Based on observations, interviews and record reviews conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, for one (1) (Resident #15) of one (1) resident reviewed, the facility did not ensure the resident's physician was notified immediately when there was a need to alter treatment significantly (discontinuing an existing form of treatment due to adverse consequences). Specifically, Resident #15 had complained of nostril pain while receiving a prescribed nasal spray four times daily and refused the medication repeatedly. There was no documented evidence that the physician or medical team was notified. The finding includes: The facility policy Change in a Resident's Condition or Status, dated March 2024, included the facility shall promptly notify the resident, their Attending Physician, and representative of changes in the resident's medical condition and/or status (e.g., changes in level of care). The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a change in the resident's medical condition requiring a change in their plan of care. Resident #15 had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with dependence on oxygen, and heart failure. The Minimum Data Set (a resident assessment tool) dated 03/03/2025 included the resident had moderately impaired cognition, was able to make themself understood and understood others, and did not exhibit behaviors. The Comprehensive Care Plan revised on 12/21/2024 included Resident #15 had chronic obstructive pulmonary disease and was to receive medications and oxygen per medical provider order. Review of Physician orders dated 03/18/2025 revealed deep sea 0.65% nose spray two sprays in both nostrils four times a day for dryness. Review of Resident #15's Medication Administration Record from 04/19/2025 to 04/23/2025 revealed Resident #15 had refused the nose spray on 7 of 17 opportunities. In a nursing progress note dated 04/17/2025, Registered Nurse Manager #3 documented Resident #15 had complained of pain to their left nostril, it was observed to be swollen, and Registered Nurse Manager #3 would notify the Nurse Practitioner. In a nursing progress note dated 04/22/2025, Licensed Practical Nurse #2 documented Resident #15 refused their nasal spray and was angry. There was no documented evidence that anyone had notified the physician or the medical team of Resident #15's complaints of pain and swelling to the left nostril, or repeated refusals of the medication. During medication administration observation on 04/21/2025 at 10:58 AM, Licensed Practical Nurse #2 entered Resident #15's room to administer their nose spray. The resident told Licensed Practical Nurse #2 the oxygen was hurting their nose, and it felt dry even with the nose spray and oxygen humidification. Licensed Practical Nurse #2 told the resident it was possible a sore in their nose was causing the pain, and they would speak to the doctor about discontinuing the nose spray. Licensed Practical Nurse #2 encouraged Resident #15 to accept the nose spray and proceeded to administer while the resident complained with each spray and required breaks in between. During a medication administration observation on 04/22/2025 at 11:04 AM, Licensed Practical Nurse #2 entered Resident #15's room to administer the nasal spray and the resident refused the medication. Resident #15 told Licensed Practical Nurse #2 the medication was not helping, it hurt their nose, and although the resident had been telling nurses the medication was causing them pain, they continued to offer it. Resident #15 said they refused the medication often and the soreness was getting worse. During an interview on 04/22/2025 at 4:23 PM, Resident #15 said the left side of their nose was sore to the touch. The resident said they had been telling the nurses that it hurt, and they did not want the medication. Resident #15 said they did not feel they needed the nose spray because it seemed to be causing more dryness to their nose and would have thought by now, someone would have told the doctor. During an interview on 04/23/2025 at 9:40 AM, the Director of Nursing said when the medical provider was not in-house, they communicated their concerns by phone. Review of the medical provider's communication book at the time revealed no documented evidence that the medical team had been notified of Resident #15 concerns or refusals of the medication. During a follow up interview on 04/23/2025 at 10:53 AM, the Director of Nursing said they first heard about Resident #15's complaints of nose pain on 04/17/2025 when the resident told Registered Nurse Manager #3. The Director of Nursing said they had reviewed the progress notes and could not find documented evidence that the nurses had communicated the resident's complaints of pain to the Nurse Practitioner prior to today. The Director of Nursing said nursing staff should report complaints of pain to the medical provider right away and Resident #15's complaints should have been reported on 04/17/2025 when first discovered. 10 NYCRR 415.3 (2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, for two (2) (Resident #33 and Resident #36) of eight (8) residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two (2) medication errors for 25 opportunities resulting in a medication error rate of eight (8) percent. Specifically, during an observation of medication administration Resident #33 and Resident #36 were administered the incorrect medication. The findings are: The facility's policy Administering Medications, revised April 2019, documented that the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1.Resident #36 had diagnoses that included constipation, chronic pain syndrome, and abdominal pain. The Minimum Data Set (a resident assessment tool) dated 03/09/2025, documented the resident was severely impaired cognitively. Resident #36's active physician's orders as of 04/22/2025 documented senna (a laxative) 8.6 milligram-give two tablets orally once daily. During an observation of medication administration on 04/18/2025 at 9:26 AM, Registered Nurse Manager #1 administered two tablets of Senna Plus 8.6-50 milligrams (a laxative plus a stool softener) to Resident #36. 2.Resident #33 had diagnoses that included constipation, chronic pain, and adult failure to thrive. The Minimum Data Set, dated [DATE], documented the resident was severely impaired cognitively. Resident #33's active physician's orders as of 04/22/2025 documented senna 8.6 milligram tablet- give one tablet orally once daily. During an observation of medication administration on 04/18/2025 at 9:36 AM, Registered Nurse Manager #1 administered one tablet of Senna Plus 8.6-50 milligrams to Resident #33. During an interview on 04/18/2025 at 12:15 PM, Registered Nurse Manager #1 stated they did not realize they had given both Resident #33 and Resident #36 Senna Plus (versus senna). Registered Nurse Manager #1 said they usually did not pass medications as they were the unit manager. Registered Nurse Manager #1 said the senna bottle was smaller than the Senna Plus bottle and the medications were given incorrectly. During an interview on 04/22/2025 at 11:36 AM, the Director of Nursing said that although the unit manager was not usually on a medication cart, they had been trained to pass medications. The Director of Nursing said the nurse should perform the five rights before giving medications and had the nurse checked, they would not have given the wrong medication to either resident. 10 NYCRR 415.12(m)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for two (2) (Residents #12 and #25) of eight (8) residents reviewed. Specifically, Resident #12 received wound care by staff who were not wearing the appropriate personal protective equipment (PPE- equipment such as gown, gloves and/or facemask worn to minimize exposure to infectious diseases). Resident #25 received an insulin injection by a staff member who was not wearing gloves and did not perform hand hygiene before or after the injection. The findings include: The facility's Infection Control Policy dated May 2024, documented that the facility will adhere to infection control standards including the practice of proper hand washing and glove usage. Gloves should be changed between residents and hand hygiene must be completed when gloves are removed. Gowns are to be worn when there is the potential for transmission of microorganisms and enhanced barrier precautions (interventions designed to reduce transmission of multidrug-resistant organisms) are indicated for a resident that has wounds or any skin openings. 1.Resident #25 had diagnoses that included diabetes, chronic kidney disease, and dementia. The Minimum Data Set (a resident assessment tool) dated 04/13/2025 documented Resident #25 was severely impaired cognitively and required insulin injections to manage their diabetes. Review of the Comprehensive Care Plan dated 11/20/2024 revealed Resident #25 was on bleeding precautions due to taking an anticoagulant (blood thinner) medication. Review of the physician order dated 10/16/2024, revealed Novolog (insulin) 10 units to be injected subcutaneously (into fatty tissue) with meals. During an observation and interview on 04/18/2025 at 1:29 PM, Licensed Practical Nurse #1 prepared Resident #25's insulin injection pen without washing their hands and then administered the insulin injection into the resident's right arm without applying gloves. Licensed Practical Nurse #1 did not wash their hands after administering the injection before exiting the room. In an immediate interview Licensed Practical Nurse #1 said they read online that they did not have to wear gloves when giving an injection with an insulin pen. During an interview on 04/18/2025 at 2:19 PM, the Administrator (acting Infection Preventionist at the time) stated their infection control policy was clear, and that nurses should wear gloves when giving an injection regardless of if the insulin was being administered with an insulin pen or not. 2.Resident #12 had diagnoses that included diabetes, dementia, and adult failure to thrive. The Minimum Data Set, dated [DATE] documented Resident #12 had moderately impaired cognitive skills and had lesions (skin wounds) on the foot that required dressings. Review of the Comprehensive Care Plan and Care Card (care plan used by Certified Nursing Assistants for daily care) initiated on 10/28/2024 and reviewed on 02/06/2025 revealed Resident #12 was at risk for pressure ulcers. Neither care plan included that the resident had open wounds on their feet or if they required enhanced barrier precautions while receiving dressing changes. Review of current physician orders on 04/17/2025 revealed for staff to clean the left ankle wounds, apply bacitracin ointment (an ointment used to prevent infection), xeroform (a moist dressing treatment) and cover with a telfa pad (a dressing that will not stick to wounds) every day starting on 03/26/2025. There were no orders for enhanced barrier precautions. In a physician progress note dated 03/03/2025 the physician documented Resident #12 continued to have a dressing in place on the left leg (wounds). In an observation on 04/21/2024 at 9:51 AM, Registered Nurse Manager #1, wearing gloves but no gown changed the dressing to Resident #12 left ankle wound. There was no sign on Resident #12's door or in their room that indicated enhanced barrier precautions were required for direct contact care. In an interview on 04/21/2025 at 2:31 PM, Registered Nurse Manager #1 stated that enhanced barrier precautions should be used for a chronic or draining wound, but they had not worn a gown when doing wound care for Resident #12 because their wound was not draining. Review of Resident #12's revised Comprehensive Care Plan dated 04/21/2025 revealed Resident #12 had a blister on the left ankle that was not intact and the resident was on enhanced barrier precautions. In an observation on 04/22/2025 at 8:50 AM, Resident #12 had a sign on the door that indicated enhanced barrier precautions including a gown and gloves should be worn when providing high contact care activities including dressing, bathing, showering, transferring, providing hygiene, and wound care. In an observation on 04/22/2025 at 8:55 AM, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 wearing gloves and no gowns assisted Resident #12 to transfer from bed using a stand lift (a mechanical lift that assists the resident to stand and transfer) to a shower chair, including touching the resident's visibly soiled incontinence brief. In an interview on 04/22/2025 at 9:05 AM, Certified Nursing Assistant #1 stated they did not notice the sign for enhanced barrier precautions for Resident #12 and should have worn a gown when transferring the resident. In an interview on 04/21/2025 at 2:55 PM, the Director of Nursing stated Resident #12's left ankle blister had opened a few months ago and the resident should have been on enhanced barrier precautions. 10 NYCRR 415.19(a) (1-3) (b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Recertification Survey conducted 11/27/23 to 12/1/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had unclean appliances and all units had foods either unlabeled, undated, or outdated. The findings are: Review of the undated facility policy and procedure (P&P) Food Storage documented sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Foods will be stored in an area that is dry, clean, and free from contaminants. All refrigerator and freezer units should be kept clean and in good working condition. Review of the undated P&P General Cleaning of the Kitchen documented food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Frequency of cleaning for each task will be defined and assigned to be the responsibility of specific positions. Observations on 11/28/23 at 9:01 AM through 9:30 AM during the initial walk through of the main kitchen, dry storage room and the refrigerator/freezer units in the basement revealed the following: - approximately 20 frozen sausage patties in an opened bag, undated in the dry storeroom freezer. - approximately 10 frozen uncooked cookie dough balls in a blue opened bag, undated in the dry storeroom freezer. - open box of store brand waffles, undated in the dry storeroom freezer. - small square pan of four uncovered eggs undated and unlabeled in the dry storage room refrigerator. -covered egg salad sandwich on a disposable plate undated in the dry storage room refrigerator. - opened bag of mixed vegetables undated in the dry storage room refrigerator. - one gallon plastic bottle of Worchester [NAME] opened and dated 7/15/22 on the dry storage room shelf. - one dented can of beets on the dry storage room shelf. - one opened bag of frozen chicken patties undated in the basement freezer. - the stove in the main kitchen had dried greasy stains flowing down the front and sides. During an interview on 11/28/23 at 9:31 AM the Food Service Director (FSD) stated they were unsure when any of the opened undated, unlabeled food items found in the refrigerator and freezer units were opened and should be dated. The FSD stated the kitchen gets cleaned daily by staff and that there was a daily cleaning list to follow. Observations on 11/29/23 at 8:40 AM revealed the exterior of the refrigerator and freezer units in basement and dried storage room were greasy and dirty. An observation on 11/30/23 at 11:32 AM revealed the stove in the main kitchen had dried greasy stains flowing down the front and sides. Review or the dietary Weekly Cleaning Assignments dated 11/26/23-12/2/23 documented as follows: - The big refrigerator in the basement is cleaned on Sunday morning by the morning cook. - The freezer in the basement is cleaned on Saturday by the morning cook. - The refrigerator in the stock room (dry storage room) is cleaned on Sunday by the evening cook. - The freezer in the stock room is cleaned on Wednesday by the evening cook. - The right oven is cleaned on Monday by the evening cook. - The left oven is cleaned on Thursday by the evening cook. During an interview on 11/30/23 at 1:06 PM Dietary Aide (DA) #1 stated some parts of the kitchen get cleaned every day like the floors and sinks, that all staff have an assigned area to clean and usually get it cleaned at the end of the shift if there was time. DA #1 stated there was a weekly list on the milk machine and the cleaning assignments change weekly. During an additional interview on 11/30/23 at 2:31 PM the FSD stated the kitchen staff have a daily cleaning assignment which should be initialed on the weekly cleaning assignment sheet when completed. Some areas are cleaned more [NAME] if staff have the time. The FSD said that assignments stay the same from week to week we just change the dates on the sheet. 415.14(h)

Based on record review and interview conducted during the Standard Recertification Survey completed on 12/29/21, it was determined that for one (Employee #3) of five employee files reviewed, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for an individual prior to hire. The findings are: On 12/28/21 at 1:36 p.m. the Surveyor reviewed documentation related to five recently hired employees. The files included that employee #3 was hired as the Activities Director on 9/30/21. The documentation provided did not include a nurse aide registry abuse screening for Employee #3. In an interview on 12/28/21 at 2:52 p.m. the Business Office Manager stated that Employee #3 was not screened for nurse aide registry abuse because the person who had been responsible for hiring the employee was unaware of the requirement to run the nurse aide registry abuse screening. Record review on 12/28/21 at 3:03 p.m. revealed the facility Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy (section 3: Screening/Prevention - Registry) included that all staff being considered for hire must also be checked with the New York State Nurse Aide Registry for a history of findings. 10 NYCRR: 415.4(b)