**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification and Complaint Survey (NY00300942) from 05/22/23 to 05/26/23, the facility did not ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health (NYSDOH), but not later than 2 hours after the alleged occurrence. This was evident for 1 resident (Resident #153) reviewed for Abuse out of 35 total sampled residents. Specifically, an allegation of abuse involving staff towards resident #153 was not reported to the NYSDOH within 2 hours. The findings are: The facility policy titled Prevention of abuse, mistreatment, neglect, exploitation and misappropriation of resident property, revised 1/2023, documented that any allegations of abuse, mistreatment, neglect, and exploitation are reported using the Nursing Home facility incident report form immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. Resident #153 had diagnoses of dementia and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #153 had moderately impaired cognition and required limited assistance of 1 person for activities of daily living. The Facility Investigation Summary dated 8/23/22 documented that on 8/19/22 at approximately 9:30AM, Registered Nurse (RN) #2 was called by assigned morning Certified Nursing Assistant (CNA) to assess Resident #153 who had a yellow ecchymosis on the left forearm. Resident #153 stated it happened the day before, had been happening for 2 weeks, and they did not know the perpetrator's name. Resident #153 identified the regularly assigned night CNA, CNA #1, as the perpetrator by picture. After assessment by a physician, an x-ray revealed no left arm fracture. The yellowish coloring of the ecchymosis indicated a healing lesion. On subsequent interviews, Resident #153 changed their version of events two times. Resident #153's roommate and other residents who received care from CNA #1 were interviewed and did not report any issues. All present staff was interviewed and denied observing any abuse towards Resident #153 and CNA #1 had no history of abuse allegations. The investigation concluded there was no reasonable cause to believe Resident #153 was abused by staff. The Nursing Home incident form documented the incident was reported to the NYSDOH on 8/19/22 at 5:24 PM. There was no documented evidence the facility reported the allegation of abuse involving Resident #153 within 2 hours of occurrence on 8/19/22 at 9:30 AM. On 05/25/23 at 4:31 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated that they reported the incident involving Resident #153 to the NYSDOH on 8/19/22 at 5:24 PM, within 24 hours, because there was no serious bodily injury. Because there was no serious injury, they were not required to report within 2 hours. The ADNS stated the language of the regulation is confusing, and they understood that for injuries that are not serious, they could report within 24 hours. 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #146 Based on record review and interviews conducted during the Recertification survey of 5/22/23 - 5/26/23, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, the Diabetes Mellitus care plan was not revised timely. This was evident for 1 of 4 residents reviewed for care planning (Resident #146). The findings are: The facility policy and procedure titled Care Planning effective date 8/2016, review date 10/22, states it is the policy to follow all the guidelines to develop resident-centered individualized care plans. The procedure includes to re-evaluate the resident's status at prescribed intervals (i.e.: quarterly, annually, or if significant change in status occurs), and then modifies the resident's care plan as appropriate and necessary. Resident #146 has diagnoses of Heart Failure, Hypertension, Renal Insufficiency, Depression and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact); the diagnoses included Heart failure, hypertension, renal insufficiency, Diabetes Mellitus, and Depression. The resident received Insulin injections 7 days. The Physician's orders included an order for insulin lispro 8 units three times/day for Type 2 Diabetes Mellitus. Start date 11/14/22, and Lantus Insulin once daily at bedtime, for Type 2 Diabetes Mellitus, start date 1/27/23, and an order to monitor Hemoglobin A1C every 3 months, start date 3/24/23. A Care Plan titled Diabetes Mellitus, Insulin Dependent Diabetes Mellitus (IDDM), effective 12/23/2022, reviewed 1/10/23; documented that the resident has elevated blood glucose level secondary to diagnosis of IDDM. The goals include that the resident will be free of observable signs and symptoms of hyper- and hypo-glycemia, and resident will minimize development of preventable side effects such as neuropathy, visual disturbances, and abnormal kidney function. The interventions include to administer medications as ordered; Monitor blood glucose level as ordered; Monitor for observable signs and symptoms of hyperglycemia or hypoglycemia. Notes: 1/10/23: Annual care plan meeting done on 1/10/22, care plan reviewed. No changes in current condition. Will monitor. There is no evidence that the care plan was reviewed and revised as per scheduled Quarterly MDS dated [DATE] or revised to reflect the order for monitor Hemoglobin A1C every 3 months. The care plan was reviewed and revised on 5/24/23 after interviews with the State Agency. On 5/24/23 at 9:31AM, an interview was conducted with Registered Nurse (RN) #1 who stated that the initiation of a Care Plan is done by the charge nurse or admitting nurse. They further stated that only an RN can initiate a Care Plan. A Licensed Practical Nurse (LPN) can do updating, but the RN needs to check it. RN #1 stated that updates are done quarterly and annually, with the MDS schedule, and as needed. The minimum time for an update is quarterly. RN #1 looked at the electronic medical record and stated that the Diabetes Mellitus care plan is not updated. They further stated that this was an oversight. On 5/24/23 at 9:43AM, an interview was conducted with Registered Nurse Supervisor (RNS) #1, who stated that the RNs are responsible for initiating care plans, the LPN can update the quarterly, but the RN does the annual and significant change updates. The RNS stated that updates are done according to the MDS schedule. The RNS stated they will add additional care plans as needed based on changes and orders. The RNS looked at the electronic medical record and noted that the Diabetes Mellitus care plan was not updated. An interview was conducted on 5/24/23 at 3:20 pm with the MDS / Case Manager, who stated that on admission, nursing starts care plans and then the MDS is done, and data is tied in with the care plans already done and those that are needed get done. At a quarterly MDS, the nurses will review and write a note. 415.11 (c)(2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey from 05/22/23 to 05/26/23, the facility did not ensure that a licensed pharmacist who conducted monthly medication regimen reviews (MRR) identified and reported irregularities of the resident's medical record to the attending physician, medical director, and the Director of Nursing (DON). This was evident for 1 of 6 residents (Resident #194) reviewed for Unnecessary Medications Review out of a total sample of 35 residents. Specifically, a medication regimen review did not identify that a resident was receiving an antipsychotic medication that was not approved for the resident's diagnosis. The findings are: The facility's policy and procedure titled Medication management/medication regimen review-monthly, revised 4/2021, documented that the consultant pharmacist would review the medical record of each resident and perform a drug regimen review at least once each month. The consultant pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician, where appropriate. Resident #194 had diagnoses of dementia, septicemia, and unspecified psychosis not due to a substance or known physiological condition. The admission Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance of 1 person with activities of daily living. Resident #194 presented no indicators of psychosis and exhibited physical and verbal behaviors towards others and rejection of care 1-3 days. The Physician's Orders dated 4/28/23, and renewed on 5/21/23, documented Resident #194 was to receive Quetiapine 50 mg orally daily in the evening and Quetiapine 25 mg orally daily in the morning. A review of the medication administration records since admission on [DATE] documented resident #194 had been receiving the nightly 50 mg dose of Quetiapine since admission, and the morning 25 mg dose was added on 4/15/23. A Psychiatry Consult dated 4/10/23 documented Resident #194 was evaluated for confusion and behavioral disturbances. Resident #194 had been agitated and more confused in the evenings. As per resident's wife, this had been happening since the pandemic started and had not been worsening. Resident #194 had a long history of alcohol abuse, and no other past psychiatric history. No depressive manic or psychotic episodes or symptoms. Resident continues to be confused, not oriented to place, or time. As per staff, Resident #194 has been increasingly combative and aggressive especially in the evenings. Family believes resident is getting confused at night because they are in an unfamiliar place. Family stated resident was on medication for sleep at night, but they do not know which medication. A 4/14/23 psychiatry follow-up note documented Resident #194 continued to have significant memory problems. Plan was to add Quetiapine 25mg in the morning for agitation and continue Quetiapine 50mg at 6 PM in the evening for agitation. A Medication Regimen Review dated 4/27/23 documented that no recommendations were made. The MRR was conducted by the Consultant Pharmacist. On 05/25/23 at 10:55AM the Medical Doctor (MD) was interviewed and stated that Resident #194 was agitated, confused, and aggressive with staff. The MD stated they were not sure of Resident #194's psychiatric history, and that they had a history of dementia. The MD stated that Resident #194 was being seen by psychiatry. The MD stated they were aware of the black box warning for the medication prescribed, but What can we do? We cannot restrain him, but he was agitated and aggressive. When asked why prescribing a medication that is not approved for elderly patients with dementia, the MD stated, You can talk to psychiatry. On 05/25/23 at 11:24 AM the Psychiatrist was interviewed and stated Resident #194 had been on Quetiapine before admission to the facility. Resident #194 had been a drinker for a long time and family noticed dementia during the pandemic. The Psychiatrist stated that at the facility, Resident #194 exhibited agitation and confusion especially at night, but Resident #194 did not exhibit psychotic behaviors. The diagnosis was neurocognitive disorder with a history of alcoholism. The Psychiatrist stated they evaluated the resident and had a full conversation with them through an interpreter. The Psychiatrist stated they were aware of the black box warning, but they were limited in what they can prescribe. Resident #194 had been on this medication, and it was working, so they would not stop it. On 05/26/23 at 10:46 AM the Consultant Pharmacist (CP) was interviewed and stated that once a month they review the charts for all residents in the nursing home and make recommendations for changes that need to be made. The facility will agree or disagree with recommendations. The CP stated they were aware of the black box warning for elderly residents with dementia on antipsychotic's. The CP was aware that Resident #194 did not have bipolar or schizophrenia diagnoses. The CP stated that at the time of the medication regimen review, Resident #194 had been seen by the Psychiatrist 3 times. The Psychiatrist was following the resident closely and the Psychiatrist believed the resident needed the medication. The CP stated the Psychiatrist was aware of the black box warning, so the CP didn't feel it was necessary to make a recommendation. On 05/26/23 at 10:59 AM the Assistant Director of Nursing (ADNS) was interviewed and stated that residents on psychotropic medications are followed regularly by Psychiatry. If they have behaviors, it is more often. The ADNS stated they have pharmacy medication reviews monthly, and the Pharmacists make recommendations. The ADNS stated they would expect the Pharmacist to make recommendations if needed. They would also expect the psychiatrist to adjust the medication as needed. 415.18 (c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey from 05/22/23 to 05/26/23, the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications. This was evident for 2 of 6 residents (resident #194 and resident # 373) reviewed for Unnecessary Medications Review out of a total sample of 35 residents. Specifically, 1) Resident #194 received antipsychotic medication, Quetiapine (Seroquel), and antidepressant medication, Trazodone, without an appropriate diagnosis, and 2) Resident #373 received an antipsychotic medication without an appropriate diagnosis. The findings are: The facility's policy and procedure titled Psychotropic medication, revised 10/22, documented that psychotropic, medications may be used only for the treatment of specific medical and/or psychiatric conditions. 1) Resident #194 had diagnoses of Dementia, and unspecified psychosis not due to a substance or known physiological condition. The admission Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance of 1 person with activities of daily living. Resident #194 presented no indicators of psychosis and exhibited physical and verbal behaviors towards others and rejection of care 1-3 days. Resident #194 recieved antipscychotic medication for 5 days routinely and as needed, and no Gradual Dosage Reduction (GDR) was attempted. On 05/22/23 at 09:31 AM, 05/24/23 at 09:56 AM, and 05/25/23 at 10:32 AM Resident #194 was observed in their room, either lying in bed or sitting in their wheelchair. Each time the resident had a calm demeanor and, while confused, responded to surveyor's questions appropriately. On 05/24/23 at 11:14 AM Resident #194 was observed in their room with visitors. Resident's spouse stated that they visit often, but when they don't visit the resident misbehaves. Spouse stated, they don't know exactly what Resident #194 does, but Resident #194 can get mad, angry, and can be strong. Spouse stated that when Resident #194 misbehaves, they received medication to make him/her sleepy. Spouse stated that Resident #194 never had a mental health problem before, and only began losing their memory during the pandemic. A comprehensive care plan (CCP) for psychotropic drug use, effective 4/1/2023, documented Resident #194 was receiving Haldol / Quitiapine medication related to diagnosis of Agitation. Interventions included establish appropriate diagnosis for medication use and evaluate for reduction of medication dose. A CCP for behavior problems, effective 4/6/2023, documented Resident #194 exhibited physically aggressive behavior towards staff/others, made attempts to get out of bed and to stand up when sitting on the wheelchair. Haldol and Quetiapine are antipsychotic medications used to treat Schizophrenia. The FDA (Food and Drug Administration) black box warning documents elderly patients with dementia-related psychosis treated with antipsychotic drubs are at an increased risk of death. Quetiapine and Haldol are not approved for use in elderly patients with dementia-related psychosis. A social work admission note dated 4/1/23 documented resident had been admitted from hospital on 3/31/23. Resident noted very forgetful and reported feeling down related to missing their family, trouble staying asleep, decreased energy and poor appetite and trouble concentrating on doing things during mood assessment. Resident was able to make needs known in Spanish. A behavior note dated 4/6/23 at 6:35 AM documented a behavior note. At 1:30 AM, Resident #194 was sitting on a chiar in front of room [ROOM NUMBER]. The resident removed their diaper and was putting on their shoes. Staff assisted the resident back to bed. At 1:45 AM, the resident was at the nursing station. They were combative and trying to get out of the w/c. The Nurse and CNA attempted to calm the resident , and the resident hit the nurse, grabbed and twisted the CNA's arm, and punched the nurse in the left eyebrow. The resident was assisted for unmet needs and transferred to a quiet area. A nursing note dated 4/6/23 at 3:13 PM documented Resident remained restless attempting to get out of chair unassisted. Medical doctor present ordered one dose of Haldol 2.5 mg and Quetiapine 50 mg once daily at bedtime and Haldol 0.5mg IM every 6 hours as needed. A psychiatry consult dated 4/10/23 documented Resident #194 was evaluated for confusion and behavioral disturbance. The consult documented that Resident #194 had been agitated and more confused in the evenings. The report documented history from the resident's spouse. The spouse reported that this behavior had been happening since the pandemic started and had not been worsening. Resident had a long history of alcohol abuse, and no other past psychiatric history. No depressive manic or psychotic episodes or symptoms. The psychiatrist noted that the resident continued to be confused, not oriented to place, or time. The psychiatrist also documented that staff reported that Resident #194 has been increasingly combative and aggressive especially in the evenings. The family believed the resident was getting confused at night because they were in an unfamiliar place. Family stated resident was on medication for sleep at night, but they did not know which medication. The resident was diagnosed with Chronic Alcohol related Dementia with rule out mild neurocognitive disorder likely secondary to Alzheimer's Dementia and rule out Dementia with behavioral disturbane. the plan was to continue Quetiapinel 50 mg at 6 PM in the evening for agitation, continue Haldol 0.5 mg every 6 hours as needed for agitation, and stop Ambien due to paradoxical reaction. The physician's orders dated 4/28/23, renewed 5/21/23, documented Resident #194 was to receive quetiapine 50 mg orally daily in the evening and quetiapine 25 mg orally daily in the morning. Behavior notes dated 4/13/23 and 4/14/23 documented Resident #194 was very restless, making several attempts to get out from the wheelchair, and redirection was not helpful. A psychiatry follow-up note dated 4/14/23 documented Resident #194 continued to have significant memory problems. Nurses reported resident was also confused in the morning for AM care. The plan was to add quetiapine 25mg in the morning for agitation, continue quetiapine 50mg at 6 PM in the evening for agitation, and discontinue Ambien to avoid Ambien contributing to the confusion. A psychiatry follow-up note dated 4/18/23 documented Resident #194 was less agitated with fewer behavioral problems since Seroquel was increased to 25 mg in the morning, 50 mg at 6 PM. No excessive daytime sedation or other side effects were noted. Diagnosis was major neurocognitive disorder most likely secondary to Alzheimer's type dementia and/or alcohol abuse disorder and/or shunt, moderate. Recommendation was to continue Seroquel 25 mg in the morning, 50 mg at 6 PM to help reduce periods of agitation with disturbances. A Medication Regimen Review dated 4/27/23 documented no recommendations were made. The MRR was conducted by the consultant pharmacist. The Medication Administration Records (MAR) since admission on [DATE] to April 2023 documented Resident #194 received Seroquel 50 mg at bedtime (9:00 PM) from 4/6 to 4/9 and Seroquel 50 mg in the evening at 6:00 PM starting 4/10/23. A morning dose of Seroquel 25 mg OD was added and administered starting on 4/15/23. A Psychiatry follow-up note dated 5/18/23 documented Resident #194 was seen via video with staff assisting with interpreting. The resident stated he did not sleep well and denied anxious or depressed mood. Resident denied audio or visual hallucinations, suicidal ideation, and homicidal ideation. Per staff, the resident was doing well and not having behavioral problems. Per the assessment, the resident had Major neurocognitive disorder most likely secondary to Alzheimer's tupe dementia and/or alcohol abuse disorder and/or shunt, moderate. The targeted behaviors were confusion and aggression. The recommendations were to continue Seroquel 25 mg in the morning and 50 mg at 6 PM to reduce agitation and behavioral distrubances. Add Trazodone 50 mg at bedtime for sleep and follow-up in 1 month. Trazodone is an antidepressant medication indicated for treatment of Major Depressive Disorder. The MAR dated May 2023 documented Resident #194 was given Seroquel 25 mg at OD at 9:00 AM from 5/1/23 to 5/26/23, Seroquel 50 mg in the evening at 6:00 PM from 5/1/23 to 5/25/23, and Trazodone 50 mg HS from 5/19 to 5/25/23. There was no documented evidence that the resident exhibited psychotic behaviors. There was no documented evidence that a gradual dose reduction had been attempted for the antipsychotic medications. On 05/24/23 at 12:03 PM CNA #2 was interviewed and stated they have been taking care of resident #194 regularly for the past 2-3 weeks. CNA #2 stated resident #194 doesn't speak English but, they can understand each other. Resident #194 is very quiet and had never been combative or aggressive, no resistance to care. On 05/24/23 at 02:57 PM RN #2 was interviewed and stated Resident #194 is quiet and cooperative, and RN #2 was not aware of any behaviors. No aggression, no refusal of care. On 05/25/23 at 10:38 AM RN #3 was interviewed and stated Resident #194 was very abusive, combative, resistant to care on the first few days after admission. RN #3 stated Resident #194 speaks Spanish and would calm down when speaking with Spanish-speaking staff or with their spouse. Resident #194 would say they wanted to go home. Resident #194 continued periodically with resisting care, sometimes refused medications. Verbally aggressive, not physical. At night, sometimes they bring Resident #194 close to the nurse's station because Resident #194 would not sleep. When Seroquel was started Resident #194 became quiet, slept most of the time, and behavior started improving gradually. On 05/25/23 at 10:55 AM, the medical doctor (MD) was interviewed and stated that Resident #194 was agitated, confused, and aggressive with staff. The MD stated they were not sure of Resident #194's psychiatric history, and that they had a history of dementia. The MD stated that Resident #194 was being seen by psychiatry. The MD stated they were aware of the black box warning for the medication prescribed, but What can we do? We cannot restrain him, but he was agitated and aggressive. When asked why prescribing a medication that is not approved for elderly patients with dementia, the MD stated, You can talk to psychiatry. On 05/25/23 at 11:24 AM the psychiatrist was interviewed and stated Resident #194 had been on quetiapine before admission to the facility. Resident #194 had been a drinker for a long time and family noticed dementia during the pandemic. The psychiatrist stated that at the facility, Resident #194 exhibited agitation and confusion especially at night, but Resident #194 did not exhibit psychotic behaviors. The diagnosis was neurocognitive disorder with a history of alcoholism. The psychiatrist stated they evaluated the resident and had a full conversation with them through an interpreter. The psychiatrist stated they were aware of the black box warning, but they were limited in what they can prescribe. Resident #194 had been on this medication, and it was working, so they would not stop it. On 05/26/23 at 10:46 AM the consultant pharmacist was interviewed and stated that once a month they review the charts for all residents in the nursing home and make recommendations for changes that need to be made. The facility will agree or disagree with recommendations. The consultant pharmacist stated they were aware of the black box warning for elderly residents with dementia on antipsychotics. The consultant pharmacist was aware that Resident #194 did not have bipolar or schizophrenia diagnoses. The consultant pharmacist stated that at the time of the medication regimen review, Resident #194 had been seen by the psychiatrist three times, the psychiatrist was following the resident closely and the psychiatrist believed the resident needed the medication. The consultant pharmacist stated the psychiatrist was aware of the black box warning, so the consultant pharmacist didn't feel it was necessary to make a recommendation. On 05/26/23 at 10:59 AM the Assistant Director of Nursing (ADNS) was interviewed and stated that residents on psychotropic medications are followed regularly by psychiatry. If they have behaviors, it is more often. The ADNS stated they have pharmacy medication reviews monthly, and the pharmacists make recommendations. The ADNS stated they would expect the pharmacist to make recommendations if needed. Or they would expect the psychiatrist to adjust the medication as needed. Resident # 373 was admitted with diagnoses which include Encephalopathy, Urinary Tract Infection (UTI) and Vascular Dementia. The Pending admission Minimum Data Set 3.0 (MDS) assessment assessed 06/04/2023 documented the resident was cognitively impaired. The assessment further documented the resident received anti-psychotropic medications daily and physician documented gradual drug reduction contraindicated on 05/16/2023. The Comprehensive Care Plan (CCP) for Psychotropic drug use 5/10/23 and interventions include evaluate action of medication and side effects, evaluate need for dose adjustment or reduction, monitor for changes in behavior and mood and observe for any signs of decline in function or cognitive status. The Physician's Order dated 05/10/2023 documented Quetiapine give 1 tablet 2 times a day for schizophrenia unspecified. The Physician's Order dated 05/11/2023 documented Quetiapine 25 mg in the evening at 6:00PM for Restlessness and Agitation. The Physician's Order dated 05/15/2023 documented an order for Quetiapine 25 mg twice daily on admission for Restlessness and agitation. The Physician's Order dated 05/16/2023 documented an order for Quetiapine 25 mg at bedtime at 9:00 PM for Restlessness and agitation. The Physician's order dated 05/17/2023 documented Seroquel 25 mg (give 1 tablet orally as one dose). Physician's order dated 05/19/2023 documented Seroquel 25 mg (once daily at bedtime). Physician's new order dated 05/19/2023 documented Seroquel 25 mg (1 tablet at bedtime for schizophrenia unspecified). Observation of Resident 373 between 05/23/2023 at 02:31 PM to 05/29/2023, the resident resting in their room in their room, visiting with family with a calm demeanor. The Medication Administration Record (MAR), starting 05/10/2023 documented the resident received Quetiapine (Seroquel) 25 mg BID daily, from 05/10/2023 -05/11/2023 for restlessness and agitation. Quetiapine (Seroquel) 25mg once daily at bedtime on 05/11/2023 - 05/12/2023. Quetiapine (Seroquel) 25mg once daily at bedtime for schizophrenia, from 05/19/2023-05/25/2023. There was no documentation in the resident's medical record that the resident had a history of schizophrenia prior to hospitalization and transfer to the nursing home. The PRI dated 05/08/2023 documented Resident #373 had no diagnosis of schizophrenia documented. Secondary diagnosis of dementia. The Level I screen dated 05/08/2023 documented Resident #373 had Alzheimer's dementia checked and no serious mental illness documented. Nursing admission note dated 5/10/2023 documented cognition alert to person with periods of confusion and forgetfulness. Diagnosis that included encephalopathy, sepsis due to complicated UTI, E-coli- ESBL severe sepsis, CVA, Dementia, urinary retention. Medical note on 05/11/2023 documented resident had a previous medical history of CVA, Dementia, hypertension, urinary retention with foley and ESBL (Extended Spectrum Beta-Lactamase) UTI and history of acute encephalopathy at hospitalization. Documented resident was oriented to self. Active diagnosis includes major neurocognitive disorder with most likely vascular dementia. Documented medications Donepezil 10 mg once daily at bedtime, memantine 10 mg once daily and Quetiapine 25 mg once daily in the evening. Documented Seroquel was decreased to 25 mg at bedtime for agitation, psyche for further recommendation ad and fall precautions. Review of Nursing progress notes documented order received to change Seroquel 25 mg twice daily (BID) to only at hour of sleep (HS) and order carried out. Resident was also on intravenous (IV) antibiotics for UTI management also. Nursing Progress note on 5/14/2023 at 02:21AM documented resident did not sleep at night trying to get up from bed and calling stated I want to get up and go. Further documented every hour monitoring to continue to resident and resident incontinent of bowel with foley. At 4:03 PM resident was observed sitting on the floor mat next to their bed. MD and representative were both notified. Nursing Behavior not on 5/15/2023 documented resident alert responsive with confusion trying to get out from bed, repositioned, took off gown and sheet and threw on floor, tried to keep foot outside, reposition and asked resident where they were going. The note documented that the resident stated that they wanted to get up and got to doctor's office. Nursing progress note on 5/15/2023 at 09:43AM documented MD made aware of behavioral issues and MD ordered another consult with the psychiatrist. A Psychiatrist Consultation note was written by the psychiatry intern on 05/15/2023. It documented an assessment for ability to perform gradual drug dose reduction or discontinue psychoactive medication: documented consider restarting Seroquel which was discontinued. No individual or cumulative side effects documented. Targeted behaviors include agitation, combative behavior and not sleeping. Recommendation restart Seroquel Quetiapine 25 mg at bedtime for sleep and behavior problems. The Psychiatrist documented in a note on 05/16/2023 that the resident had been more agitated since Seroquel had been discontinued. They noted that they had been somewhat more combative and not sleeping at night. Continues to have significant memory problems and does not realize they are in a nursing facility or why they are here. They documented a diagnosis of major neurocognitive disorder most likely secondary to vascular dementia moderate. They did not document schizophrenia as a diagnosis. They documented that the resident was much less agitated on Seroquel and worse when off of this medication. They recommended to restart Seroquel at 25 mg nightly to help reduce agitation at night and insomnia. No side effects and good results noted when resident on this medication prior. Nursing progress note on 5/17/2023 at 04:33AM documented resident did not sleep all night, continuously trying to get out of bed, staff stayed with then to meet needs, provided snack, ate, incontinence care given, repositioned. The resident continued to come out of bed. Resident was assisted to chair and kept in front of nurse's station. Medical progress note on 05/17/2023 documented resident evaluated status post fall seen sitting on floor and no injuries noted and documented alert, episodes of confusion same as baseline. During an interview on 05/24/23 at 04:44 PM, an interview was conducted with CNA # 3 and stated that resident #373 behaviors include resident #373 climbing out of bed and having to be monitored throughout the evening shift. There are no other behaviors they are aware of. Nonpharmacological interventions include check if need ADL care, make sure resident not wet, ask resident is they are hungry and television. If you notice any change in behavior, they will notify nurse or supervisor. There is no CNA accountability task to monitor which behaviors are present for the resident. During an interview on 05/24/23 at 04:50 PM, RN # 2 stated Resident #373 is on Seroquel because they do not sleep at night. Resident had a history of getting out of bed at night and had a fall. Resident was placed on 25 mg of Seroquel at night. RN #2 stated that Resident #373 did well during the morning shift. When resident having issues sleeping's call medical provider. RN#2 stated that Resident #373 does get up when wet and agitated. Resident 373 was seen by psychiatrist. Resident 373 has Alzheimer's disease unspecified and schizophrenia unspecified and diagnosis is usually in the notes during admission. RN #2 reviewed the admission note and stated that diagnosis not written as schizophrenia, but secondary diagnosis was dementia. The pharmacist does the Medication Regimen Review (MRR) twice a week on rotating units and they communicate to them if any errors and communicate to pharmacy leader to contact DON if needed. During a follow up interview on 05/25/2023 at 04:36 PM and 5:02PM, Registered Nurse Supervisor (RNS # 2) was interviewed and stated the Resident #373 came in on Seroquel and resident was seen by psych for behaviors that included pulling out intravenous line and tried to pull out Foley catheter and peripherally inserted central catheter (PICC) line. Seroquel was discontinued from twice daily to only at night. Resident is sleeping better and the 1st week we had to manage 1:1 at times and they were combative during care. RN #2 stated that Resident #373 had behaviors at home, where they were also kicking and throwing things. Resident #373 behaviors included restlessness and agitation. The diagnosis was given by MD #2/Medical Director. RN #2 stated that on 5/19/2023 they took the order for Seroquel and entered the diagnosis of schizophrenia. RN#2 said in the eUHR there is a screen where the diagnosis for the medications. In a follow-up interview on 05/26/2023 at 11:24AM, RN #2 stated that they entered in the wrong diagnosis when they took the telephone order from MD#2. They stated that restless and agitation were the correct diagnosis. When an order is put in, it has to be signed by the medication nurse. The order is reviewed by another nurse then forwarded to the medical provider. Resident 373 does not have schizophrenia. They have restlessness and agitation and behavior of pulling intravenous (IV). During morning report, they are informed of the resident's primary and secondary diagnosis. As of 5/25/23 the resident still had incidents of restlessness at night. During an interview on 05/25/2023 at 11:40 AM, the Psychiatrist stated Resident #373 was on the psychotropic medication at the hospital. They were consulted to see the resident after behavior with staff due to possible encephalopathy complicated by UTI. The Seroquel is used for agitation when resident became combative. Resident 373 has vascular dementia and had sepsis in hospital which may affect their behavior. Any diagnosis is written in resident notes and the resident does not have any schizophrenia diagnosis. If we stop medication we come back in week and we were called in 3-4 days after staff stated resident was worse. Seroquel was initiated for resident. Resident 373 was not sleeping at night, had physical aggressiveness. History was obtained from the resident's representative. It is alright to use medication for the resident since it is for Alzheimer's disease. Symptoms to monitor includes sleepiness, increased appetite and metabolic syndrome. A low dose may not affect the resident. Residents have different tolerance levels to medications. The medication was discussed with resident's representative, and they agreed with the plan of care. Vascular dementia management medications include Aspirin 81 mg, Donepezil and Memantine. The Psychiatrist said that the resident is doing well on those medications. A Gradual Drug Reduction (GDR) for Seroquel was done and medication was stopped. The Resident is currently receiving Seroquel at night for sleep. During an interview on 05/25/2023 at 03:12 PM, the Pharmacist stated they were familiar with black box warning for Seroquel used in elderly residents. In the elderly it can cause cardiovascular and other issues. They were aware that a psychiatric evaluation was done for the resident approximately 6 days post admission. However, it is dangerous to just stop medication. There was no psych eval in hospital and it was hard to pinpoint why the resident was prescribed the medication while in the hospital. Seroquel can be used for schizophrenia and for neurocognitive bipolar. This medication should not be used to manage symptoms. The Medication Regimen Review (MRR) are done daily for residents. If there are any medication discrepancies, they reach out to provider and let them decide. During interviews conducted on 05/25/2023 at 12:13 PM and 12:28PM and again at3:42 PM, the Medical Doctor (MD #2) who is also the Medical Director stated that Resident #373 had a diagnosis of vascular dementia and dementia unspecified not schizophrenia. On 5/7/2023 or 5/8/2023 while Resident #373 was in the hospital they were placed on Seroquel with an indication of agitation. The resident had a foley and with their behaviors there was a risk to injury such as traumatic hematuria. It was beneficial to temporarily place on Seroquel at a lower dose and monitor to determine if they should discontinue completely. They tried to take wean off the medication. As a result, the resident had multiple falls and aggressive behavior. They are aware of the risks this is why psychiatry and medical were monitoring. MD#2 stated that the black box warning can apply to any resident based on their present situation. MD#2 stated that the Pharmacist did not indicate any medication irregularities during their review. They stated that nonpharmacological interventions were included for this resident. MD #2 stated that psychiatry communicates recommendations and they do try to avoid prescribing unnecessary antipsychotic medication. They attend the resident's interdisciplinary treatment team (IDTT) meetings. The resident has a foley catheter and was on antibiotics. There can be confusion and agitation with infection and foley use. This may decrease once foley is removed. During an interview on 05/26/2023 at 11:35AM, RN #4 stated that when a resident comes in with a diagnosis, they ask the doctor to clarify diagnosis for the order, this includes telephone orders. Resident #373 has dementia. Psychotropic medication include Seroquel and stated they are not sure what it is used to treat. RN #4 stated that the resident has exhibited agitation, but they are usually quiet when they provide care. They talk to resident calmly and answer calmly and explain medication when administered. RN #4 stated that the resident receives Memantine for dementia given in the morning. No refusals of meds for resident and explained to resident before administration. We don't want any misdiagnosis with the residents, make sure resident get correct medication for the correct diagnosis. No sleep disturbance aware of for resident when they come in the morning resident sleeping and resident 373 gets up when ready to eat breakfast. During an interview on 05/26/23 at 01:21 PM, the Assistant Director of Nursing (ADON) stated that the diagnosis in the medical record should be accurate. The nurse should read consultant recommendation and follow up with MD on all telephone orders. The nurse should look at diagnosis from the doctor. You cannot give medication for a diagnosis that a resident does not have. The diagnosis has to be in the resident's chart. When you see a schizophrenia diagnosis, we have to validate the diagnosis. The ADON stated that if the resident came from the hospital with a diagnosis of schizophrenia, then there would have been involvement from social services and the MDS coordinator along with psychiatrist. The interdisciplinary treatment team reviews the MDS and, social services reviews diagnosis in morning report. In order to provide the right care for the resident you cannot enter a diagnosis that is not part of the medical record, accuracy is very important. The ADON said that the diagnosis of schizophrenia may have been a typo and error. 415.18(c)(1)

Based on observation, record review and interviews, the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive and at a safe and appetizing temperature. Specifically, during the dining observation task, during the breakfast meal of 5/22/23, milk was not served at a safe and appetizing temperature. The findings are: A Policy and Procedure titled Taste & Temperature Control - remote dining, effective 5/15, revised 4/17, states that food is maintained at proper temperatures during meal service. It states the procedure that prior to the start of each meal period, there is an evaluation of the taste and temperature of food. This information is documented on a taste and temperature log. Cold foods should be held at temperature that will ensure HACCP standards are met at time of delivery. Cold foods, such as milk, butter, ice cream, and juices are refrigerated during service or properly iced. The dining server will transport sandwiches along with other cold items inside the cold bin. Once the dining room is reached, the items will be transferred into the pantry refrigerators waiting to be served on resident's trays. A Policy and Procedure titled Dining Room Meal Service Procedures, effective 11/18, no revision date, states the policy is to ensure residents receive meals in an accurate, safe, and timely manner. Cold foods should be held at temperature that will ensure HACCP standards are met at time of delivery. Temperature of cold foods will be recorded per taste and temperature log standards. Each tray will be pre-set in the kitchen with resident's meal ticket, utensils, napkins, and condiments. Food service employees will compile the rest of the tray up on the units by adding cold food items first (milk, juice, etc.) from the cold bin. Dietary server will pull one or two trays at a time, placing them on top of steam table, assembling the hot food plate, soup, and hot beverage. The HACCP Daily Taste Panel Chart, dated 5/22/23 3rd floor, had attached to it the HACCP Critical Control Points Daily Temperature Log, undated/floor not indicated, reflecting blank temperatures for the cold food items served at the breakfast meal. On 5/22/23 at 7:44AM, the breakfast trays for the 3rd floor were observed to be set up with juice, milk. cottage cheese, and yogurt. Also observed were 2 trays of supplements/nourishments, each tray with a quart of milk. On 5/22/23 at 8:09AM, the first resident's breakfast tray was set-up with hot food. No temperatures observed to be taken of hot or cold food prior to delivery. On 5/22/23 at 8:43AM, the State Agency took a 4-ounce container of milk off the last breakfast tray prepared prior to its service to the resident (a replacement milk was provided) in order to check its temperature. On 5/22/23 at 8:45AM, the Dietary Aide (DA) was interviewed and asked for the time that breakfast is scheduled to be served. The DA stated that breakfast service starts at 7:45AM. The trays are set up the night before with the condiments. The DA starts work at 7AM and gets the trucks, collect their supplies, and come to the unit. The DA further stated that their partner/co-worker, put the milk and juices on the trays around 7:25-7:30'ishAM. No temperatures were taken as they do not have a thermometer. The DA stated the manager or cook takes the temperature before it goes into the hot box in the kitchen. Today there was a hold up of service on the unit because of an issue with the coffee machine. On 5/22/23 at 8:52AM the Food Service Manager (FSM) came to the unit with a thermometer to check the temperature of the 4-ounce container of milk. The temperature was 50 degrees Fahrenheit. The DA was asked if this is an appropriate temperature and they stated it is not an appropriate temperature for milk. The FSM was asked about the temperature of milk. They stated milk should be between 35 to 37 degrees Fahrenheit, and that 50 degrees is not appropriate. The FSM stated that the cold items are put on the trays up on the unit. Breakfast service is started between 7:45 - 7:50AM. Staff usually put the items on 5 to 10 minutes before that. They stated usually the manager comes up and takes temperatures. The FSM stated that today they did not check the cold food temperatures. On 5/22/23 at 1:51PM, an interview was conducted with the Director of Food & Nutrition (DFN) who stated that the staff come in at 7AM. The trays are set up with the condiments the night before. The staff put their cold bin together (a container with cold items, ice it down and come to the unit). Once on the unit, the staff organize the trays, and at around 7:30AM they put the cold items onto the trays. The cold food item temperatures are done by the manager. The manager will verify hot food temperatures as well. The breakfast starts at 7:45AM. The manager takes hot food temperatures on the unit and will hit a few cold items here and there. The DFN stated that the nursing staff is responsible for putting the quart of milk (on the nourishment trays) into the refrigerator. 10NYCRR 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey (CM6T11), the facility did not ensure that infection control practices were maintained. This was evident for 1 of 6 units (Unit - 2 North) observed for Infection Control. Specifically, a Certified Nursing Assistant (CNA #3) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC between residents and having inconsistent hand hygiene. The findings are: The facility policy titled Infection Control last reviewed 05/2023, documented actions we take to eliminate reservoirs include they are everywhere! Everywhere you touch, there is an organism. Cleaning and disinfecting of community use items is critical in both compliance and prevention to include digital blood pressure machines. During an observation on 05/24/2023 from 3:59PM- 4:25PM, CNA #3 entered Resident #373's room without donning gloves and gown. CNA #3 took Resident #373's blood pressure (BP) on the right arm, pulse oximetry on right hand 2nd digit and used an oral thermometer to take the temperature. After completing the vital signs for Resident #373 they documented the resident's vital signs, removed the pulse oximetry, recorded additional readings and removed blood pressure cuff from resident's right upper arm. The items were placed into a caddy on the vital signs machine. The caddy was taken out of room. The blood pressure cuff fell on floor and the blood pressure cuff and pulse oximetry was wiped with a purple wipe with bare hands. CNA #3 proceeded to room [ROOM NUMBER] and took the vital signs of Resident #378 who was wearing a short sleeve shirt and documented their vital signs and proceeded to get linen for the resident in the cart close by the resident's room doorway. CNA #3 assisted Resident #378 to make the resident's bed. On 05/24/2023 at 04:11PM CNA #3 applied hand sanitizer to their hands. The BPC is not cleaned after use. CNA #3 proceeds to room [ROOM NUMBER] and the BPC was applied to Resident #374 who was wearing a short sleeve shirt and applied BPC to right upper arm and took their blood pressure, placed pulse oximetry on right hand 2nd digit, temperature done and documented. The pulse oximetry and BPC were placed in the caddy were not cleaned and no hand hygiene done. CNA #3 assisted Resident #377 to get to a sitting position for blood pressure by assisting them holding their left hand. BPC was applied to the right arm above long sleeve shirt, temperature done, CNA #3 removed resident's shirt, blood pressure done on bare skin with assistance of therapy staff present after curtain drawn for privacy from open doorway. The BPC was removed, and vital signs recorded, and hands sanitized. The BPC was not cleaned after use. CNA #3 does hand hygiene with soap and water in resident bathroom and walks to room [ROOM NUMBER] with the BPC and after plugs up the BPC in the wall outlet opposite room [ROOM NUMBER]. On 05/24/2023 at 4:44 PM, CNA #3 stated BPCs should be cleaned when finished taking vital signs. They forgot to clean the vital signs machine in between residents in rooms. For infection control don't want to pass anything to anyone. They have had in-service on infection control so far this year. Vital signs machine should be sanitized between each resident to prevent spreading infections between residents. On 05/25/2023 at 4:58PM, RNS #3 stated that the vital signs machine should be cleaned after each resident's use. We use purple wipes for the vital signs machine and handwashing and per policy. Staff are inserviced on this and upon hiring for infection control. Cleaning is for infection control. On 05/26/2023 at 01:00PM, the Infection Preventionist stated they do rounds daily and to make sure everything is in place by observing staff. In terms of infection control, if have an outbreak we failed and during COVID-19 could not help, control COVID-19. If there is a vital signs machine, [NAME] if you share it you clean it so staff can remember and we have enough of purple top wipes and cleaning of equipment. We don't want the spread of infection on residents' skin and we use standard precautions and make sure equipment is sanitized for all residents use and there is no spreading of anything in between use of equipment. On 05/26/2023 at 01:30 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated they do rounds daily. Staff have to clean equipment between usage. Disposable cuff for infectious disease has their own machine and after isolation is discarded. It should be cleaned between residents as part of infection control and can't use on another resident; any residue or dead tissue have skin infection and they may transmit it to another resident. On 05/26/2023 at 01:45PM, the Director of Nursing was interviewed and stated they do rounds in the morning and after morning meeting and on the 3-11 shift 3-4 times daily. Shared equipment should be cleaned before and after use. Cleaned at start of shift and if not used before. Make sure not transferring infections, microorganisms from previous patients to prevent contamination. 415.19 (a)(1),(b)(4)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, sliced turkey lunchmeat stored in the refrigerator was not discarded in a timely manner and time/temperature control for safety foods (TCS) were not at acceptable temperatures (41 degrees Fahrenheit or less). This was evident during the Kitchen Observation task. The findings are: The facility policy Food Safety revised 06/2020 documented the Food and Nutrition Department has a comprehensive food safety and self-inspection system that includes equipment monitoring to ensure the effectiveness and quality of the food safety program for all of our food service customers. Temperature records for Critical control points for all patient and cafeteria meals served are maintained and monitored. The temperatures are taken twice during meal service at breakfast lunch and dinner. The facility policy Sanitation and Infection Control- Meal Service Area (Pantry) effective 3/2020 documented Food and Nutrition department in collaboration with Environmental Services will maintain a clean and safe meal service area (pantry) and follow food safety protocol to prevent the transmission of disease-carrying organisms. Pantry refrigerators must maintain Temperature Controlled for Safety (TCS) food at 41 degrees Fahrenheit or below. All TCS foods must meet the following temperature requirements cold foods are transported in a cold bin and held at 40 F or below. On 05/22/2023 between 06:51AM and 07:24 AM, an initial tour of the kitchen and facility's emergency food supply was conducted. In was observed in the produce refrigerator there were two 5-pound (lb) containers of cranberry grain salad and one - 5-pound container of Asian noodle salad labeled with a use by date of 5/21/2023. In the meat refrigerator a pan containing 3 individually plastic wrapped slices of turkey labeled with preparation dates of 5/12/2023, 5/15/2023 and 5/16/2023 were observed. On 05/24/2023 between 12:14PM-12:24PM, the pantry refrigerator food temperature was taken on the 2nd floor dining room by FSM #1. The refrigerator temperature was 56 degrees Fahrenheit (F). The following items were observed not below 41F. FSM #1 took the temperatures with a thermometer of three containers of thickened milk in 4-ounce (oz) containers which had temperatures of 57.5F and 58.3F, two- 4 oz containers of cottage cheese had temps of 46.6F and 46.7F. Temperature was repearted with a second thermometer which showed 54F. Thickened milk temperature redone was 60.9F. The temperature log was last filled out on the 7-3 shift on 5/23/2023. On 05/24/2023 between 12:36PM-12:42 PM, the dining room pantry refrigerator on the 3rd floor was at 46 degrees Fahrenheit. The temperatures taken by FSM #3 with a thermometer of two 4 oz containers of Coleslaw with use by date of 5/26 showed a temperature of 55.1F and 55.7F and a Roast beef sandwich at 57.4F. On 05/24/2023 between 12:53 -12:59 PM, the dining room pantry refrigerator on the 4th floor was at 44 degrees Fahrenheit. There was an 8 oz carton of fat free milk with expiration date of 5/14. The temperature was taken by FSM #3 with a thermometer of 2 eggsalad and one turkey sandwich. The turkey sandwich temperature was 53F and the egg salad sandwich temperatures were 53.3F and 53.4 F. The temperature log documented 40F on 5/24/23 (7-3 shift). On 05/22/2023 at 07:46AM, an interview was conducted with the storeroom/porter person who stated they are familiar with First In First Out (FIFO). They do check with manager and check items if they are going to expire to make sure they are used up if they can and if they cannot, then throw them out. We can't serve expired food to patients. They got FIFO training every few months and training in 2023. Labeling items training also. Daily stock received on Monday, Tuesday and Thursdays, milk on Monday, Wednesday and Friday and bread delivered daily. On 05/23/2023 at 4:43PM, an interview was conducted with the Dietary Aide/Porter who stated they sliced turkey meat recently and they sliced some this past Saturday. They only slice meat when they do meal preparation. Sliced turkey is held for 3 days. Held for 3 days because don't want people to get sick. They check pans before they slice the meat to see what is there. There was no sliced turkey that needed to be discarded and sandwich person used up the turkey and told them they needed some turkey sliced. The chef does in-service for them in relation to food contamination/food safety. On 05/22/2023 at 07:54AM, an interview was conducted with the [NAME] helper who stated they sliced meat last week on Thursday. Slicing meat is a daily activity and slice for deli section of the cafeteria. Provide sliced meat for sandwiches for the nursing home. Meat is kept for 2 days once sliced. Food safety is followed, so meat is not kept too long, so it gets contaminated and make patients sick. On 05/24/2023 at 10:28AM, an interview was conducted with the [NAME] helper/preparation person who stated they sliced meat yesterday and was not here on the weekend. Friday was the last time they cut meat. We cut meat for the nursing home and hospital. They would throw away meat if expired. Meat is held for 3 days. Food spoils and due to the growth of bacteria is why meat should be discarded. We had food safety in-service last week. We date food items and after the 3rd day they must be discarded. No one wants food that has bacteria. On 05/24/2023 at 10:40AM, an interview was conducted with the Food Service Manager (FSM #2) who stated they do round's every morning and obviously they missed that. Three days is the time frame for holding the food to maintain food quality and to follow the facility policy. All food produced should be used within 3 days and should be discarded afterwards to maintain food safety. Sliced meat is used for nursing home residents. The facility cares for immune compromised and elderly /high risk residents which is why the policy documents to discard after three days. There was no log available that documented the meat slicing task. On 05/24/2023 at 10:46AM, an interview was conducted with the Food Service Director (FSD) who stated they do rounds daily. On Mondays they go through food items and discard items that need to be discarded. We have a three-day policy to make sure we are giving the best food products. In relation to meat items, we may have to observe and smell the product. Deli meat is used for the nursing home. There were issues with listeriosis in the past and we had meat cooked in the oven and changed the policy to discard meat every 3 days. It should not have happened. The chef comes in and goes through boxes. Staff trained to look at everything. On 05/24/2023 at 12:26PM, the Food Service Manager (FSM #1) for the 2nd floor kitchen pantry was interviewed and stated when the food items come up they are stocked in the refrigerator. The refrigerator should be 27- 40 degrees Fahrenheit. On 05/24/2023 at 12:42PM, the Food Service Manager (FSM #3) for the 3rd floor kitchen pantry was interviewed and stated that the refrigerator temperature should be 30-40 Fahrenheit. Nurses take temperature of the refrigerator. Food items are stocked before we came up to serve lunch. Foods should be served at the correct temperature to decrease the potential of contamination, mold and foodborne illness. On 05/24/2023 between 12:53PM -12:59P in the 4th floor pantry, the temperature on the thermometer in the refrigerator was observed to be 44 degrees F. There was one - 4 oz fat free milk carton in the refrigerator stamped with a sell by date of May 14 15:24 L2 PLT#34-1594. Also observed was 1 egg salad sandwich dated 5/26/2023 and 1 turkey sandwich dated 5/26/23. FSM #3 did the temperature of the turkey sandwich temperature was 53 F. Egg salad sandwich was 53.4F. On 05/25/2023 at 01:01PM, the FSM#3 was interviewed and stated the date on the milk is 5/14/2023 and it is expired. Nurses normally check refrigerator for food items. On 05/24/2023 at 01:05PM, an interview was conducted with the 4th floor RN #5 who stated they took the temperatures this morning and they did not notice the expired milk. If anything is expired, they throw out in the morning and evening. We don't want any infection or food contamination or food poisoning. On 05/25/2023 at 03:53PM, the 3rd floor LPN (LPN # 2) was interviewed and stated every shift they take temperatures. If the temperature is not within the proper range, then we tell the supervisor. Food for residents can freeze or spoil so the temperatures must be correct. On 05/24/2023 between 02:43PM and 5:00PM, the 2nd floor Registered Nurse Supervisor (RNS #2) was interviewed and stated the nursing staff on the south side of the unit is assigned to take the pantry temperature but are not documented. In order to keep food safe and consumable and to prevent food poisoning or food borne illness food needs to be kept at adequate temperature, so the residents are safe. On 05/26/2023 at 01:11PM, an interview was conducted with the Infection Preventionist (IP) who stated they play a role for infection control and food safety. The hold time for food is 2 days. When the refrigerator is checked, staff should look for expired food items. Food items should be labeled and dated. Any food items should be checked for an expiration/use by date for food safety to ensure the resident is not eating something that is contaminated, I was informed of the expired milk in the refrigerator. We need to make sure items are not outdated since it poses a risk. We constantly check the refrigerator for expired items. 415.14 (h)