/injury to Resident #466 face. During intermittent observations from 10/23/23 to 10/26/23 between 10:00 AM and 2:00 PM, Resident #466 had a quarter size pink/purple bruise noted below their left eye. During an interview on 10/25/23 at 3:40 PM, Registered Nurse Supervisor (RNS) #5 stated they did not recall a bruise to Resident #466's face when they were admitted and that they only did a part of the admission assessment. RN #5 stated if any skin issues were present upon admission, they would have documented the issue on the admission assessment form. During an observation and interview on 10/26/23 at 7:42 AM, RNS #4 stated there was a purple area to the left side of Resident #466's face, it looked like a bruise or an abrasion, and that they had not noticed it before. During an interview on 10/26/23 at 7:51 AM, Certified Nurse Aide (CNA) #5 stated the bruise to Resident #466's face was there since the resident arrived at facility. CNA #5 stated they reported the bruise to Licensed Practical Nurse (LPN) #6 they thought about 2 days ago. During an interview on 10/27/23 at 11:03 AM, the Assistant Director of Nursing (ADON) stated they completed Resident #466's admission assessment, thoroughly assessed the resident, and that they did not note any bruising or abrasions to their face. The ADON stated they expected staff to report bruises/abrasions to the Unit Nurse or Supervisor. The ADON stated, RNS #4 made them aware of the bruising on 10/26/23. The ADON stated they had not had time to document and that injures of unknown origin should be reported within 2 hours. During a telephone interview on 10/27/23 at 1:05 PM, LPN #6 stated they did not recall any bruising or abrasions to Resident #466's face and did not recall anyone reporting it to them. LPN #6 stated if someone had reported a bruise to them, they would have reported it to the Nursing Supervisor. During an interview on 10/27/23 at 11:13 AM, the Administrator stated they were not made aware of the injury until 10:00 AM today (10/27) and would have expected any injuries of unknown origin to be reported, so an investigation could have proceeded. The Administrator stated the injury should have been reported within 2 hours. 10NYCRR 415.4 (b)(4)

Based on observation, interview, and record review conducted during a Standard survey completed on 10/27/23, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that alleged violations are thoroughly investigated for one of three residents (Resident # 466) reviewed. Specifically, there was a delay in the initiation of an investigation into a bruise of unknown origin to the resident's face. The finding is: Review of policies and procedures (P&P), titled Abuse Prohibition: Screening/Training/prevention/Identification, Investigation, Reporting/protection of Resident/Employee/Coordination with QAPI, dated 8/2022 documented Facility staff identifying alleged abuse must report immediately to the nursing supervisor. The Supervisor then will notify the Director (DON) of Nursing or Designee immediately and a formal investigation will begin. If there is an injury of unknown origin, staff members assigned to the unit for the 24 hours prior to the discovery of the injury must provide statements to determine cause the injury. 1. Resident #466 had diagnoses of anxiety, depression, and dementia. The Minimum data Set (MDS-a resident assessment tool) dated 10/21/23 documented Resident #466 had severe cognitive impairments. During an observation on 10/23/23 at 10:15 AM, Resident #466 had a quarter size pink/purple bruise noted below their left eye. The resident was unable to state how it occurred. On 10/24/23 at 3:00 PM, the Administrator was asked to provide accident and incident investigations for Resident #466, and none were provided by the facility. During an observation and interview on 10/26/23 at 7:42 AM, RNS #4 stated there was a purple area to the left side of Resident #466's face, it looked like a bruise or an abrasion, and that they had not noticed it before. Additionally, they stated they should start an accident and incident investigation. During an interview on 10/26/23 at 7:51 AM, Certified Nurse Aide (CNA) #5 stated the bruise to Resident #466's face was there since the resident arrived at facility. CNA #5 stated they reported the bruise to Licensed Practical Nurse (LPN) #6 they thought about 2 days ago. During a telephone interview on 10/27/23 at 1:05 PM, LPN #6 stated they did not recall any bruising or abrasions to Resident #466's face and did not recall anyone reporting it to them. During an interview on 10/27/23 at 11:03 AM, the Assistant Director of Nursing (ADON) stated they were informed on 10/26/23 in afternoon about Resident #466's abrasion on face. The ADON stated they spoke Resident #466's husband and spoke with staff but did not document the investigation until 10/27/23 and they should have documented it was reported to them. During an interview on 10/27/23 at 11:13 AM, the Administrator stated they were notified by the ADON at 10:00 AM today about the injury. LPN #6 should have reported the injury immediately to the Nursing Supervisor so an investigation could have proceeded. They expected the ADON to complete an investigation within 5 days of the allegation of abuse. 10NYCRR 415.4 (b) (3)

Based on observation, interview, and record review conducted during the Standard survey completed 10/27/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #87) of five residents reviewed for ADLs. Specifically, Resident #87 was observed with dark debris under their fingernails. The finding is: The policy and procedure (P&P) titled Baths/Showers/Bed Baths revised 1/17 documented on a weekly basis the charge nurse will be responsible for checking the resident's fingernails are cut, clean and filed on their bath day. The Certified Nursing Assistants (CNA) will be responsible for the resident's nails to be cut, clean and filed daily. 1. Resident #87 had diagnoses that included hemiparesis (weakness on one side of the body) of left side, right wrist fracture, and glaucoma (an eye condition that can cause blindness). The Minimum Data Set (MDS- a resident assessment tool) dated 7/27/2023 documented Resident #87 was always understood, always understands, was cognitively intact and did not reject care. Additionally, the MDS documented Resident #87 had severely impaired vision and required extensive assistance for personal hygiene. The comprehensive care plan (CCP) dated 9/27/23 documented Resident #87 had an ADL, mobility deficit and required moderate assistance for personal hygiene. The CCP further documented Resident #87 had impaired visual function related to legal blindness, glaucoma, macular degeneration (an eye disease that causes vision loss), and dry eye syndrome. Review of the closet care plan dated 10/26/23 documented Resident #87 required moderate assistance for personal hygiene. Additionally, it documented diabetic nail care to be done by the nurse. Review of the Treatment Administration Record dated 10/1/23-10/31/23 documented Resident #87 did not refuse their showers or nail care on 10/11/23, 10/18/23 and 10/25/23. Review of the nursing Progress Notes from 10/1/23 at 11:59 PM to 10/25/23 at 12:55 PM revealed Resident #87 had no refusals of nail care. Based on observation and interview on 10/23/23 at 11:50 AM, Resident #87's fingernails were approximately 0.25 (inches) long with dark brown debris under them. Resident #87 stated they did not like their nails that long, they would rather have their nails clipped flush against the tip of their fingers. Resident #87 stated they told a staff member they wanted their fingernails trimmed more but they did not know who the staff member was because they were blind and could not see them. Resident #87 stated they could not remember the name of the staff member they talked to. During an observation on 10/23/23 at 2:19 PM, Resident #87 was in their room eating a sandwich, holding the sandwich with their left hand. Resident #87's fingernails of their left hand had dark brown debris under them. During an observation on 10/24/23 at 2:34 PM, Resident #87's fingernails were long with dark debris under them, on both right and left hands. During in observation on 10/25/23 at 12:36 PM, Resident #87 was in the dining room and was feeding themselves peas and carrots, using their left fingers. Resident #87's fingernails, on both their right and left hands, were long and had dark brown debris under them. During an interview on 10/25/23 at 1:44 PM, CNA #1 stated they provided incontinent care to Resident #87 in the morning. CNA #1 stated Resident #87 was compliant with care in the morning. CNA #1 stated they noticed Resident #87's nails were dirty, but they did not attempt to clean the nails because they did not think Resident #87 would allow them to provide nail care. CNA #1 stated Resident #87 usually refused care, so that was why they did not attempt to clean their nails. CNA #1 stated CNAs were responsible for nail care. CNA #1 stated they were going to let the nurse know that Resident #87 had dirty nails, but they did not let the nurse know yet. During an interview on 10/25/23 at 1:47 PM, Licensed Practical Nurse (LPN) #8 stated they were not told that Resident #87 had dirty nails on 10/26/23 by the CNA. LPN #8 stated they have seen Resident #87 eat with their hands. LPN #8 stated they would tell Resident #87 not to eat with their hands, but they were very independent and didn't like being told what to do. LPN #8 stated it was hard to say what the debris was under Resident #87's nails. LPN #8 stated Resident #87 was supposed to have a shower on evening shift of 10/25/23 and usually they would clean and cut the resident's nails then. LPN #8 stated they would look at Resident #87's nails and attempt to clean and cut them. LPN #8 stated Resident #87 was dependent on the staff to provide care. During an interview on 10/26/23 at 1:21 PM, LPN #2 stated they expected the CNAs to check and clean resident fingernails daily. LPN #2 stated if a resident refused care, the CNA should bring it to the nurse's attention, and it should be documented. LPN #2 stated CNA #1 should have attempted to clean Resident #87's nails earlier in the day and if Resident #87 refused, they should have notified the nurse earlier in the day, not the end of the day. LPN #2 stated it was expected any refusal would be documented in the progress notes. LPN #2 stated there was a potential for a problem with the debris under the nails and then eating food using fingers. LPN #2 stated the nurses had a good rapport with Resident #87 and they would have been able to clean the nails if Resident #87 refused. LPN #2 stated it was their responsibility to make sure the CNAs and LPNs on the floor were completing care for the residents. During an interview on 10/26/23 at 3:35 PM, Registered Nurse (RN) #3 Acting Director of Nursing (DON) stated every time the staff saw that residents had dirty nails, they should have cleaned them. RN #3 stated when a resident refuses care, it was expected the staff notify the unit manager or supervisor and write a progress note. RN #3 stated there was a lot of bacteria behind nails and if the resident put their fingers in their mouth or scratched their face, that could have caused an infection. During an interview on 10/27/23 at 11:36 AM, the Administrator stated, it was expected that resident nails were clean. The Administrator stated if Resident #87 had refused care, then it should have been attempted again at a different time. The Administrator stated it was expected the CNA attempted to clean Resident #87's nails every morning and CNA #1 should have alerted LPN #8 earlier in the day. The Administrator stated it was not expected for residents to eat with dirty nails. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, conducted during the Standard survey completed on 10/27/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for four (Resident # 56, #11, #79, #147) of 10 residents reviewed for quality of care. Specifically, Resident #56 was not provided with compression stockings as ordered, Resident #11 was administered a medication without a physician's order, and Resident #79's oxygen was not administered as ordered. Additionally, Resident #147 lacked evidence that blood sugars were obtained and Humalog insulin per sliding scale was administered as ordered. The findings are: Review of the policy and procedure (P&P) titled Medication Administration Policy revised and dated 9/2021 documented the facility was to ensure that all medications are administered properly per regulatory guidelines, and to follow the five rights of administration. The P&P, titled medication Treatment Nurse check dated 7/18/2015 documented purpose to ensure accurate and treatment sheets. The P&P titled Glucose Testing- Use of Glucometer date revised 10/18 documented it shall be the policy to perform finger stick blood glucose testing on those residents medically require per MD (physician) order, and per nursing judgement if signs and symptoms of hypo/ hyperglycemia is noted. Under procedure record finger stick blood glucose results on the eMAR (electronic medication administration record) and follow MD orders for specific resident's fingerstick results. The P&P titled Oxygen Therapy, revised 5/19, documented the procedure for administering oxygen is to obtain an order, from a Medical Doctor (MD) or Nurse Practitioner (NP), for oxygen, which includes the method of administration, flow rate, and frequency. It also documented to apply the oxygen per the MD/NP orders. 1.Resident #56 had diagnoses that included renal insufficiency, anemia, and hypotension. The Minimum Data Set (MDS- a resident assessment tool) dated 9/15/2023 documented Resident #56 was cognitively intact, was understood and was able to understand others. The Comprehensive Care Plan (CCP) dated 10/25/23, documented Resident #56 had a potential fluid deficit and included TED stockings (compression stockings (TEDs, thromboembolism deterrent stockings - elastic stockings used to prevent blood clots) were to be applied in morning, removed at night, and legs were to be elevated when resting. The physician orders summary report for Resident #56 dated 10/25/23, revealed an order dated 10/13/23 for TED stockings to be put on every day and evening shift for edema (swelling). Review of Treatment Administration Record (TAR) dated 10/13/23 to 10/24/23, documented that TEDS stockings were signed by nurses as applied and removed. During multiple observations on dates 10/23/23 and 10/24/23 between 9:00 AM and 2:00 PM Resident #56 did not have their TED stockings on as ordered. During an interview on 10/23/23 at 12:26 PM, Resident #56 stated they were waiting for TED stockings and stated it's been 2 weeks, since my doctor ordered them for me. During an interview on 10/24/23 at 2:34 PM, Certified Nurse's Assistant (CNA) #2 stated they did not see TED stockings for Resident #56. During and observation and interview on 10/24/23 at 2:51 PM, Registered Nurse Supervisor (RNS) #1 referred to the Treatment Administration Record (TAR) and stated that the TEDs were being signed off as applied & removed. RNS #1 stated they should have measured Resident #56 for TEDs and obtained stockings from the pharmacy. RNS #1 stated that the night shift nurse should be applying the TEDs, and the evening shift nurse should be removing them. During an interview on 10/24/23 at 3:10 PM, Registered Nurse (RN) #3 (the Acting Director of Nursing) stated they expected orders for the TED stockings to be implemented within one to two days and was not aware Resident #56 needed TED stockings. Nurses should be verifying the treatments they sign for in TAR, if not that would be falsification of documents. RN #3 stated the 11 PM-7 AM nurses were responsible for order audits. During a telephone interview on 10/25/23 at 8:25 AM, Licensed Practical Nurse (LPN) #2 stated they did not recall Resident #56 wearing TED stockings, but they ask the CNA responsible and then document in TAR. During interview on 10/27/23 at 1:48 PM, Nurse Practitioner (NP) #1 stated they ordered the TEDS on 10/13/23 and expected orders to be implemented within 1 to 2 days. They stated that TEDS stockings were important for the resident's lower leg edema and to promote venous return. 2. Resident #11 had diagnoses that included chronic kidney failure, congestive heart failure, and chronic pain. The MDS dated [DATE] documented Resident #11 was cognitively intact, was understood and was able to understand others. During a medication pass observation on 10/24/23 at 9:23 AM, LPN #7 administered the following medications to Resident #11: - Bumetanide 1mg (diuretic - medication that promotes excretion of urine)- multidose pack (medication packaging bundles together by date and time) - Wellbutrin ER 100mg (antidepressant, extended release)- multidose pack - Lexapro 10mg (antidepressant) - multidose pack - Metoprolol ER 25mg (used to lower blood pressure)-multidose pack - Gabapentin 300mg (used to treat seizures and nerve pain)- multidose pack - Zofran 4mg (used to treat nausea)- multidose pack - Norco 10-325mg (narcotic pain medication) - Aspirin 81 milligrams (mg) - Probiotic 1 capsule (supplement) - Vitamin B12 ER 1000 micrograms (mcg) (supplement) During the observations LPN #7 verbalized the names of the drugs being administered and put all the medications into a plastic medicine cup. Review of the physicians' orders revealed Bumex 1mg by mouth daily was discontinued on 10/20/23. Review of the Medication Administration Record (MAR) dated 10/1/23 -10/31/23, revealed the Bumex 1 milligram (mg) was discontinued on 10/20/2023. During interview on 10/24/23 at 12:45 PM, RN #3 (Acting Director of Nursing) stated they expected the nurses to follow the five rights on medication administration and to verify in the eMAR (electronic medical record) that the medication was ordered. RN #3 stated that when a medication was discontinued, it should be removed from the drawer. RN #3 stated the Bumex for Resident #56 had been discontinued. During a telephone interview on 10/25/23 at 1:28 PM, NP #3 stated they made several changes to Resident 56's diuretic due to chronic kidney failure. NP #3 stated they expected nurses to implement orders within a day for medications. They stated too much diuretic could cause worsening kidney failure. During an interview on 10/25/23 at 3:20 PM, LPN # 7 stated they gave Resident #56 the Bumetanide and did not realize it was discontinued as it was in med cart. 3. Resident #147 had diagnoses that included type 2 diabetes mellitus (DM), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and hypertension (HTN- high blood pressure). The MDS dated [DATE] documented Resident #147 was sometimes understood, sometimes understands and was severely cognitively impaired. Receives insulin injections. Review of the Order Review History Report dated 10/26/23 revealed Humalog Kwik Pen (a pen that's prefilled with insulin) Subcutaneous (beneath the skin) Solution Pen-Injector 100 UNIT/ML (milliliters). Inject as per sliding scale: if (blood sugar) 140-169=2 Units; 170-209=3 Units; 210-249=4 Units; 250-289=6 Units; 290-329=7 Units; 330-379=8 Units; 380-450=10 Units. If FS (finger stick blood sugar) >450 give 10 Units and Call MD/ NP. If FS 70 call MD/ NP, subcutaneously before meals and at bedtime for IDDM (insulin dependent diabetes mellitus) with a start date of 3/11/23. The untitled CCP initiated 3/20/23 revealed Resident #147 had diabetes mellitus and included interventions that diabetes medication and fasting serum blood sugar as ordered by doctor. Review of the Medication Administration Record dated between March 11, 2023, through October 26, 2023, under the scheduled medication Humalog Kwik Pen subcutaneous Solution Pen-Injector 100 UNIT/ML. Inject as per sliding scale: if 140-169=2 Units; 170-209=3 Units; 210-249=4 Units; 250-289=6 Units; 290-329=7 Units; 330-379=8 Units; 380-450=10 Units. If FS (fasting sugar) >450 give 10 Units and Call MD/ NP (Nurse Practitioner). If FS 70 call MD/ NP, subcutaneously before meals and at bedtime for IDDM revealed blanks for both the BS (blood sugar) and amount of insulin given for the following: -March 2023 had 1 blank -April 2023 had 3 blanks -May 2023 had 5 blanks -June 2023 had 7 blanks -July 2023 had 17 blanks -August had 11 blanks -September had 2 blanks -October had 3 blanks Review of the progress notes between March 11, 2023, through October 26, 2023, revealed no there was no documented evidence regarding blood sugars or insulin were administered. During a telephone interview on 10/27/23 at 8:53 AM, LPN #11 stated they have a side paper with an itinerary for each resident in which they record the medication passes on and then go into the eMAR later and document it. LPN #11 stated this was not how they were supposed to do it and they should be documenting directly into the eMAR after the medication was given. During an interview on 10/27/23 at 10:38 AM, LPN #10 Acting Unit Manager stated all the nurses were to have documentation for each medication in the eMAR and should not be leaving blanks. It is an issue that there were blanks as you do not know if the resident had their finger sticks done and received their insulin. During an interview on 10/27/23 at 10:51 AM, RN #3 (Acting Director of Nursing) stated they expected all the staff to fill in the eMAR whether medications were given or refused. They stated they should not be leaving any blanks and would assume the fingerstick was not done if there was a blank. During a telephone interview on 10/27/23 at 11:25 AM, the Consultant Pharmacist stated they would expect the nurses to be documenting in the eMAR when they were providing any kind of medication even if the resident refuses. They stated there should not be any blanks. It is important with this medication because it would indicate if the resident has had a loss of glycemic control. During an interview on 10/27/23 at 12:23 PM, MD #1 stated they would expect the nurses to follow the doctor's orders and document whether the medication was given. They stated this medication, if not given could affect the resident's blood sugar levels. 4. Resident #79 had diagnoses that included chronic obstructive pulmonary disorder (COPD- a chronic lung disease characterized by shortness of breath), anemia, and generalized muscle weakness. The MDS dated [DATE], documented the resident understood and understands, was cognitively intact, and received oxygen. The CCP initiated 3/17/23, documented Resident #79 had the potential for altered respiratory status related to COPD and received oxygen at 2 liters per minute (LPM) via nasal cannula (NC). The Order Review History Report documented an order for oxygen at 2 LPM via NC. During intermittent observations on 10/23/23 at 10:15 AM, 10/25/23 at 8:17 AM and 1:19 PM and on 10/26/23 at 8:32 AM and 8:45 AM, Resident #79 was receiving oxygen at 4.5 LPM via NC. The Treatment Administration Record (TAR), from 10/23/23 to 10/26/23, documented Resident #79 received oxygen at 2 LPM via NC every shift. Nursing staff documented on the TAR that the order was completed. During an interview on 10/25/23 at 1:19 PM, Resident #79 stated that their oxygen should be set at 2 LPM. Additionally, Resident #79 stated they do not adjust their own oxygen. During an interview on 10/26/23 at 8:35 AM, CNA #6 stated that the CNA's did not adjust the residents' oxygen. They stated that was the responsibility of the nurses. During an interview on 10/26/23 at 8:45 AM, LPN #9 stated that Resident #79 was supposed to be receiving oxygen at 2 LPM. LPN #9 stated that it was important to follow the physician's order for the oxygen flow rate, because the resident had COPD, and too much oxygen could cause the resident to have more difficulty breathing. During an interview on 10/26/23 at 1:33 PM, RN #3 (Acting Director of Nursing) stated they expected the nursing staff to apply the oxygen as ordered by the physician. They stated that if a resident with COPD was ordered to be on 2 LPM of oxygen, and was given 4.5 LPM, it could cause them to go into respiratory distress. During an interview on 10/27/23 at 12:38 PM, MD #1 stated they expected nursing staff to deliver oxygen for residents at the prescribed rate. MD #1 stated that it was important to have oxygen at the prescribed rate because receiving too much oxygen could lead to hypoxia (low blood oxygen level) and shortness of breath. 10NYCRR 415.12

Based on observation, interview and record review conducted during a Complaint Investigation (Complaint #NY00323013) during the Standard survey completed on 10/27/23, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. Specifically, Certified Nurse Aide (CNA) #10 was not wearing a N95 mask while caring for Resident #266 who tested positive for COVID-19, and they donned/doffed (putting on/ taking off) their PPE (personal protective equipment) in the hallway outside of the resident's room. In addition, the precaution infectious waste bin was placed next to the clean PPE stand outside of the resident's room in the hallway. The finding is: The policy and procedure titled Infection Control Policy updated 7/2023 documented it is the policy of the facility to provide safe, sanitary, comfortable living environment and reduce the risk of acquiring and transmitting communicable diseases and infections for all residents, staff, volunteers, visitors including other individuals providing services under a contractual arrangement. The facility will ensure Infection Prevention and control program is compliant with Federal and State regulatory requirements as well as evolving approaches to management of infection in the nursing home. PPE will be worn by staff with residents on isolation precautions which includes gowns, gloves, mask, and/ or eye wear, if necessary, based on preventing transmission of infection. Isolation precaution setup includes proper signs outside the resident's room, a storage bin that contain PPE will be located outside the door. Upon entering the room, donning of PPE will be completed. Prior to exiting the room, the PPE will be removed properly and disposed of in the precaution bin located in the room. 1. Resident #266 had diagnoses including COVID-19, chronic ischemic heart disease (heart's arteries are narrowed by plaque, reducing blood flow) and bradycardia (slow resting heart rate). The MDS (minimum data set) dated 10/16/23 documented resident is understood, usually understands, and is cognitively intact. Review of the progress notes dated 10/23/23 at 9:44 AM revealed the resident had complaints of chest congestion, coughing, and nausea. The MD ordered a COVID-19 swab which was positive, the resident was made aware, and isolation was initiated. During an observation on 10/23/23 at 12:18 PM, CNA #10 donned the following PPE: gloves, gown, regular surgical face mask, and face shield in the hallway outside of Resident #266's room. They then went and got Resident #266's lunch tray and went into their room. CNA #10 then came out of room with the full PPE still on and doffed it off outside the room and the neighboring resident's room in the hallway. They placed the worn PPE in the precaution waste bin that was directly next to the clean PPE bin outside the room and in the hallway. CNA #10 then walked across the hall to wash their hands. Housekeeper #1 was standing at their cleaning cart within six feet of where CNA #10 was doffing the PPE talking with CNA #10. Outside Resident #266's door there was a stop sign posted and two precaution signs one for droplet precautions and one for contact precautions. Next to the door frame outside the room in the hallway against the wall was the bin full of PPE equipment that contained N95 masks, gowns, gloves, and face shields. The precaution waste bin was directly next to the PPE bin. During an interview on 10/23/23 at 12:26 PM, CNA #10 stated they should have been wearing an N95 mask but there were none outside the door in the PPE bin. They stated they should have asked the manager for one but did not. They stated they doffed their PPE outside the room in the hallway because that was where the garbage bin was. They stated when a resident was on precautions the garbage bin is normally inside the room but that it wasn't and that is why they had to come out in the hallway to doff their PPE. During an interview on 10/23/23 at 12:31 PM, Housekeeper #3 stated they have worked on the COVID-19 unit before and that the waste bin should be in the room and not outside in the hallway. They stated when they go into that room to clean today, they will move the waste bin into the room. During an interview on 10/23/23 at 12:44 PM, LPN (Licensed Practical Nurse) #13 stated they did not set the PPE up like that. They stated it was an infection control issue with the waste basket outside the door and that it should be inside the room so staff can doff everything in the room. During an interview on 10/26/23 at 3:37 PM, Registered Nurse (RN) #3 Acting Director of Nursing/IP Infection Preventionist (IP) stated when a resident tested positive for COVID-19, it was expected the PPE tote would be placed outside the resident's room. The PPE tote was filled with gowns, gloves, face shield and N95 masks. The IP stated it was expected staff don the correct PPE including an N-95 mask. The IP stated there would also be signs placed on the door to let staff know what PPE should be used. The IP stated it was expected staff would doff their used PPE inside the resident's room and it should be disposed in a soiled bin inside of the room. The IP stated it was not acceptable for staff to doff PPE outside the room because they were then bringing the germs outside the room, and that would be considered a break of infection control. The IP stated because of the break of infection control, it was possible staff would spread COVID-19 to other residents. During an interview on 10/27/23 at 11:45 AM, the Administrator stated, when a resident tested positive for Covid, there was signage that was posted on the door to tell staff what kind of PPE they need to wear before entering the room. The Administrator stated the PPE was set up outside the door and was readily available for the staff. The PPE included eye protection like face shields or goggles, gowns, gloves, N95 masks, and surgical masks if staff wanted to wear a surgical mask over their N95. The Administrator stated it was expected staff would wear an N95 mask when entering a COVID-19 positive room. The Administrator stated, if I remember correctly staff should put on the PPE outside the COVID-19 positive room and take off the PPE inside the room because technically it was contaminated. The Administrator stated it was expected to keep the infection inside the room, so the PPE waste bin would be set up inside the room. The Administrator stated, if N95 masks were not available, it was expected the staff member find the nursing supervisor and ask for one before going in the room. 10 NYCRR 415.19(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint Investigation (Complaint # NY00316751, NY00322136) completed during a Standard survey (completed on 10/27/23, the facility did not provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior. Specifically, 6 (Units 1AB, 1CD, 2AB, 2CD, 3AB, 3CD) of 6 units reviewed for the environment had issues with floors sticky with food or brown colored debris in resident rooms and in dining rooms; walls spackled, not sanded or painted, with dried liquid splatters or black debris on them; shower rooms with dried, brown debris on shower chairs and on the floor; shower stalls with discolored tiles in disrepair; bathtubs with spider webs, insects, incontinence briefs, hospital gowns, hoyer (mechanical lift) slings, and brown debris in them; laminate missing from bathroom sink vanities; opened, unlabeled shampoo/body wash bottles in shower rooms; dried brown liquid on a tube feed pole; ceiling paint peeling; resident equipment not cleaned and in disrepair; and an over the bed table in disrepair. The findings are: 1. Review of the policy and procedure titled Quality Assurance Performance Improvement dated 11/2019 documented that the facility's mission statement was to promote the service delivery in the area of quality of life for their residents. Review of the facility Campus Senior Living Environmental Services Department Duty List dated 5/19/2021 documented that resident rooms, bathrooms, and shower rooms are to be cleaned on a daily basis. Review of the Resident Council Minutes for August 2023 documented that the residents' issues included the cleanliness of the dining room in between meals. During an interview on 10/23/23 at 11:10 AM, Resident #29 stated that they have insects in their room and the insects bother them. During a telephone interview on 10/23/23 at 11:18 AM, a family member of Resident #20 stated that the resident's room had issues with the floor being sticky, there were food debris on the floor, and that the walls and the ceilings were in disrepair. Intermittent observations on 10/23/23 between 9:00 AM to 3:00 PM on the resident units revealed the following: Unit 1AB Resident room [ROOM NUMBER] - food debris along the side of the bed; multiple areas of patched wall not sanded and not painted including a 36 (inch) by 24 area behind the head of the bed; 42 by 29, 36 by 30, 48 by 30 patch by the bed; a 12 by 12 patch by the closet; a 3 by 3 patch under an outlet; multiple gashes in the wall behind the head of the bed; drywall missing from the wall by the nightstand 1 by 4. Resident room [ROOM NUMBER] - Broken tile under the window; a baseboard under the air conditioner pulled out from the wall. Unit 1CD Dining Room - floor had multiple amounts of food debris under and around the tables; floor was sticky to walk on and the outside perimeter near the border there was build-up of debris and black dried substance along the edges; tables had food debris and stains on them; the windowsills had debris build-up, dead spiders hanging and spider webs; the walls in the dining room had dried food splatters on them. Unit 2AB Resident room [ROOM NUMBER] - fly tape hung on resident's door. Resident room [ROOM NUMBER] - tube feed pole with multiple dried, beige colored dried liquid on the pole and the pole stand; dried, brown liquid splatters on wall next to bed from floor to ceiling approximately 36 wide. Shower Room B hall - empty bag of chips on the floor in the tub room; dead insects on windowsill; used towel on the floor in the closet area. Unit 2CD Resident room [ROOM NUMBER] - small, flying insects in room; leg urine bag with urine on the back of the toilet in the bathroom. Resident room [ROOM NUMBER] - dried, brown liquid spilled on heater, garbage on floor. Unit 3AB Resident room [ROOM NUMBER] - dried, caked on brown debris on both sides of wheelchair. Common Area between 3AB and 3CD - spider webs on valances; 8 by 6 area next to door missing molding with black debris on it; black stained drops on carpet that cover an area of 16 feet. Unit 3CD Resident room [ROOM NUMBER] - gouged areas behind the head of the bed with exposed dry wall; an empty plastic cup with a dried, red liquid on the floor under the bed. Resident room [ROOM NUMBER] - over the bed table (bedside table) had laminate chipped or removed all around the sides of it; recliner chair stained with a brown substance on the side. Shower Room C hall - middle restroom call light cover broken with jagged edges; handle missing from under the sink cabinet; shower room paint peeling. Dining Room - floor sticky with food debris on the perimeter of the floor; tabletops not wiped from previous meal. Intermittent observations on 10/24/23 between 8:00 AM to 12:00 PM on the resident units revealed the following: Unit 1AB Resident room [ROOM NUMBER] - peeled paint on wall behind head of bed, 12 by 3; exposed drywall 12 by 1 by head of bed; wall heater cover was crooked and not flush with heater. Resident room [ROOM NUMBER] - floor sticky; patched area behind head of bed not sanded or painted, 6 by 4. Shower Room B hall - missing shower tile with exposed drywall underneath; black debris along wall with towels and hospital gowns on floor in front of it; tub with black debris and towels in it. Shower Room A hall - soiled hospital gown with dried, red substance on it; tub with brown colored debris in it; wet towel in shower stall with brown debris on it; floor next to shower threshold was peeled back; 12 diameter area on ceiling was stained brown with 5 by 3 hole in the center. Unit 2AB Resident room [ROOM NUMBER] - used condom catheter (a urine collection device that covers male genitalia) was on the back of the toilet; dried, red liquid on the sheets, on the call light, and on right bed handrail. Resident room [ROOM NUMBER] - towel wrapped around pillow with no pillowcase on, strong urine smell in room. Dining Room - floors had food and paper debris throughout the dining room, under tables; floor was sticky, and the edges and corners of the floor had debris and black caked on substance; tabletops were not wiped down from the previous meal; windowsills had dust and cobwebs on them. Unit 3AB Residentroom [ROOM NUMBER] - resident room had no decorations, personal affects, or personal pictures, and was not homelike. Unit 3CD Resident room [ROOM NUMBER] - dried, red liquid remained on the floor underneath the bed. Intermittent observations on 10/25/23 between 8:00 AM to 11:00 AM on the resident units revealed the following: Unit 1CD Dining room - food debris remained on the floor and was sticky. Dust, debris, and cobwebs on the windows remained. Walls have drip stains of dried brown liquid down the wall. Unit 2CD Shower Room C hall - used toilet paper with brown debris in front of linen closet; small pile of brown debris in shower stall; multiple unlabeled, opened bottles of shampoo and body wash in shower stall; toilet in restroom had yellow water in it and black debris on the inside of the toilet bowl; shower chair had broken arm with jagged edges; shower drain with hair and paper on it. Intermittent observations on 10/26/23 between 12:00 PM to 4:00 PM on the resident units revealed the following: Unit 1AB Resident room [ROOM NUMBER] - wall not sanded or painted 36 by 18 near head of bed; multiple brown debris spot on bathroom floor 36 by 72. Resident room [ROOM NUMBER]- patches on the wall not sanded or painted; black lines on wall 18 long by ½ wide; brown spots on floor. Resident room [ROOM NUMBER] - multiple brown debris spots in bathroom floor leading to the door and floor was sticky; wall by bathroom door gouged 12. Shower Room B hall - brown debris in tub 12 on tub seat; 7 stained orange shower tiles; floors brown stained area 36 by 12 next to shower stall; cracked peeling paint on ceiling next to shower stall. Shower Room A hall - dirty linens in sink and used gown in tub, brown stained washcloths in shower stall. Shower Room B Hall - 13 tiles with brown and orange staining, brown debris in corner. Unit 2AB Resident room [ROOM NUMBER] - floor sticky; black streaks on wall behind bed 10 to 18 high Resident room [ROOM NUMBER] - dried brown debris on tube feed pole; wall had brown liquid streaks from ceiling to floor. Shower Room B Hall - dirty washcloth dried with brown and black debris, empty snack bag on the floor of tub room, dirty towel on floor of the linen closet. Unit 2CD Resident room [ROOM NUMBER] - missing veneer on bathroom sink, 12 on support, 24 on sink, peeled with jagged edges. Shower Room C hall - spider web and 3 insects in the bottom of the tub; dirty socks on shower room floor and floor was sticky. Unit 3AB Resident room [ROOM NUMBER] - 6 long by 1 wide area not painted and there was no drywall under wall lamp cord. Resident room [ROOM NUMBER] - 36 long by 18 wide area not sanded and not painted; no personal pictures or effects noted in room; 27 gouged areas in wall behind nightstand; 12 by 1 area behind the wall lamp cord, not painted and no drywall. Shower Room B hall - green shower chair with a small amount of brown debris on seat. Unit 3CD Resident room [ROOM NUMBER] - gouged wall area 12 long by 1 wide not sanded and not painted. Resident room [ROOM NUMBER] - over the bed table with missing veneer around all edges; a large, stained area approximately 12 in diameter on side of recliner chair. Shower Room D hall - 9 tiles cracked, 13 black stained tiles in shower stall; green shower chair with brown streaked debris on seat and a used hoyer sling in the tub. During an interview on 10/25/23 at 9:35 AM, Certified Nurse Aide (CNA) #6 stated that Environmental Services (EVS) was responsible for cleaning the shower rooms and tubs. They stated that CNAs should clean up the shower room of any brown debris on the floor and EVS should disinfect the floor. They stated that shampoos and body washes may be brought in by family and should be labeled. During an interview on 10/25/23 at 9:50 AM, Licensed Practical Nurse (LPN) #9 stated that whatever CNA showered a resident should make sure the shower room was clean including cleaning up any brown debris. They stated that EVS should disinfect any areas that were cleaned. During an interview on 10/26/23 at 9:01 AM with Activity Aide #1, they stated during an observation of the common area between Unit 3AB and Unit 3CD that EVS is responsible for cleaning the common area and it should be cleaned. During an interview on 10/26/23 at 9:55 AM, CNA #8 stated that the shower equipment including the chairs should be wiped down with disinfectant wipes between showers. They stated that shower chairs should have towels on them before a resident is placed on it. They stated that the shower chair should not be used if it has any issues and reported to maintenance. During an interview on 10/26/23 at 10:48 AM with Housekeeper #2, they stated that they were responsible for cleaning resident rooms daily. They stated if they cannot finish their work for whatever reason, they were to report it to the Field Operations Manager. They stated that they tried to remove the stains from the floor, but they could not get the stains out. They stated that they have tried to get stains off a wall, but they could not remove it and they reported to the Environmental Services Manager. During an interview on 10/27/23 at 8:01 AM with Floor Technician #1 on Unit 1AB, they stated during an observation that the chemicals they use causes the floors to be sticky. They stated that they have used plain hot water to remove the stickiness of the floor but that did not help. They stated that the food debris on the dining room floors are stuck there and they have not been able to get them off the floor. They stated that the floors need to be stripped of wax before the debris could be swept up. They stated that they use a carpet cleaner for the heavy traffic areas but that doesn't always work. During an interview on 10/27/23 at 8:15 AM, CNA #1 stated that the substance in the tub on Unit 1AB on Hall A was dirt and that EVS was responsible for cleaning that. During an interview on 10/27/23 at 8:45 AM, Registered Nurse (RN) Nursing Supervisor #4 stated they expected staff to pick up any dirty or used linen and put them in the proper areas. They stated that EVS were responsible for cleaning resident rooms and shower rooms. During an interview on 10/27/23 at 9:03 AM with Housekeeper #1, they stated that there were insects in the tub on Unit 2CD C hall and EVS was responsible for cleaning the tub. They stated they will clean the insects right away. During an interview on 10/27/23 at 9:11 AM with CNA #3, they observed room [ROOM NUMBER] feed pump pole and stated anyone could wipe up the spilled feed on any resident's feed pump pole. They stated that it's just common sense to clean up any spill of any kind on resident equipment. During an interview on 10/27/23 at 9:15 AM with Maintenance Worker #1, they stated that the wall in Resident room [ROOM NUMBER] with the dried, brown liquid needed to be painted over. They stated if EVS tried to clean it and it wasn't coming off, it needed to get painted. During an interview on 10/27/23 at 10:29 AM, the Facilities Operations Manager stated that they don't have part time EVS staff to help keep the facility clean when the full timers are off. They stated that they have to hire an outside company to fix the walls and paint them. They stated that the Maintenance Manager tried to keep up with all the wall issues, but it didn't always happen. They stated that the floors will probably need to be stripped and waxed to be cleaned properly. During an interview on 10/27/23 at 10:42 AM, the Environmental Services Operations Manager stated that they believed staff had not been using the cleaning chemicals correctly and that was why the floor was sticky. They stated that EVS staff was responsible for cleaning resident rooms, shower rooms, and the common areas. They stated any issues with resident equipment should be reported to them or Maintenance. 10 NYCCR 415.5(h)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a Compliant Investigation (Complaint #NY00316751) completed during the Standard survey completed on 10/27/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (Main Kitchen) of one and six (Units 1AB, 1CD, 2AB, 2CD, 3AB, and 3CD) of six serveries. Specifically, the main kitchen had undated and/or unlabeled food items; multiple food equipment had food splatters, black thick debris buildup, and/or grease buildup; multiple stacked pans visibly wet; floors in the kitchen and refrigerators had debris and dirt buildup; hand sinks had a thick layer of grayish debris build-up and/ or lime build-up; sanitizer sink of the three compartment sink was found to have no sanitizer in the water and the sanitizer solution log was blank for the month of October 2023; and the walk-in freezer had ice/ frost buildup along the entire ceiling with ice build-up on parts of the floor. Additionally, the serveries on the units had issues with outdated, undated and/or unlabeled foods; build-up of food splatters, debris and/or grease on the outside/inside of the equipment, on the counters under the equipment and by the steam table area, food shields by the wells and on the floors. Refrigerators had missing thermometers and equipment was broken. The findings are: The policy and procedure (P/P) titled Labeling & Dating updated 10/23 documented all foods will be appropriately wrapped, labeled, and dated based on food storage guidelines. All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. The P/P titled Cleaning Schedule updated 10/23 documented cleaning schedules are used to maintain high levels of sanitation in the Food & Nutrition Services department and serve to assign cleaning tasks to various kitchen staff members. The daily cleaning schedule delineates how often equipment must be cleaned and whose responsibility it is to clean each specific piece of equipment or area. Heavy cleaning such as under equipment, walls and floors and major equipment can be planned on a weekly basis. The P/P titled Kitchenettes/ Pantries dated 11/22 documented each resident care unit with a standard pantry or kitchenette will have food and beverage supplies stocked as requested. Items are labeled, dated, and rotated. Outdated or unlabeled perishable items will be discarded. Designated staff will clean pantries on a routine basis. The P/P titled Unit Food Storage revision date 5/18 documented food is to be stored, prepared, distributed, and served under sanitary conditions to reduce the risk of food borne illness. Non-personal food items such as juice, milk, canned fruit etc. shall be dated once opened. After three days unused portions will be discarded. Unused portions will be discarded after three days, or less dependent on the food item. 1. During an observation of the main kitchen on 10/23/23 between 8:48 AM and 10:15 AM, the following was observed: -The walk-in refrigerator by the entrance to the kitchen near the elevators had large amounts of debris and a slice of cheese on the floor under the racks. Floor was soiled- not swept or clean. -The walk-in freezer by the entrance to the kitchen near the elevators had an opened packaged of muffins with five left which were not wrapped, dated, or labeled and the condenser was dripping liquid, forming an ice buildup on a box of food that was being stored beneath it. -The back nourishment area reach in cooler contained an undated/ unlabeled 2-3 gallon clear pitcher of a white liquid, an undated/ unlabeled 4 oz. (ounce) plastic container of a white fluffy substance which appears to be cottage cheese, an undated/unlabeled 8 oz glass with a beige color liquid, an undated/unlabeled opened 24 oz. bottle of water with ¼ left, two undated opened 30 oz. jars of grape jelly, an undated/unlabeled large rectangular tin with prunes in their juice covered with clear plastic, an undated/unlabeled square tin with ten peeled hard boiled eggs in it covered with clear plastic wrap, an undated/unlabeled plastic container filled with what appears to be ham salad, and an undated/unlabeled opened 10 gallon white plastic container of mixed fruit. -Twenty-four multiple sized stacked metal pans sitting on a rack were stored visibly wet between each pan. -Three can openers were found to have a thick buildup of black debris. -Outside of the oven and hot box were both grimy/greasy and dirty. -The griddle had a ¼- ½ (inch) thick build-up of black greasy food debris on the edges of the griddle and in the area where it drains. -In the dry storage area there was an opened undated package of cookies, an undated opened package of confectionary sugar, and an undated opened bag of breadcrumbs. -The reach in refrigerator marked Doesburg & Forest contained a large metal pan of egg salad dated 10/20. -The first walk in refrigerator around the corner from the Doesburg & Forest refrigerator contained a small container of pesto mayo dated 10/16, two-one gallon opened containers ¼ full of balsamic vinaigrette with no open date, 64 oz opened ½ full container of BBQ marinade with no open date, 46 oz opened container of prune juice with no date, black to-go container wrapped in clear plastic wrap with no date or label. The lighting inside the walk- in was dim. -The walk-in refrigerator labeled Produce had an unpleasant odiferous smell to it. There was a large amount of food debris on the floor under the racks. The floor was grimy and sticky. The lighting was dim. -The back walk- in freezer directly next to the door from the service corridor, on the entire ceiling, was covered with approximately ½-1 thick frost/ ice. The top frame of the door had a layer of frost/ice build-up. In addition, the floor had spots where there were chunks of ice build-up. -Hand sinks were dirty with either black grayish debris buildup or [NAME] lime scale build-up inside the sink, around the water faucets and the water spigot. Some sink stations were missing either hand soap and/or paper towels. During an interview on 10/23/23 at 9:30 AM, the Assistant Director of Food Service (ADFS) stated when food was opened, they were to label and date it. After 3 days the food should be thrown away. We have a cleaning schedule for the equipment, floors and refrigerators but if something spills or needs immediately cleaning, we do it then. The ADFS stated the can openers need to be cleaned and will be clean today along with the refrigerators mentioned. Pots and pans were to be dried on the rack prior to stacking them as they should not be stacked wet. The ADFS stated the test strip indicated there was no sanitizer in the water. They stated all the pots and pans that were sitting on the drying rack will need to be re-sanitized. They stated the supervisors were to check for proper sanitizer daily and mark on the log sheet. They stated the sheet was blank for the month of October 2023. The ADFS stated they did not know why the freezer had frost buildup but thought it was because the door was left open too long. During a follow-up observation on 10/25/23 at 8:21 AM the nourishment refrigerator contained the same food items listed for 10/23/23, still unlabeled and dated. In addition, there was two opened 46 oz. container of honey thick water and nectar thick cranberry juice with no date, an opened 32 oz. honey thick milk with no date, a plastic container filled with 2-3 cups of what appeared to be tuna salad with no label or date and an opened package of cheddar cheese cubes with no date. There was no Sanitizer Solution Log posted in the kitchen by the three-compartment sink. The walk-in freezer still had the frost/ ice buildup along the ceiling and ice in various areas of the floor. Hand sinks were still dirty. During an interview on 10/25/23 at 8:33 AM, the Director of Food Service (DFS) stated they cleaned the refrigerators and the one that was marked Produce was really bad and did smell. They stated it should have been cleaned a while ago. They stated that all opened food items should be labeled and dated and were not aware of any issues that were found on 10/23/23. They stated food should be thrown way after 3 days. The stated the issue with the sanitizer was on the supervisors and that they should be checking the water daily and marking it on the posted log sheets. They stated all the equipment, floors, and refrigerators were on a cleaning schedule. They stated there had been an issue a little while back with the two walk-in freezer in the back. They stated there was pipe leaking above both freezers, one of the lines froze up which caused the condensation build-up. They stated they needed to move all the food from the one freezer to the other and shut it down to defrost but had not gotten a chance to do that yet. 2. During observations of the unit serveries the following was revealed: Unit 1CD: During an observation of the 1CD servery and dining area on 10/23/23 at 11:29 AM revealed the following: -The outside counter in front of the steam table was filthy. There were orangish/red dried food debris around the hot cereal/soup well. In front of the steam wells was soiled with brown food debris/ sugar crystals. The food shields were dirty with splatters of dried food. There was a large dried brown stain and smaller stains in front of the toaster area. Along the edges was a buildup of black debris. -Inside the servery the counter tops had debris, food particles and food spills which included underneath the microwave, juice machine and coffee maker. The toasters had crumbs and were dirty on the outside of them. Countertop was dirty with crumbs and food debris. -Outer part of the microwave, juice machine and coffee maker had splattered food and smears. The inside of microwave spills of dried food and debris in it. - One side of the standup refrigerator/ freezer had a sign to do not use and was broken. -The juice machine was broken. -There was lime scale build-up around the ice dispenser and the drain area was caked with brownish/ gray sludge looking substance. -The sink with dish area was filthy with food debris, and a slimy grayish substance. -The floor had food particles and debris on it, including underneath all the equipment. The floor was sticky. -The cooler under the counter did not have a thermometer. -The tabletops were dirty with breakfast food and spills on them. They had not been wiped down after the breakfast meal. Unit 2CD: During an observation of the 2CD servery on 10/23/23 between 12:01 PM and 12:47 PM revealed the following: - Steam table glass was soiled with splatters and drips of a white liquid substance. - Stainless steel soup reservoir was soiled with brown debris and contained approximately an inch of water with debris floating in it. - Plate warmer was not functioning. During an observation of the 2CD servery on 10/25/23 at 8:23 AM revealed the following: - Steam table glass was still soiled with splatters and drips of a white liquid substance. - Metal container of oatmeal was sitting in the soup reservoir, still soiled with brown debris and water with debris floating in it. During an observation of the 2CD servery on 10/25/23 between 12:06 PM and 1:05 PM, the following were observed: - Steam table glass was still soiled with splatters and drips of a white liquid substance. - Stainless steel soup reservoir was still soiled with brown debris and contained approximately an inch of water with debris floating in it. - Toaster on right side of servery was soiled with crumbs and greasy residue, along with the area surrounding it. - An open, five-pound, container of peanut butter with the lid off. Container was soiled with smears of peanut butter on the bottom, sides, and lid. - Plastic bags of both wheat bread, and hamburger buns, open to the air, sitting next to steam table. - An undated, unlabeled, open squeeze container of yellow liquid sitting on the counter next to the steam table. - An open one-gallon container of liquid butter alternate sitting on counter next to steam table. Unable to read date written in black marker. Lid not secured. Label reads to store in cool dry place after opening. - Floor of servery was soiled with food debris and paper garbage. - Trash can was open to air with no lid. Half filled with food and paper garbage. Large fan, hanging from the ceiling, blowing directly down onto the open trash can. - Microwave soiled with brown dried liquids inside, on top, sides, and rotation glass. - Ice machine soiled with black and white debris on dispenser and drip tray. 2-CD nourishment fridges contained: - unopened, 32-ounce non-fat vanilla yogurt. Handwritten date of 10/23, sell by date 10/30/23. - Five open, undated 46-ounce apple juice containers. - Open, undated 46-ounce orange juice container. - Open, 46-ounce apple juice container with handwritten date 9/13/24. - Open, 32-ounce Thick-n-Easy, nectar consistency, handwritten date 5/12/24. - Unlabeled, black plastic bag with full takeout container inside. - Clear plastic container of fruit, labeled shelf life date 10/21/23. Unit 2AB: During an observation of the 2AB servery on 10/24/23 at 8:07 AM revealed the following: -The countertop where the steam table was located had a large crack containing food debris approximately 2-3 feet long. The countertop was soiled with food debris and food stains. Cracks along the edges had black caked in food debris. -The glass shield in front of the steam table was dirty with food splatters and smudges on the inside and outside. -Inside the servery the counters had debris and spills on them and under the equipment. -The equipment had smudges and dirty areas on the outside of them. Inside the microwave had dried food. -The floor had food debris and dirt build up though out, under the counters and equipment. -Table tops in the dining room had food particles and dried food stains from the dinner from the night before. Intermittent observations of the following serveries on 10/26/23 between 2:30 PM and 3:15 PM revealed the following: Unit 1AB servery: the tall refrigerator's bottom compartment had a large red, dried liquid spill with salt packets stuck to the wall and bottom of refrigerator. There were two dirty food scoops on the sink tray with dried food debris. Equipment (toasters and microwave) was dirty with food crumbs and splatters. Unit 1CD servery: Equipment (microwave/juice dispenser/ grate/ catch) was soiled with food splatters and standing liquids/substances in the grate and catch. There were the multiple juice glasses stacked on a lunch tray and were visibly wet. Three lunch trays with dirty dishes on the sink tray. A hot/cold therapy gel pack was stored in the bottom freezer compartment of the tall refrigerator. Unit 2AB servery: Dirty dishes on the sink tray; The tall refrigerator's bottom freezer compartment was soiled with spills; the refrigerator contained unlabeled, undated soup container; the juice dispenser catch had standing yellowish liquid. Unit 2CD servery: a lunch tray with multiple wet juice glasses on it; juice dispenser catcher with standing yellowish liquid. Unit 3AB servery: a lunch tray with multiple wet juice glasses on it; the toaster and microwave were soiled food crumbs and/ or splatters. Unit 3CD servery: a lunch tray with multiple wet juice glasses on it; microwave soiled with food spills and splatters; toasters with food crumbs on and underneath them; a lunch tray with dirty dishes on them. During an interview on 10/25/23 at 12:19 PM, the DFS stated dietary was in charge of all the serveries on the units. They stated food service staff should be wiping everything down like the counter tops, microwave, coffee, and juice machine after each meal. They should be sweeping the floors after each meal. They stated environment staff would be the ones who would mop the floors. They stated the dirty dishes were taken down to the main kitchen to be washed and brought back up for each meal as all the dish machines were broken on the unit serveries. They stated there was no money to fix the broken equipment like the refrigerators, freezers and dish machines in the serveries and they make do with what they have. The DFS stated the dining room area was cleaned and maintained by environmental staff, except for the tops of the tables which were to be wiped down after each meal by dietary staff. During an interview on 10/25/23 at 1:05 PM, Food Service (FS) worker #1 stated that the FS workers were responsible for cleaning the serveries and maintaining the nourishment fridges. FS worker #1 stated that the nourishment fridges were checked daily and that juices were good for 3 days once they were opened. The person that opened the container should have written the open date on the container. FS worker #1 stated that takeout containers should not be in the nourishment fridges and the fruit dated 10/21/23 should be thrown out because it could be spoiled. FS worker #1 stated that the servery should be kept clean because it was not safe to prepare food in an area that was dirty. During an interview on 10/27/23 at 8:11 AM, with the Assistant Food Service Director, they stated that the serveries should be cleaned after every meal, and it was the responsibility of the food service worker to clean it. They stated this included the equipment like toasters, microwaves, and refrigerators. During an interview on 10/27/23 at 9:00 AM, with Food Service worker #1, they stated that food service workers were the only ones who were responsible for cleaning the serveries. They stated that they were supposed to clean all the equipment. 10 NYCRR 415.14(h) 14.1.43(e), 14-1.85, 14-1.110(a)(b)(c)(d), 14-1.112(a)(2)(3), 14-1.116, 14-1.170, 14-1.171(a)

Based on observation, interview, and record review conducted during a Standard survey (Complaint # NY00278639) completed 9/6/22 through 9/12/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #134) of five residents reviewed. Specifically, the facility did not report an injury of unknown origin to the State Agency within the two-hour time frame, as required. The finding is: The policy and procedure (P&P) titled Abuse Prohibition: Screening/Training/Prevention/Identification, Investigation, Reporting/Protection of Resident/Employee/Coordination with QAPI revised 8/2022 documented federal and state regulations require the reporting of alleged violations of abuse, mistreatment, and neglect, including injuries of unknown origin, immediately to the facility administrator in accordance with state law, to the Department of Health (DOH) within 5 days of the incident. Providers will comply with that part of the Federal reporting requirement to state officials in accordance with state law by following the reasonable cause requirement defined in the New York State Public Health Law (NYS PHL), Section 4803-d. Federal regulations require that, the facility must ensure that all alleged violations involving mistreatment, neglect and abuse . are reported immediately to the administrator of the facility and to other official in accordance with State law. Providers should report alleged violations of abuse, mistreatment, neglect, injuries of unknown origin, or misappropriation of resident property, only if, and when the reasonable cause threshold has been achieved. 1. Resident #134 was admitted to the facility with diagnoses including schizophrenia, dementia, and osteoarthritis (degeneration of joint cartilage and the underlying bone). The Minimum Data Set (MDS- a resident assessment tool) dated 8/4/22 documented Resident #134 had severe cognitive impairment. The MDS documented the resident required extensive assist of one to two staff with activities of daily living (ADL's) and was non ambulatory. The comprehensive care plan (CCP), dated 3/23/21, documented Resident #134 had arthritis, was at risk for altered musculoskeletal related to osteoporosis (weak, brittle bones). Review of the Progress Notes dated 3/20/21 at 10:11 PM documented Registered Nurse (RN) #1 was called to assess Resident #134, who was sitting in their recliner chair with a possible hematoma (collection of blood under the skin) to left shin area. Their left lower extremity (LLE)/foot appeared externally rotated. The origin was unable to be determined. The resident was unable to state what happened. A call was placed to medical provider with a new order for STAT (immediate) x-rays. Further review of Progress Notes documented the following: -3/21/22 at 1:53 AM the x-ray results were reviewed, and the results were called to the Nurse Practitioner (NP). New order to transfer Resident #134 to the hospital. -3/21/22 at 10:00 AM Resident #134 was admitted to the hospital with a left lower leg fracture. Review of the NYS DOH Automated Complaint Tracking System (ACTS-software that logs and tracks nursing home (NH) complaints) lacked documented evidence the facility reported Resident #134's, injury of unknown origin as required. Review of an accident/incident reported dated 3/20/21 at 10:03 PM, prepared by RN #1 documented, Resident #134 was noted with a bump to their LLE, and the foot was externally rotated. Resident #134 was unable to give a description of how the injury occurred. There was no documented evidence the injury of unknown origin was reported to the NYS DOH. Review of facility, undated Resident #134 Investigation, completed by the former DON (Director of Nursing), lacked documented evidence the injury (fracture) was reported to the NYS DOH. During an interview on 9/12/22 at 8:50 AM, Licensed Practical Nurse (LPN) #1 stated they were informed of the bump on Resident #134's LLE by Certified Nurse Aide (CNA) #1. After inspecting the bump, on 3/20/21 at 9:45 PM, LPN #1 stated they immediately notified RN #1. LPN #1 stated the RN #1 Supervisor would be responsible to notify Administration/DON and they would be responsible to notify NYS DOH, if required. During an interview on 9/12/22 at 10:41 AM, RN #1 stated they no longer worked at the facility, it was long time ago, and couldn't recall all the exact details. RN #1 stated they were not aware, at the time, but are aware now, of the required timeframes for reporting incidents to the NYS DOH. RN #1 stated they would have notified the former DON of the incident and it would have been the former DON's responsibility to report the injury of unknown origin to the NYS DOH. During interview on 9/12/22 at 10:54 AM, the current DON stated they did not work at the facility at the time of the incident, and I can't say why it wasn't called in. It depends on the facility's investigation/summation. If you don't suspect abuse, are able to rule it out, or if there was no reasonable cause to suspect abuse it would not be required to be reported to the NYS DOH. During interview on 9/12/22 at 12:07 PM, the Administrator stated they both (themself and the DON) have a copy of the NYS NH incident reporting manual and use that as their guide for reporting requirements. We will have to review the regulations on reporting requirements. 415.4 (b)(2)

Based on observation, interview, and record review conducted during a Standard survey started 9/6/22 and completed 9/12/22, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice for one (Resident #28) of one resident reviewed. Specifically, there was a lack of documented evidence to address the care needs and ongoing monitoring of the access sites for complications, and a lack of a physician's order to address the removal of the pressure dressing post dialysis. Additionally, the care plan was not developed to include the location of access site/s, to monitor for potential complications such as bleeding, patency (bruit/thrill) (a rumbling or whooshing sound you can hear/a rumbling or buzzing sensation that you can feel), blood pressures (BP's) should not be taken from access arm, and that a pressure dressing should be removed post dialysis. The finding is: The facility policy and procedure (P&P) titled Hemodialysis revised 11/16 documented to remove dialysis dressing post dialysis per MD/NP (Medical Doctor/Nurse Practitioner) orders; assess for signs and symptoms of bleeding from the shunt (Arteriovenous (AV) fistula (a tube or device surgically implanted to create an artificial connection between an artery and a vein); monitor for signs and symptoms of infection, to monitor bruit and/or thrill and not use the access site arm to take blood pressures. The policy did not include how to manage a permacath (a flexible tube inserted into a vein at the neck or upper chest to use for short-term dialysis treatment). The P&P Comprehensive Resident Care Plan revised 10/19 documented that each resident will have a comprehensive individualized interdisciplinary care plan. The care plan will include measurable goals to assist resident in attaining the highest functional level. 1. Resident #28 was admitted to the facility with diagnoses including end stage renal disease, hypotension and neuropathy (a disorder affecting the nervous system). The Minimum Data Set (MDS - a resident assessment tool) dated 6/16/22 documented Resident #28 was understood, understands and was cognitively intact. The MDS documented that Resident #28 was on dialysis. The Comprehensive Care Plan (CCP) with revision date of 6/11/22 documented Resident #28 required dialysis relate to renal failure. The interventions included monitor labs; monitor vital signs; monitor/document/report as needed any sign and symptoms of infection to access site. The CCP did not address; location of access site/s; to monitor and at what frequency to monitor the access cites for potential complications (bleeding, bruit/thrill); that blood pressures should not be taken from access arm, and that pressure dressing should be removed post dialysis. The Order Review History Report dated 9/9/22 documented an order for dialysis three times a week. The order documented a location and time of pick up. The Medication Administration Record and the Treatment Administration Recorded dated 9/1/22 - 9/9/22 revealed there were no documented orders to address the care needs of the dialysis access sites to include: AV fistula pressure dressing removal, to check the AV fistula site for bruit/ thrill, to monitor for bleeding and infection at the access sites or that BP's should not be taken in the arm of the access site. Review of the Nursing Admission/Readmit Screener dated 6/10/22 documented Resident #28's right arm AV fistula site was clear. The form did not document the resident had a permacath at the time of admission. The Progress Notes dated 9/1/22 - 9/8/22 revealed Licensed Practical Nurse (LPN) #5 documented the fistula was intact to right arm and was positive for bruit and thrill, and catheter to right chest was in place with no bleeding noted on 9/1/22, 9/6/22, 9/7/22 and 9/8/22. Additional review revealed there was no further documented evidence that the AV fistula and permacath were monitored. Review of the NP Progress Note dated 9/6/22 documented that Resident #28 AV fistula showed no concerning findings and the shunt in now being used in dialysis. The progress note did not address the permacath. During an observation on 9/6/22 at 10:39 AM, Resident #28 was observed to have a permacath in their right chest wall, which was cover with a dressing, and had an AV fistula in the right arm that was covered with a dressing. During an interview at the time of the observation Resident #28 stated they went to dialysis on 9/5/22 and their treatment was completed using both the permacath and the AV fistula. At this time Resident #28 independently removed the dressing covering the AV fistula access site. The resident stated they were not sure as to why, but the nurses do not remove the pressure dressing on their fistula. During an interview on 9/12/22 at 9:39 AM, Resident #28 stated the dialysis center accessed their AV fistula for their 9/9/22 dialysis treatment, and on 9/10/22 the nurse did not remove the dressing, so they removed it themself. During an interview on 9/9/22 at 3:34 PM, LPN #4 (evening shift nurse) stated they were familiar with Resident #28. LPN #4 stated on dialysis days they monitor the access sites (right arm AV fistula/right chest catheter) for bleeding and listen for bruit and thrill. LPN #4 stated on days the resident does not go to dialysis they do not monitor the access sites for bleeding nor listen for bruit and thrill. LPN #4 stated they do not know why they don't, but they know it should have been done. During a telephone interview on 9/9/22 at 3:42 PM, the dialysis clinic Registered Nurse (RN) #4 stated they were the nurse responsible for Resident #28 while they received their dialysis treatments. RN #4 stated Resident #28 was in a transition period which meant they use both, the permacath and the AV fistula, to complete Resident #28's dialysis treatments. RN #4 stated they would expect a nurse from the nursing home to remove the pressure dressing the morning after the dialysis treatment. Resident #28 should not be removing the pressure dressings independently, as the resident had neuropathy and would not be able to apply enough pressure to the area if bleeding was to occur. During an interview on 9/9/22 at 4:10 PM, RN #3 stated they were the 3:00 PM -11:00 PM Nursing Supervisor. They stated their there should be an order for the nursing team leader to take the resident's blood pressure, check the access site for bleeding, remove the pressure dressing after a resident return from dialysis and for the nurse to look at the post-dialysis paperwork for any changes. During an interview on 9/12/22 at 9:26 AM, LPN #5 stated they were Resident's #28 full-time 7:00 AM - 3:00 PM shift nurse. LPN #5 stated that they would check Resident #28's dialysis shunt sites on their chest and arm for bleeding during the shift they work, but they do not touch the dressings. During an interview on 9/12/22 at 10:06 AM, RN #5 (Unit Manager), with LPN #6 (Assistant Unit Manager) present, RN #5 stated that Resident #28's dialysis treatments were completed via the permacath. RN #5 stated that Resident #28's AV fistula was not used since admission because it was not accessible. RN #5 stated that the shunt should be to monitor for bleeding when a resident returned from dialysis and then every shift. RN #5 stated that they do not audit the provider orders after admission, and they do not know why there was not an order written to monitor for bleeding at dialysis access site every shift upon admission. RN #5 stated that if Resident #28 had a dressing on top of their fistula after dialysis the nurse should have noticed it and they would expect the nurse to monitor the dressing and chart it in the medical record. During an interview on 9/12/22 at 10:32 AM, the NP stated that Resident #28 was receiving their dialysis treatment via the right AV fistula and that they do not know if the dialysis center was using the permacath site. The NP stated their expectation would be for the nursing staff to be checking for a thrill, monitor for signs of infection and monitor for bleeding at the access site and that they should have had orders in place. During an interview on 9/12/22 at 11:17 AM, the Director of Nursing (DON) stated if an AV fistula was used for dialysis, there should have been orders to monitor the fistula for bruit and thrill daily; the access site for bleeding and signs infection every shift, and for the pressure dressing to be removed after 8 hours. Additionally, the DON stated the orders should also include that there should be no blood pressures and blood draws taken in the arm that had an AV fistula. The DON stated they were unaware the dialysis center was using the AV fistula for Resident #28. The DON stated that since admission Resident #28 did not have any orders in place to monitor the dialysis access sites and was not sure as to why not. The DON stated that a permacath site should have an order to be monitor signs of bleeding and signs infection every shift. In addition, the DON stated the access site/s and removal of the pressure dressing did not specifically need to be care planned for because there should have been an order for location and to remove the dressing. The DON stated that monitoring the dialysis access site for bleeding should have been on Resident #28's care plan. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Standard survey started on 9/6/22 and completed on 9/12/22, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all sleeping areas with fuel-burning appliances, and on-going preventative maintenance of carbon monoxide detectors. This affected three (First Floor, Second Floor, Third Floor) of three resident use floors and one of one Basement. The findings are: According to the 2020 Fire Code of New York State, patient rooms in nursing homes are defined as sleeping units. In residential and commercial buildings that contain a fuel burning appliance, carbon monoxide detection shall be installed in all rooms, occupiable space, dwelling units, sleeping areas, and sleeping units that contain a fuel-burning appliance. Additionally, the 2020 Fire Code of New York State stated carbon monoxide detectors shall be maintained in good working order in accordance with Section 915 of this code, National Fire Protection Association (NFPA) 720 (Standard for the Installation of Carbon Monoxide Detection and Warning Equipment), and the manufacturer's instructions/recommendations. Review the facility's policy and procedure called, Emergency Procedures - Carbon Monoxide Detectors, revised 3/9/22, revealed carbon monoxide detectors are designed to monitor the air and detect carbon monoxide from any source of combustion. Additionally, the policy and procedure stated inspection of carbon monoxide detectors will be included in routine audits, a percentage should be checked at each audit, and 100 percent (%) of the facility must be inspected annually. The policy and procedure did not address placement of carbon monoxide detectors. 1. Observation throughout the facility on 9/6/22 from 8:45 AM until 1:30 PM revealed the resident sleeping rooms were located on the First, Second, and Third Floors. Each resident room was equipped with a PTAC unit (Packaged Terminal Air Conditioning - a type of ductless cooling and heating unit). Observation in vacant resident room [ROOM NUMBER] on 9/9/22 at 1:00 PM revealed the PTAC unit was uncovered and a natural gas line was observed on the unit. During an interview at this time, the Facilities Director stated all PTAC units in the facility were fueled by natural gas. Observations in 47 occupied resident rooms on the First Floor on 9/12/22 from 8:10 AM until 9:00 AM revealed 16 resident rooms (34%) did not have a carbon monoxide detector. Observations in 29 occupied resident rooms on the Second Floor on 9/12/22 from 9:00 AM until 9:30 AM revealed nine resident rooms (31%) did not have a carbon monoxide detector. Observations in 55 occupied resident rooms on the Third Floor on 9/12/22 from 9:30 AM until 9:50 AM revealed 20 resident rooms (36%) did not have a carbon monoxide detector. Review of the most recent fire alarm system inspection device list, dated 5/19/22, revealed the facility's fire alarm system did not include any carbon monoxide detectors. 2. Observation throughout the facility on 9/6/22 and 9/12/22 revealed single-station plug-in carbon monoxide detectors with battery back-up were located in the Boiler Room (Basement), Main Kitchen (Basement), and multiple resident rooms on the First, Second, and Third Floors. Review of the carbon monoxide detector manufacturer's user guide revealed the following, To keep your alarm in good working order, you must follow these steps: test the alarm one time per week by pressing the test/reset button, and vacuum the alarm cover one time per month to remove accumulated dust. During an interview on 9/8/22 at 2:45 PM, the Facilities Director stated they did not know how many resident rooms had carbon monoxide detectors, there was no inventory log kept to track carbon monoxide detectors and it was possible that some were being thrown away, because they were constantly replacing them, but no records were kept. The Facilities Director also stated they were unaware of the manufacturer's preventative maintenance guidelines, and no one was performing any preventative maintenance on the facility's carbon monoxide detectors. During an interview on 9/9/22 at 10:15 AM, the Facilities Director stated the facility's policy and procedure stated annual testing should be done on 100% of all carbon monoxide detectors, but that was not being done at this time. Additionally, the Facilities Director stated the manufacturer's preventative maintenance guidelines should be followed. During an interview on 9/12/22 at 11:38 AM, the Administrator stated there should be a carbon monoxide detector in every resident room and they were unaware of the number of carbon monoxide detectors that needed to be replaced. The Board of Directors approved the purchase of 20 new carbon monoxide detectors prior to the start of the Department of Health Survey on 9/6/22 and if more than 20 were needed, they would be ordered. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on interview and record review conducted during a Complaint investigation (Complaint # NY00250444) during the Standard survey completed on 1/31/20, the facility did not ensure that one (Resident #269) of three residents reviewed for hospitalization, received written bed-hold notice upon transfer, or in the case of emergency transfer, within 24 hours. Specifically, there was no documented evidence the resident and the resident's representative were notified, in writing, of the bed hold policy when the resident was admitted to the hospital. The finding is: Review of the facility policy and procedure (P&P) titled Transfer/Discharge Notification last revised 10/17, revealed in event the resident is being transferred or discharged to the hospital the attached form labelled as Bed-Hold Confirmation will be provided to the receiving hospital notifying of bed hold status. The attached form was not provided to the survey team. 1.Resident #269 was admitted to the facility with diagnoses of non-traumatic chronic subdural hematoma (bleeding in the brain), dementia and atrial fibrillation (irregular heart rate). The Minimum Data Set (MDS-a resident assessment tool) dated 6/22/19 documented the resident was rarely to never understood. The Nursing Progress Notes dated 7/12/19 at 8:00 AM documented the writer (Registered Nurse #3) was called to the unit due to a reported unresponsive episode. When RN #3 entered the room, the resident was alert and responding verbally. The daughter reported to the writer (RN #3) that she had already called 911. When RN #3 was in the room the daughter called 911 a second time stating she wasn't happy the EMT's (emergency medical technician) had not arrived yet, however they did arrive while the daughter was on the phone. The Nurse Practitioner (NP) was called and notified of resident's daughter calling 911 to send resident to the emergency room (ER). NP on call in agreement to send to ER per the family/ responsible party (RP) request. The Nursing Progress Notes dated 7/12/19 at 3:52 PM, documented the ER was called requesting updated status of the resident. The hospital staff reported the resident was being admitted to the hospital. Review of the Psychosocial Progress Note dated 7/12/19 at 4:15 PM, revealed the Director of Social Work (SW) contacted the hospital ER and the ER staff stated the resident was going to be admitted . Additionally, the note documented SW would follow up as needed. Review of the Nursing Progress Notes dated 7/12/19 at 5:52 PM, revealed RN #3 spoke with hospital ER staff and it was reported the resident would be admitted the hospital, with a diagnosis of orthostatic hypotension (form of low blood pressure that happens when standing up from sitting or lying down) with an admission time of 4:07 PM. There was no documentation of written notification of the bed hold policy being sent to the resident or resident's representative. Review of the facility Notice of Transfer or Discharge revealed the facility will hold the resident's bed only if verbal and/or written permission is obtained from the resident and/or designated representative. Additionally, it documented an area for a resident or designated representative to confirm or decline a private pay bed-hold. Review of facility letter head memo sent the resident's RP, dated 7/16/19, signed by the facility Administrator, documented the facility was sending the letter to confirm that the RP terminated the resident's residency at the facility effective 7/12/19 by contacting 911, having the resident removed from the facility and cleaning out the room. There was no documentation regarding a bed-hold notice. During an interview on 1/30/20 at 1:06 PM, the Director of SW stated the resident's daughter called 911 requesting discharge to the hospital. She vacated the room and took all of the resident's belongings. She stated, we assumed the daughter was discharging the resident from the facility. The administrator sent the certified letter, regarding discharge, to the resident's daughter. During an interview on 1/30/20 at 1:14 PM, the Administrator stated the daughter took the resident and all the belongings in the room. I thought it was reasonable to assume they did not want to return. They initiated the discharge, cleaned out the room so, I thought that the resident did not want to return. During an interview on 1/31/20 at 8:44 AM, the Director of SW reviewed the resident's electronic medical record (EMR) and stated there was no documentation in the EMR about a bed-hold. SW stated that SW was responsible to issue written notification to families. If the discharge is unplanned, we try to touch base with the family after we confirm the resident was admitted to the hospital. We assumed the family did not want to return. I was off the Monday following the resident's admission so that is probably why I didn't have any follow up documentation. During an interview on 1/31/20 at 1:24 PM, the Director of Nursing stated SW was responsible to send written notice of transfer or discharge and any information regarding bed-hold. If it is off shift or weekend the nursing Supervisor would leave a note for myself and/or SW regarding a resident transfer to hospital and SW follows up to send notice to the resident or RP. 415.3 (h)(1)(iv)(d)

Based on observation, record review and interview completed during the Standard survey completed on 1/31/20, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #128) of two residents reviewed for range of motion (ROM) services was not provided with a rolled washcloth to the left hand at all times as recommended by Occupational Therapy (OT) and as indicated on the comprehensive care plan (CCP). The finding is: The policy and procedure (P&P) entitled Range of Motion Assessment with a revision date of 10/2011 documented the purpose of the policy was to identify and develop a treatment plan for patients with contractures, or for those at risk for developing contractures. Findings of the Physical Therapy (PT)/OT evaluation/screen and the recommendations to nursing for treatment will be documented in the Rehab section of the medical record. When a recommendation is made to the nursing staff for ROM, approaches to the identified problem will be incorporated in the care plan. 1. Resident #128 was admitted to the facility with diagnoses of cerebrovascular accident (CVA, stroke) with left hemiparesis (weakness of one side of the body), dementia, and diabetes (DM). The Minimum Data Set (MDS- a resident assessment tool) dated 12/29/19, documented the resident was cognitively intact, understood and understands. The MDS documented the resident had a functional impairment of the upper extremity on one side. Review of the CCP dated 4/4/19 revealed the resident had an Activity of Daily Living (ADL) selfcare performance deficit related to hemiplegia (paralysis of one side of the body), limited mobility and limited ROM. The interventions to included having a rolled washcloth in the left hand at all times and the washcloth changed daily as needed (PRN). Review of the Closet Care Plan (guide used by staff to provide care) dated 12/16/19 revealed under Dressing/Splint Care left hand rolled washcloth at all times, change daily PRN. Review of the resident's chronological medical record revealed the following: -12/27/19 - OT Quarterly Screen - adaptive equipment recommendations to nursing left hand rolled wash cloth at all times daily PRN. -1/15/20 - OT Annual Screen - resident's left hand held in fisted position, high/abnormal muscle tone in LUE. -1/15/20 - OT-Therapist Progress & Discharge Summary - positioning: left hand, rolled wash cloth at all times to patient's tolerance, change daily and PRN. -11/12/19 to 1/30/20 - Nursing Progress Notes - no documentation of resident refusing or removing the rolled washcloth from the left hand. During intermittent observations on 1/27/20, 1/28/20, 1/29/20 and 1/30/20 between the hours of 8:02 AM to 1:46 PM the resident was observed with left hand fingers curled into palm, holding hand in a fisted position. During an interview on 1/27/20 at 10:19 AM, the resident stated there has not been a rolled washcloth placed in their left hand in a while. In addition, stated I must have lost it one night in bed and I haven't gotten it back. On 1/30/20 at 1:31 PM the resident stated, if they want to put it in, I would wear it. During an interview on 1/30/20 at 1:46 PM, Certified Nurse Aide (CNA) #1 stated the night shift gets the resident out of bed and a rolled wash cloth should have been put in their left hand, but they must have forgotten to put it in there. Additionally, she stated I know she doesn't have one in today. Anyone can put it in if it comes out or is not in the hand. During an observation on 1/30/20 at 1:48 PM, the resident agreed to CNA #1 placing a rolled washcloth into their left hand. CNA #1 was able to gently open the resident's left hand and placed a rolled washcloth in the palm of the resident's left hand. The resident's hand had an unpleasant smell to it. During an interview on 1/30/20 at 1:53 PM, the Licensed Practical Nurse (LPN) #3 Resident Care Coordinator (RCC) stated she would expect to be notified if there was a break in the care plan (CP) and it should be corrected. I would expect a CNA to notify the nurse if there were any issues with a resident. Additionally, she would expect the CNA's to notify the unit nurses if the resident was removing or refusing the rolled washcloth so that could be documented in the progress notes and the nurses could follow up with the resident. During an interview on 1/30/20 at 3:17 PM, the OT assistant stated the resident is very self- driven and was just on an OT program for about two weeks. The resident's hand will get foul smelling, very quickly, being rolled in a fisted position and requires good hand hygiene. The CNA's are responsible for putting the rolled washcloth into the resident's hand. The OT assistant was not notified that the resident was refusing or not tolerating the rolled wash cloth being put into their left hand. During an interview on 1/30/20 at 3:30 PM, the RCC stated the resident's hand was foul smelling when she went to check the resident. During an interview on 1/31/20 at 8:53 AM, the Director of Nursing (DON) stated she would expect to see documentation in the progress notes if the resident refused or removed the rolled wash cloth so nursing could notify OT and the CP could be updated. 415.12 (e)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 1/31/20, the facility did not provide food and drink that was palatable, attractive, and served at appetizing temperature. Specifically, three (servery test trays on units 1AB, 1CD & 3AB) of four survery test trays observed for food temperatures during the lunch meal on 1/30/20 had issues involving food items that were not palatable and not served at appetizing temperatures. Resident A was involved. The findings are: The policy and procedure (P&P) titled Taste and Temperature Control Food Holding dated 1/2016 documented prior to the start of each meal period, there is an evaluation of the taste and temperature of the food. Hot foods must be cooked to required internal temperature based on food safety guidelines. Food temperatures should be taken just prior to service to ensure that holding temperatures of 135 degrees are maintained. Review of the Resident Council Meeting minutes dated 12/12/19 revealed several food service concerns were discussed at the meeting including residents voiced that at times some breakfast items such as oatmeal, coffee and toast are not served hot enough and the juices are not served cold enough. 1. Resident A was admitted to the facility with diagnoses including diabetes mellitus (DM- high blood sugar), atrial fibrillation (irregular heartbeat), and constipation. The Minimum Data Set (MDS-a resident assessment tool) dated 12/20/19 documented the resident was understood, understands and was cognitively intact. During an interview on 1/28/20 at 10:57 AM with Resident A stated the food was cold, they did not like the taste of the food and it was bland. a.) Observation of the Unit 1AB servery on 1/30/20 at 11:50 AM revealed the lunch meal service was started for the residents in the dining area and in their rooms. After all trays were served at 12:28 PM, a test tray was conducted at 12:29 PM. The Food Service Worker, using a facility digital thermometer, obtained temperatures of the food on a plate. The results were as follows: -ham measured at 130.8 °F (degrees Farenehight (F)) and tasted cold -scalloped potatoes measured at 124.2 °F and tasted cold bland and they had a hard texture. During an interview on 1/30/20 at 12:34 PM, the food service worker stated hot foods start out at 165 °F and should be at least 140 °F at the end of service. During an observation and interview on 1/30/20 at 12:47 PM, Resident A was eating in their room and stated the ham was ok, but the scalloped potatoes were cold, bland and hard. b.) Observation of the Unit 3 AB servery on 1/30/20 revealed at 12:28 PM the last resident's lunch tray was served. A test tray was conducted at 12:30 PM with the food service worker, using a facility digital thermometer. The following plated food temperatures were obtained: - ham measured at 130.8 °F and tasted cool. - scalloped potatoes measured at 122 °F and tasted bland with no flavor - capri blend veggies measured at 118.5 °F and tasted cool During an interview on 1/31/20 at 7:35 AM, the Food Service Director stated the hot food items should be at 141°F . During an interview on 1/30/20 at 12:52 PM, the Registered Dietitian (RD) stated she would like to have hot food above 135 °F. c.) Observation of the Unit 1 CD servery on 1/30/20 revealed at 12:28 PM the last resident's lunch tray was served. A test tray was conducted at 12:40 PM with the Food Service Director using a facility digital thermometer. The following plated food temperatures were obtained: - ham measured at 101.4 °F and tasted cool. - capri blend veggies measured at 96.1 °F and tasted cold. - Cranberry juice measured at 63 °F and tasted luke warm. - water measures at 60.4 °F and tasted luke warm. During an interview on 1/31/20 at 12:51 PM, the Food Service Director stated hot foods should be served at least 135 °F, and the cold items should be 41 °F or less. Ham is a tough one, it loses its heat quickly. 415.14(d)(2)

Based on observation, interview, and record review conducted during a Standard Survey completed on 1/31/20, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. One of one main kitchen and three (Unit Two, Unit Three, and Unit Four) of three unit kitchenettes had an issue with outdated food, unlabeled food, unclean/ sanitized food equipment, stacked pots and pans ready for use that were visibly dirty and wet, soiled and dust covered ceiling diffusers and vents and peeling paint above food service areas. The findings are: Review of a facility policy and procedure titled Unit Food Storage dated 5/18 revealed non-personal food items such as juice, milk, canned fruit, et cetera shall be dated once opened. After three (3) days unused portions will be discarded. Unused portions will be discarded after three days or less, dependent on the food item. Items such as ketchup, mustard, salad dressing, skippy cups (individual sizes ice cream) etc. will be discarded in accordance with manufacturer's expiration date. Observations in the Main Kitchen on 1/27/20 between 7:56 AM and 9:00 AM revealed the following: - Five racks with three to four shelves on each rack had ready to use stacked pots and pans. Multiple pots and pans had dried food debris in them and had a greasy feeling to them. - Two stand-up mixers were soiled with dried food and debris splattered on at the top of the mixer and on the stem where the mixer blade would be placed. - Can opener blade was soiled and had dried food debris on it and at the time was being used to open canned vegetables. Interview on 1/27/20 at 8:30 AM the Executive Chef stated these are clean cart of pots and pans. These pots and pans should not have been put on this cart. They should have been washed again. The mixers and can opener should have been cleaned after each use. Observation in the Third Floor A/B Servery on 1/27/20 at 8:25 AM revealed a plastic to-go container was stored in the rear cooler and it contained approximately eight ounces of cooked noodles and was labeled with a resident name, but no date. During an interview at the time of the observation, a Dietary Aide stated this container should have a date on it, and she is not sure when it came. Family members can bring in food for the residents, but they are not allowed to walk into the Servery to put food into the coolers themselves. Continued observation in the Third Floor A/B Servery on 1/27/20 at 8:32 AM revealed a stainless steel container of scrambled eggs, approximately 16 ounces, was stored in the front cooler. It had a sticker on the top but the date was not filled in. Additionally, in this front cooler, three of four stainless steel containers of lettuce salad were undated. During an interview at the time of the observation, a Dietary Aide stated she expected the dates to be filled out on the stickers on all food containers, including salad. She did not know when these containers came from the Main Kitchen. Observation on 1/27/20 at 8:35 AM in the Second floor AB Servery, revealed a resident specific plastic container of rice pudding dated 1/23/20. Interview with the Registered Dietitian on 1/27/20 at this time stated food items should be thrown out after 3 days. Observation on 1/27/20 at 9:38 AM in the Second Floor C/D Dining Room, revealed six of seven ceiling diffusers and vents had visible soil and dust, including the vent above the food service area. Interview at the time of the observation, the Environmental Services Manager stated it appears to be a mix of dust and maybe something that splashed up. She said it needs to be wiped off. She added that cleaning the ceiling vents and diffusers is a weekly task, but she does not know when they were last done. Observation on 1/27/20 at 10:28 AM at the Nurses' Station in the First Floor C/D Dining Room, revealed three ceiling diffusers and the ceiling vent closest to the station had a visible layer of dust. The ceiling vent above the food service area of the servery had peeling white paint pieces approximately three quarters of an inch by three quarters of an inch hanging down. Interview at the time of the observation, the Environmental Services Manager stated the diffusers and vents need to be vacuumed. At this time, a Dietary Aide stated last week someone scrubbed the vent above the servery food service area and it caused the white paint to start to come off. 415.14 (h) 14-1.43(e) 14-1.90 14-1.110(d) 14-1.116 14-1.170