Based on observation, record review, and interview during the recertification and abbreviated (NY00297353) surveys conducted 3/25/2024-3/29/2024, the facility did not implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 3 residents (Resident #23) reviewed. Specifically, recreation aide #8 witnessed an alleged abuse incident by certified nurse aide #7 towards Resident #23 and did not intervene to stop the interaction and did not immediately report the alleged abuse to Administration per the facility policy. Additionally, certified nurse aide #7 completed their shift after the alleged abuse incident occurred. Findings include: The facility policy Resident abuse, neglect, mistreatment and misappropriation of resident property revised 1/2024 documented the facility encouraged and supported all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. All employees and volunteers would receive training on the abuse policy prior to direct or indirect resident contact. It was the policy of the facility that residents would be protected from the alleged offender. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. Resident #23 was admitted to the facility with diagnoses including Parkinson's disease (a progressive neurological disease), dementia, and repeated falls. The 4/25/2022 Minimum Data Set Assessment documented the resident had intact cognition, did not reject care, required extensive assistance of 1 with activities of daily living, had no falls since admission or the prior assessment, and used both bed and chair alarms daily. The 5/4/2022 comprehensive care plan documented the resident had Parkinson's disease and required assistance with activities of daily living. On 6/1/2022, the comprehensive care plan was updated to include they were high risk for falls. Interventions included tab (bed/chair) alarms to alert staff if the resident was attempting to ambulate, anticipate the resident's needs and assist as needed, educate on safety needs and document, and a toileting program. The facility's 6/9/2022 investigation completed by illegible name, documented: - between 12:30 PM and 1:00 PM on 6/9/2022, Resident #233 reported to (former) social worker #11 that they observed something violent involving Resident #23 in the dining room after the lunch meal. Resident #23 was in the dining room, and they were standing up from their wheelchair when certified nurse aide #7 entered the dining room and shoved Resident #23 into their wheelchair. They observed certified nurse aide #7 put their hands on Resident #24's chest and stated, I am not going to ask you and pushed the resident down. The resident felt certified nurse aide #7 was upset and overreacted. - Recreation aide #8's undated/untimed statement documented they walked into the dining room and observed Resident #23 standing up from their wheelchair. The resident's tab alarm (chair alarm) was sounding as they went over to assist the resident. Certified nurse aide #7 came into the dining room and pushed the resident down. Certified nurse aide #7 had their hands on the resident's shoulder as they stood in front of the resident. After the incident, certified nurse aide #7 quickly took Resident #23 out of the dining. They stated they did not report the incident when it occurred as they knew another resident would report it. They noted they were trained if they witnessed any abuse they should intervene and report the incident but did not because it happened so quickly. - Certified nurse aide #7's undated/untimed statement documented Resident #23 was standing up in the dining room, their alarm was not sounding, and they asked the resident to sit in their chair three to four times. They assisted the resident back into their wheelchair by placing their hands on the resident's lower back and shoulder. They stated the resident punched them in the stomach and scratched them and was in one of their moods. They did not tell anyone about the incident. After the incident in the dining room, they brought the resident back into their room. Once in the resident's room they pulled the privacy curtain and the resident started standing again and they put them in their recliner chair. - Resident #24's undated/untimed statement documented certified nurse aide #7 pushed them into their wheelchair with both of their hands on their chest. The resident reported no pain at the time of the interview. They felt certified nurse aide #7 was mad because they were trying to stand up and stated, we are not going to do this. The resident also stated once certified nurse aide #7 brought them into their room they pushed them into their recliner chair. - The facility Administrator assessed the resident on 6/9/2022 who denied pain and had no marks evident. - Certified nurse aide #7 was placed on leave pending the investigation and could not return unless instructed. - The facility's investigation concluded there was reason to believe certified nurse aide #7 placed their hands on the resident and moved them in a downward direction into the chair. It was felt the employee acted in anger. On 6/17/2022, certified nurse aide #7 was terminated from the facility. Certified nurse aide #7's timecard for 6/9/2022 documented they punched in at 6:31 AM and punched out at 2:30 PM. During an observation and interview on 3/25/2024 at 11:04 AM, the resident was in their room watching television. They had a tab alarm (chair alarm) on their recliner. They stated an unknown staff member had pushed them into their chair, but they could not recall when the event occurred. They stated they did not get hurt. They remembered facility staff talking to them about the incident and nothing like that had happened since then. During an interview on 3/26/2024 at 1:15 PM, former recreation aide #8 (now a registered nurse) stated they had received abuse training upon hire and annually. They stated they were taught if they witnessed any form of abuse, they should try to stop it and report it immediately. They stated on 6/9/2022, they entered the dining room to assist other residents to their room after the lunch meal. At that time, they had heard Resident #23's tab alarm (chair alarm) sounding. They heard certified nurse aide #7 telling Resident #23 to sit down, but the resident did not do what was asked of them. Certified nurse aide #7 grabbed Resident #24's shoulders while they were standing and pushed the resident back into their wheelchair. After certified nurse aide #23 pushed the resident into their wheelchair, they quickly took the resident out of the dining room. They stated other residents were in the dining room and they knew the residents would report the incident. They did not report the incident and about 15 to 20 minutes later the Director of Nursing came to speak to them. They were reeducated on the abuse policy, and they knew that they should have attempted to intervene and should have reported the incident, but it all happened so quickly. During an interview on 3/27/2024 at 12:02 PM, the Director of Nursing stated they expected if staff observed anything concerning that they should intervene and report the incident immediately. On 6/9/2022, Resident #233 reported to former social worker #11 they observed a serious incident in the dining room between certified nurse aide #7 and Resident #24. Former social worker #11 immediately contacted them, and an investigation was started. During the investigation statements were obtained. Unfortunately, recreation aide #8 did not report the incident and Resident #233 was the one who alerted staff to the incident. Registered nurse/former recreation aide #8 was removed from care when the investigation was started and reeducated on the abuse policy. Certified nurse aide #7 was also placed on leave pending the investigation and was terminated after the investigation was completed. During an interview with the Administrator on 3/27/2024 at 12:29 PM, they stated all staff received abuse training upon hire and annually. They expected any staff who witnessed abuse to intervene and report the incident. They stated activity aide #8 should have attempted to intervene and alert staff to the incident, but the incident happened so quickly, and Resident #233 alerted former social worker #11, and the investigation was started. Certified nurse aide #7 was placed on leave and was terminated after the investigation was completed. Registered nurse/former recreation aide #8 was reeducated on the abuse policy. 10NYCRR: 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 9 residents (Resident #14) reviewed. Specifically, Resident #14's prepared medications were left in a cup unattended on their bedside table for over 5 hours and licensed practical nurse #3 documented the medications were administered at 6:00 AM when they were not. Findings include: The facility policy Medication Policies Program reviewed 9/2023 documented medications were administered by a licensed nurse. The person that administered the medication ensured the six rights (right person, medication, dose, route, time, and documentation). Resident medication was accurately acquired, received, dispensed, administered, and documented in a safe and efficient manner. The facility policy Self-Administration Policy reviewed 9/2023 documented residents had the right to self-administer medications. Standards had to be met that included the resident had a secured area the medications were maintained if they were poured and administered in their room and a physician order was obtained. Residents' ability to self-administer medications was evaluated on admission, readmission, at the time of a significant change, and at least annually. If a resident was self-administering their medications, the nurse followed up at the end of their shift and verified if they had taken all their medications. Resident #14 was admitted to the facility with diagnoses including osteoporosis (weakness of the bones), edema (fluid swelling) and gastro-esophageal reflux disease (stomach acid flows up). The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, required set up assistance for eating and oral hygiene, and did not reject care. The comprehensive care plan initiated 2/29/2024 and revised 3/6/2024 documented the resident was at risk for complications due to advanced age with multiple medical diagnoses. Interventions included medications were administered as ordered. The 3/8/2024 physician orders documented the resident was to receive the following oral medications at 6:00 AM: - furosemide (diuretic) 20 milligram tablet, one tablet by mouth daily for edema - Ocuvite cap Lutein and Zeaxanhin (helps to protect eye health), one tablet by mouth daily for vision loss - oyster calcium with vitamin D 500/200 (treats osteoporosis), one tablet by mouth daily for supplement - acetaminophen 500 milligram tablet, two tablets (1000 milligrams), by mouth two times a day for pain There was no documented evidence of a physician order to self-administer medications. During an observation and interview on 3/25/2024 at 11:17 AM, Resident #14 was dressed and seated in their recliner chair in their room. There was a plastic medication cup on their bedside table that contained one red pill, one green pill, two large round white pills and one small round white pill. There was no staff present in the room. The resident stated these were their morning medications and the nurses always left them there and did not watch them take the medications. They stated there was always a medication cup there when they woke up in the morning. The Medication Administration Record documented the following medications were administered by licensed practical nurse #3 on 3/25/2024 during the scheduled 6:00 AM medication pass: - furosemide 20 milligram tablet, one tablet by mouth one time a day - Ocuvite cap Lutein and Zeaxanhin one tablet my mouth one time a day - oyster calcium with vitamin D 500/200 one tablet by mouth one time a day - acetaminophen 500 milligram tablet, two tablets (1000 milligrams), by mouth two times a day During an interview on 3/29/2024 at 5:56 AM licensed practical nurse #3 stated they were assigned to Resident #14 on the morning of 3/25/2024 and gave them their 6:00 AM scheduled medications. They had one hour before and after the administration time to give the medications. Medications were signed off after watching the resident take the medications and a medication signed as given meant they watched the resident swallow the medications. If they did not watch the resident swallow the medications, they could not be certain if they were taken. It was important for residents to take their ordered medications to keep them medically stable and safe. The nurse stated the routine medication administration process for Resident #14 was they woke the resident up in the morning and let them know their medications were on the bedside table. It was not appropriate medications were left at bedside. They were not aware the medications were still on the bedside table hours after the scheduled administration time and hours after their shift was over. They should not have documented them as given and if another resident had taken the medications an adverse reaction could have occurred. During an interview on 3/29/2024 at 10:07 AM registered nurse Unit Manager #2 stated when medications were administered and signed on the Medication Administration Record, it meant the nurse ensured the medications were taken by watching that the resident. It was acceptable to administer medications an hour before or after the scheduled administration time. They stated if residents were alert and oriented, prepared medications could be kept at the bedside if there was an appropriate physician order. If that was the case, the nurse went back to their room within the acceptable administration time parameters and ensured medications were taken and verified this by the end of their shift. There was a medical need for medications, and it was important they were taken as ordered. If the resident had not taken the medications at 11:17 AM, it was not appropriate the nurse documented them as given at 6:00 AM. During an interview on 3/29/2024 at 10:48 AM the Director of Nursing expected the nurses to make sure medications were taken by the resident and it was not appropriate to leave the medications in Resident #14's room. There was one hour before and after the medication administration time to give the medications and if they were given outside of the acceptable time frame, the time given was documented on the medication administration record. If a resident had a self-administer order the nurse poured the medications and put them in their room but then returned to the room within an hour to ensure the medications were taken. Self-administration required a physician order. Resident #14 did not have an order to self-administer, and medications should not have been left in their room. If medications were being left in their room, the proper process should have been followed and a physician order to self-administer medications should have been obtained. Medications were important to control medical issues and disease processes. An adverse reaction could occur if anyone other than the intended recipient took the medications. 10NYCRR 415.11(c)(3)(i)

) Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not review the risks and benefits of enabler rails or obtain informed consent prior to the installation of enabler rails with the resident or resident representative for 10 of 10 residents (Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62) reviewed. Specifically, there was no documented evidence the risks and benefits of enabler rails were explained to the residents, or their representatives or consents were obtained prior to bed rail use for Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62 Findings include: The facility policy Physical Restraints last reviewed 9/2023, documented the facility is committed to reducing the use of unnecessary physical restraints and ensuring residents are free of physical restraint unless permitted by federal regulation. Physical Restraint included any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily, and which restricts freedom of movement or normal access to one's body. Enabler Rails are constructed of metal and are used to aide in bed mobility. Types of devices that may be considered restraints include enabler rails. Physical restraint evaluation was to include the interdisciplinary team must carefully weigh the risks and benefits to the resident with the use of restraints and document all considerations on the physical evaluation restraints form. For the resident to be fully informed, the facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including use of a restraint, not using a restraint, and alternatives to restraint use. 1) Resident #59 had diagnoses including legal blindness and left sided hemiplegia (muscle weakness or partial paralysis on one side of the body). The 3/5/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had functional limitation with range of motion with impairment of one arm, was dependent for rolling side to side, sit to lying, lying to sitting on edge of the bed, and transfers, and had no enabler rails or alarms. During an observation on 3/26/2024 at 9:00 AM, the resident was in their room in a recliner. There were bilateral enabler rails on their bed. The resident stated they did not know about the rails on their bed. The 11/1/2023 restraint evaluation form completed by the Director of Nursing documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The form documented the device was not considered a restraint. The care plan part 1 (care instructions) initiated 2/29/2024 documented the resident required physical assistance with positioning in bed or chair, transfers, and toileting, and used enabler rails/assistive device. The comprehensive care plan revised on 3/11/2024 documented enabler rails were used for increased independence with bed mobility and were not considered a restraint. Interventions included quarterly assessment if used. The resident was at risk for falls related to visual disturbance, and the resident was legally blind and required assistance from staff for direction during transfers. The resident had times of moving around in bed, turned sideways in bed, and did not know where the boundaries were. The goal was to have no falls during the quarter. Approaches included keep bed in lowest position while occupied, and use of enabler rails/assistive devices to help with bed mobility/boundaries while in bed. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. 2) Resident #80 had diagnoses including cerebral infarction (stroke), multiple bilateral rib fractures, and right sided hemiplegia and hemiparesis (paralysis of one side of the body). The 3/12/2024 Minimum Data Set assessment documented the resident had intact cognition, had functional limitations with range of motion in both legs and arms, was dependent with rolling left to right, sitting to lying, lying to sitting, transfers, and did not use enabler rails. During an observation on 3/27/2024 at 9:44 AM, the resident was lying in bed on their back with the head of bed elevated above 30 degrees with enabler rails on both sides of bed. During an interview on 3/28/2024 at 9:30 AM, the resident did not respond when asked if they utilized the enabler rails or if anyone gave consent for their use. During a phone interview on 3/28/2024 at 2:51 PM, the resident's representative stated they did not recall consenting for the enabler rails on the bed or discussing it with anyone at the facility. The 3/7/2024 restraint evaluation form completed by the Director of Nursing documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The device was not considered a restraint. The resident's care plan part 1 (care instructions) dated 3/5/2024 documented the resident was dependent for positioning, toileting, transfers, and personal care. The comprehensive care plan initiated 3/6/2024 documented the resident was unable to position themself independently and therefore required assistance for positioning. Upon admission the resident was very weak with increased right sided weakness and required a mechanical lift for transfers. Approach for bed positioning included head of bed elevated at least 30 degrees for gastrostomy tube feedings. The resident required enabler rails bilaterally, which provided the resident with the ability to be more independent with bed mobility and they were not considered a restraint. A goal was for the resident to communicate more independence with the use of enabler rails. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. 3) Resident #4 had diagnoses including dementia and left sided hemiplegia and hemiparesis (paralysis of one side of the body). The 2/12/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had functional limitation in range of motion on one side of both upper and lower extremities. The resident was dependent for bed mobility, dependent for transfers, and did not use enabler rails. During an observation and interview on 3/25/2024 at 1:36 PM, the resident was in their room in a recliner with pillows on left and right side of her. They had enabler rails on both sides of the bed and shrugged their shoulders when asked if they could use them. During an observation on 3/26/2024 at 11:34 AM, the resident was in bed with enabler rails up. The 2/28/2024 restraint evaluation form completed by registered nurse #2 documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The device was not considered a restraint. The 2/8/2024 care plan part 1 (care instructions) documented the resident required assistance of 2 for positioning in bed or chair and transfers. The comprehensive care plan dated 2/12/2024 documented the resident was a fall risk related to visual disturbance, left sided hemiparesis, and history of falls prior to admission. The resident required enabler rails bilaterally, which provided the resident with the ability to be more independent with bed mobility and were not considered a restraint. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. During an interview on 3/28/2024 at 12:11 PM, physical therapy aide #6 stated new residents were evaluated by the physical therapist on admission. Bed enabler rails were used to help residents with increased independence. They could be dangerous, cause entrapment, or could cause injuries. The interdisciplinary team discussed the need for residents to use enabler rails. There was no consent needed if a device was not considered a restraint. Enabler rails did not restrict mobility and usually aided with mobility. Resident #59 could not use enabler rails independently but used them with cueing. They were not sure if there was a specific assessment tool for enabler rail use. During a phone interview on 3/28/2024 at12:24 PM, social worker #9 stated that therapy and nursing assessed to make sure residents were appropriate for enabler rail use. They also determined if they were a restraint and discussed risks. The only time they obtained consent was if it was determined it could be a possible restraint. During an interview on 3/28/2024 at 12:40 PM, registered nurse manager #2 stated enabler rail use was determined on admission or throughout their stay if there was a change of status, and they thought the resident may benefit from them. Nursing and therapy determined together if they were put on, kept, or removed. A head to toe assessment was performed of the residents'' abilities. If they had good range of motion in their upper extremities, then they could reposition themselves better. There was no specific assessment form used. On admission they discussed risks and benefits and there were very few risks. If they thought there was a risk, they would not use them. No written consent was needed. They evaluated the use on the restraint form, if they thought it was a restraint, they could not use them. During an interview on 3/28/2024 at 12:49 PM, the Director of Nursing stated there were no restraints in the facility. Any devices that could potentially be restraints were assessed. Enabler rails, recliners, low beds, seat belts could all be considered restraints. If mobility was not limited, they were not restraints. There was no specific assessment tool for enabler rails. Therapy and nursing decided on enabler rails. They were discussed with the resident and a physical assessment was done before deciding to use them. Anything added to a bed could pose a risk for injury or entrapment. There was no documented risk/benefit discussion with residents or their representatives. Consent was only needed when a device was considered a restraint. Resident #59 could be appropriate for use of enabler rail with guidance. Their left sided hemiparesis may make it hard for them to use them independently. Risk / benefit should be discussed and usually was during assessment. There was no consent obtained or documentation of risk/benefit discussion. During an interview on 3/29/2024 at 9:51 AM, certified nurse aide #10 stated resident care information was found in care plan books. It contained instructions for transfers, oral care, incontinence, diet, and assistance needed. Bed enabler rails were used for the resident to assist themselves with bed mobility. They could possibly be a danger to residents who were not able to get up safely without assistance. Resident #59 needed staff assistance for positioning, transfers, dressing and toileting. The resident could not see their enabler rails to use them independently and needed guidance to use them. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the main kitchen had undated and uncovered food, the food slicer and can opener had food debris on them, and ceiling tiles and walls were not clean. Findings include: The facility policy Kitchen Cleaning Standards revised 5/2023 documented cleaning of the kitchen is a difficult task as many things need to occur to prepare meals, meet resident needs, and assure appropriate food temperatures. Cleaning the kitchen is everyone's responsibility. Many areas of the kitchen are high and difficult to reach and may need maintenance to assist. If areas require cleaning, put in a maintenance request. Many areas are subject to spray and soiling, every effort should be made to clean these areas when needed. Any concerns regarding cleaning needs should be communicated to the cook, who can get staff to assist. The facility policy, Food Delivery and Storage revised 5/2023 documented sufficient storage facilities are provided to keep foods safe and wholesome. Food is stored, prepared, and transported at an appropriate temperature and by methods to prevent contamination. Leftover foods are labeled, covered, and dated when stored. Leftover food is used within 3 days or discarded. All storage areas, refrigeration and freezer units are always kept clean and in good working condition. The following observations were made in the main kitchen on 3/25/202 between 9:10 AM and 9:49 AM: - a 1/4 size hotel pan with chicken tenders was uncovered in the walk-in cooler. - a 1/4 size hotel pan with 1 serving of French fries was uncovered in the walk-in cooler. - 4 undated 20-ounce applesauce cups were on the top shelf in the walk-in cooler. - 1 5-pound plastic sour cream container was undated and had dried white/yellow substance on the outside of the container. - 1 5-pound box of chicken nuggets, 1 10-pound box of sausage patties, and 1 bag of frozen rolls were uncovered and left open to air in the walk-in freezer. - the food slicer arm and can opener were unclean with dried brown food debris. - multiple 20-ounce salad dressing cups were undated and placed on a sheet pan with dried food debris in the dry storage room. - 1 plastic quart of butter was left uncovered by the toaster. The following observations were made in the main kitchen on 3/27/2024 between 11:40 AM and 12:15 PM: - there were unclean ceiling tiles in the dish room. - there were unclean walls on the dirty side of the dish room. During an interview on 3/25/2024 at 9:22 AM, food service supervisor/cook #4 stated food should be covered to prevent contamination. Food should be dated to know when it was opened and prepared. They stated the open food in the walk-in freezer should have been kept closed to prevent physical contamination or freezer burn and the undated food should be thrown out. During an interview on 3/29/2024 at 9:47 AM, the Administrator stated all items in the walk-in cooler and freezer should be covered to protect them from contaminants. All open food products must be dated, and frozen items should be stored in a bag within a box. They stated during the observation on the morning of 3/25/2024 staff were preparing for the next lunch meal, and it was usual to prepare lunch items after breakfast was served. All food items identified in the walk-in cooler and freezer were items for the next meal. It was possible that the open butter on the counter was used between meals or for a late breakfast. Ham was sliced for the upcoming lunch special, and the outside layer of the ham had a brownish sugar layer. The can opener would have been used to prepare food for the staff vending machine around 6:30 AM and there was no need to use the can opener for any resident meals that morning. They stated they put in a work order on 3/24/2024 for the kitchen ceiling to be cleaned and the walls in the kitchen were cleaned weekly. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 12/7/21-12/10/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one isolated area (kitchen exhaust hood area) in the main kitchen. Specifically, the kitchen exhaust hood and Ansul lines (special hazard fire protection products) over the oven and stoves were grease and dust laden. Findings include: The semi-annual hood cleaning logs documented the kitchen hoods were last cleaned on 9/9/21 and 5/11/21. When observed on 12/7/21 at 10:18 AM, the ventilation filters under the kitchen exhaust hoods over the cooking appliances (stove, fryer, and ovens) contained grease and were dust laden in sections. The Ansul suppression lines were observed with grease and were dust laden. When interviewed on 12/8/21 at 11:40 AM, the Food Service Manager stated maintenance should be cleaning hoods semi-annually by taking the vents outside to power wash and degrease them. The Manager stated 9/2021 was the last time the hood cleaning maintenance was completed. When observed on 12/8/21 at 12:03 PM, the kitchen hoods over the oven had gaps between filters and the hoods and suppression lines were observed with grease and were dust laden. When interviewed on 12/8/21 at 1:45 PM, the Facility Manager stated they cleaned the kitchen hood vents semi-annually by taking them out and power washing them. They did not clean the Ansul suppression lines/piping. They did put the filters back into place when clean, but they did not notice the filters were not fitting tightly in line together. The last time they cleaned the hood vents and filters was in 9/2021. If it needed more cleaning the kitchen would need to notify them, and they had not been notified. 10NYCRR 415.29 (j)(1)

Based on observation, interview, and record review during the recertification survey conducted from 12/7/21-12/10/21 the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 2 of 2 nursing units (Units 1 and 2) reviewed. Specifically, the facility policy Food Brought in From Home did not document how long food items could be kept before discarding, how to safely reheat and serve residents' personal food including how to properly take food temperatures and what appropriate reheating temperatures were. Finding include: The facility policy Food Brought in From Home dated 7/12/21, did not document how to safely reheat food for residents, how to take temperatures of the food, what temperature foods must be reheated to, or how long residents' food brought in from outside the facility should be kept before being discarded. During an observation on 12/7/21 at 11:47 AM, the Unit 2 nourishment refrigerator had 3 resident food items that were properly labeled. There was a Tupperware container with a slice of pie, a lidded paper cup container of soup, and a Tupperware container with meat sauce. All the items were dated 12/7/21. There was no probe thermometer observed in the small kitchenette where the nourishment refrigerator was located. When interviewed on 12/7/21 at 11:47 AM, licensed practical nurse (LPN) #3 stated the staff who received the food brought in by a family was supposed to label and date the food items and store them in the unit refrigerators. Staff on the floor could heat up food items to the desired temperature at the resident's request. They did not take temperatures of the food before serving it to the resident. The LPN was not aware of thermometers being available and they were not trained to use them when microwaving food. When interviewed on 12/7/21 at 11:49 AM, the Director of Nursing (DON) stated the food items brought in from the outside should have labels with resident names and dates. When the resident wanted to eat the items staff would heat them up using the facility microwave. The staff would warm up the food and ask the resident how it was and if they would like it hotter. The temperature would be the resident's preference. The DON stated they did not use thermometers to measure the specific temperature of food items. When interviewed on 12/8/21 at 11:40 AM, the Food Service Manager stated nursing staff used the microwave to reheat food. They did not believe nurses were looking for a specific temperature and were not using thermometers when reheating food. The Manager stated staff would ask residents if items were hot enough. The Manager stated staff discarded food items older than three days. This was checked daily, and they did not know if nursing was trained on these processes. When interviewed on 12/9/21 at 11:30 AM, the Administrator stated the temperature of foods was determined by residents when foods were given to them based on the resident's preference. The nurses did not use thermometers when reheating food for residents. Nursing had never been trained on how to take food temperatures or what temperatures food should be reheated to. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey 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 infection for 4 of 13 residents (Residents #24, 40, 59, and 71) observed during medication administration. Specifically, the nurse did not perform hand hygiene between residents during medication administration. Findings include: The facility 9/20/18 Hand Hygiene Policy documented that all staff will be expected to wash hands with soap and water if alcohol-based hand rub is not available before direct contact with a person, after contact with objects (including equipment) in the person's care setting. Using hand sanitizer is acceptable when hands are not visibly soiled. 1) Resident #24 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke). The 4/5/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition. The 5/9/19 physician order documented Tylenol 650 milligrams (mg), take two tablets by mouth two times a day for pain, and Keppra 250 mg by mouth two times a day for seizures. 2) Resident #40 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA, stroke), hyperlipidemia (high level of fat in blood) and diabetes. The 4/8/19 MDS assessment documented the resident had intact cognition. The 6/1/19 physician order documented atorvastatin 20 mg by mouth at bed time for high cholesterol, glipizide 10 mg take twice a day for blood sugar, levetiracetam 500 mg by mouth twice a day for seizures, and iferex 150 mg by mouth twice a day for anemia. 3) Resident # 59 was admitted to the facility on [DATE] with a diagnosis including atrial fibrillation (abnormal heart beat) and congestive heart failure. The 4/30/19 MDS assessment documented the resident had severely impaired cognition. The 6/1/19 physician order documented Bisoprol 2.5 mg by mouth twice a day for atrial fibrillation/hypertension Extra Strength Tylenol 500 mg, take two tablets by mouth twice a day. 4) Resident #71 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD). The 5/13/19 MDS assessment documented the resident had intact cognition. The 6/1/19 physician order documented omeprazole 20 mg by mouth twice a day. During an observation on 6/5/19 at 3:32 PM licensed practical nurse (LPN) #6 was observed sitting at the nursing station prior to the medication administration. She proceeded to the medication cart and did not perform hand hygiene before preparing medications for Resident #24. Before she administered medications to Resident #24 she was observed positioning the resident's head with her bare hands. She administered Resident #24's medications, did not perform hand hygiene and proceeded to prepare medications for Resident #71. She administered the medications to Resident #71, returned to her medication cart, did not perform hand hygiene, and prepared medications for Resident #59. She then locked her medication cart, went to get hand sanitizer, returned to medication cart and performed hand hygiene with the hand sanitizer. After medication administration to Resident #59, she touched the resident's personal property while in the room and did not perform hand hygiene before preparing medications for Resident #40. She completed Resident #40's medication administration and did not perform hand hygiene when finished. During an interview on 6/5/18 at 8:23 AM, LPN #6 stated that the process was to wash hands or use sanitizer between administering medications to residents. She stated that she forgot and normally she would have done so. During an interview on 6/6/19 at 9:50 AM, the Director of Nursing stated the expectation when passing medications was for staff to wash their hands or use hand sanitizer before and between residents to prevent the spread of germs. She stated a rule of thumb was after using hand sanitizer three times, staff should wash their hands with soap and water. 10NYCRR 415.19 (b)(4)