Based on observation and interview, the facility did not ensure food was prepared and stored according to professional standards for food safety. Specifically, cold foods were not held at a safe holding temperature, prior to service, to prevent bacterial contamination. The findings are: During an observation on 12/13/2023 at 11:00AM, the Food Service Director (FSD) was obtaining pre-meal service temperatures of cold foods held on ice on the tray line. Multiple cold sandwiches were found to have temperatures greater than a safe holding temperature of 41 degrees Fahrenheit (F) or less, including: Egg salad sandwich 45.5 degrees Fahrenheit Turkey and cheese sandwich 53.2 degrees Fahrenheit Ham and cheese sandwich 55.3 degrees Fahrenheit In an interview at that time, the Food Service Director (FSD) stated that staff had made the sandwiches at about 9AM that morning and had stored them in the freezer. The FSD stated they will discard the sandwiches being held on the tray line. In an interview on 12/13/23 11:16 AM, the Dietary Aide (DA #1) responsible for preparing the sandwiches that morning stated that they made the sandwiches after 8AM and stored them in the freezer at around 9AM. Dietary Aide #1 stated that today the stock staff had turned off the freezer for deliveries, and that happens on Wednesdays and Thursdays. At that, the Dietary Aide #1 and surveyor checked the freezer, found that it was off, and checked the freezer thermometer which read +18 degrees Fahrenheit. In a follow up interview on 12/13/23 at 11:22 AM, the Food Service Director stated they would have turned the freezer off because it is too cold in there. In an interview on 12/13/23 at 11:25 AM, Dietary Aide/Cook #2, who was responsible for accepting and storing frozen foods deliveries that day, stated that when they pack away the frozen food, they turn off the freezer and leave the door ajar because the fan blows hard, it makes the air misty, and it is overwhelming and difficult to see things. Dietary Aide/Cook #2 stated that they turn the freezer back on between packing items. When asked if they had turned the freezer back on today, Dietary Aide/Cook #2 stated they thought that they did, but they were not 100% sure, as they had been called away to go to the storeroom. Dietary Aide/Cook # 2 stated that frozen foods are received on Wednesdays and Thursdays. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #133 was admitted with diagnoses that included shortness of breath and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #133's January 2020 physician's orders revealed the following: Ipratropium-Albuterol Solution (DuoNeb bronchodilators), three milliliters via mask every six hours for SOB. Oxygen at two liters per minute via nasal cannula as needed for SOB. Review of the comprehensive care plan revealed no care plan in place related to oxygen therapy. In an interview on 01/28/20 at 12:53 PM with the MDS Coordinator she stated the Unit Manager together with the interdisciplinary team was responsible for initiating a care plan for Resident #133. The MDS Coordinator stated there was no care plan in place related to oxygen therapy for Resident #133. 415.11(c)(1) Based on interview and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan with measurable goals, time frames and interventions to meet the needs of 1 of 4 residents (#54) reviewed for pressure ulcers and 1 of 3 resident (#133) reviewed for respiratory care. Specifically, Resident # 54 did not have a care plan in place to address a stage 3 sacrum pressure ulcer and Resident # 133 did not have a care plan to address oxygen therapy. The findings are: Resident #54 was admitted with diagnoses that included; Type 2 Diabetes Mellitus, Parkinson's Disease and Alzheimer's Disease. Review of the Annual Minimum Data Set (MDS-a resident assessment tool) dated 11/13/2019 and the Quarterly MDS dated [DATE] revealed that the resident had a stage 3 pressure ulcer. Review of the January 2020 physician's order documented; Silver Sulfadiazine Cream 1%, apply to sacrum topically twice a day for stage 3 pressure ulcer post cleanse with normal saline. Review of the physician's note dated 01/22/2020 revealed that the resident had a stage 3 pressure ulcer to the sacrum for the past 230 days duration. An interview conducted with the Unit Manager #1 on 01/28/2020 at 11:13 AM revealed that it is the Unit Manager's responsibility to initiate and update care plans. She further stated that Resident #54 developed a pressure ulcer in May 2019 but it was not care planned. An interview conducted with the Director of Nursing (DON) on 01/29/2020 at 01:33 PM revealed that there was no care plan developed for the stage 3 pressure ulcer.

Based on observation, interview and record review conducted during the recertification survey, the facility did not implement an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development of communicable diseases and infections. Specifically, 1. a Licensed Practical Nurse (LPN) did not perform hand hygiene prior to administration of medications and 2. the facility did not protect oxygen equipment from surface and air contaminants. The findings are: 1. Observation on 1/23/2020 at 10:16 AM revealed that Resident #133 was in bed while the oxygen concentrator was on and set at 2 L/min. However, the oxygen tubing including the nasal canula was on the floor. Resident #133's nebulizer mask was on the bedside table, unbagged. Further observation on 01/24/2020 10:39 AM showed that Resident #133's nebulizer mask was again on the bedside table, unbagged. Additional observation on 01/28/2020 11:00 AM showed that Resident #133's nebulizer mask was again on the bedside table, unbagged. 2. Observation on 1/23/2020 at 10:25 AM and again on 1/27/2020 at 4:00 PM revealed that Resident #11's BiPAP mask was on top of the BiPAP machine unbagged. 3. Observation 01/28/2020 at 10:45 AM with the Assistant Director of Nurses (ADON), Unit Manager #1 and the Maintenance Director revealed that Resident #11's BiPAP mask was on top of the BiPAP equipment, unbagged. The resident was wearing the nasal canula for oxygen support. The oxygen concentrator had two areas for filters, one on each side. The Maintenance Director confirmed the right side of the concentrator was missing a filter and the filter on the left side was saturated with white particles. 4. Observation during an initial tour of the facility on 1/23/2020 revealed that Resident #67's nebulizer mask was draped over items at the bedside and was unbagged. Further observation on 01/28/2020 at 10:48 AM with Unit Manager #1 revealed that the nebulizer mask was unbagged and sitting on top of the beside stand. 5. Observation on 01/28/2020 at 10:02 AM with Registered Nurse #3 revealed that Resident #104's nebulizer tubing was on the floor. 6. During an initial tour of the facility on 1/23/20 Resident #348's BiPAP mask was draped over the equipment and unbagged. During follow up observation and interview on 1/28/2020 at 9:48 AM with Licensed Practical Nurse (LPN) #2 the filter on the back of Resident #348's oxygen concentrator was saturated with a white substance. LPN #2 said, It's filthy. LPN #2 also said the filters on the oxygen concentrators were supposed to be inspected and maintained weekly by the Maintenance Department. During an interview on 1/28/2020 the Maintenance Director said that the maintenance staff are to check the oxygen concentrator filters weekly. He said they may have missed this one (Resident #348's). The Maintenance Director said that the maintenance staff do not document the weekly oxygen concentrator checks. 415.19 (a) (1-3)

Based on record reviews and interviews conducted during a recertification survey, the facility did not ensure that 1 out 1 resident was given the opportunity to participate in the development, review, and revision of her care plan. Specifically, resident #84 was not invited/included in her annual care plan meeting. The finding is: Resident #84 has diagnoses and conditions including Quadriplegia, Respiratory Failure, and Guillian Barre Syndrome. The Annual Minimum Data Set (MDS, a resident assessment and screening tool) dated 10/4/17 indicated the resident scored 15 out of 15 on the BIMS (Brief Interview Mental Status; used to measure memory recall and orientation) and suggested the resident to be cognitively intact. An invitation was sent and was addressed to the resident's spouse on 9/28/17 to attend the annual evaluation at the Comprehensive Care Plan Meeting which had been scheduled to take place on 10/10/17. The Comprehensive Care Plan sign in sheet with an Annual MDS Assessment Care Plan date of 10/10/17 did not note the resident or her spouse being in attendance. There was no reason documented as to why the resident and or her husband were not able to attend. Resident #84 was interviewed on 5/22/18 at 11:18 AM and she stated she did not remember ever being invited to a care plan meeting in the past two years since she had been in the facility. The Unit 3 Social Worker (SW) #1 was interviewed on 5/30/18 at 1:00 PM and she said that the residents were invited to care plan meetings for Annual and Significant Change MDS but not a quarterly basis. She stated that the residents were aware of the meetings but could choose not to attend. When requested, SW #1 was unable to provide a signature attendance sheet signed by this resident. SW #1 stated they tried to document when a resident does not attend the care plan meetings but she could not guarantee that a note was done. She further stated that upon checking for documentation of the resident/family not wishing to attend the care plan meeting, she was unable to locate such note. The resident's representative was interviewed on 5/31/18 at 10:56 AM and stated that he said he does not remember ever being invited to a meeting with the staff to discuss the care of the resident. He further stated that he probably attended one before but only attended the facility meeting either weekly or monthly that involved discussions or concerns at the facility. 415.11(c)(2)(i-iii)

Based on record review and interview the facility did not ensure that catheter care was provided in accordance with professional standards of care. This was evident for 1 of 2 residents (#14) reviewed for catheter care. Specifically, the order to change the Foley catheter was not clearly written that resulted to changing the catheter contrary to the medical provider's order. The finding is: Resident #114 has diagnoses and conditions including Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms, Bladder Neck Obstruction, and Hemiplegia and Hemiparesis following Cerebral Infarction. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) dated 4/10/18 indicated the resident had an indwelling catheter at the time of the assessment. The person-centered care plan for Indwelling Foley Catheter last updated on 5/6/18 indicated the resident has a catheter for urinary retention due to BPH with dysuria (difficulty in urination) and Bladder Neck Obstruction. Interventions included but not limited to change the Foley catheter every 6 weeks using size 18 FR with 15cc balloon. The care plan was also updated on 5/6/18 and indicated that the Foley catheter was removed in the hospital on 5/4/18 and a new one was inserted using 16FR with 10cc balloon due to bladder neck obstruction. The May 2018 Treatment Administration Record (TAR) that included the instructions when to change the Foley catheter documented to change the Foley catheter every 4 weeks otherwise instructed, every night shift every Tuesday for urinary retention. size 16FR 10cc balloon size. Review of the Physician's Orders for May 2018 included the order for the Foley Catheter that read the same as above. During the month of May, as indicated by initials on the TAR, the resident's catheter was changed on 5/15/18 and on 5/22/18, as well as on 5/4/18 when the catheter was changed in the hospital, prior to admission, as noted on the above care plan. The nursing and medical progress notes of 5/11/18 to 5/29/18 revealed no documented evidence to indicate the reason(s) for changing the catheter. The unit Registered Nurse (RN) manager was interviewed on 5/29/18 at 3:00 PM and she stated she didn't know the reason why the catheter was changed on 5/15/18 and 5/22/18. The RN reviewed the physician's order and stated that the instructions were confusing. She stated further that the night nurses probably read the order as it is and changed the Foley catheter every Tuesday instead of every 4 weeks. Following surveyor intervention, the unit RN manager rewrote the order to read, Change Foley catheter every 4 weeks as needed. In an interview on 5/31/18 at 9:00AM, the RN manager stated she would include the word and so the order would read Change Foley catheter every 4 weeks, and as needed. 483.25(e)(1)-(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not ensure that food storage practices met professional standards of practice. Specifically, 1 out of 2 nourishment refrigerators (Second Floor) contained foods that were either expired, undated or post dated. The finding is: Nourishment refrigerators were observed on 5/31/18 at 03:29 PM and the following items were found in the Second Floor refrigerator: - spaghetti and sauce for room [ROOM NUMBER] was undated; - ravioli and sauce for room [ROOM NUMBER] was undated; - sweet potato had the resident's name and was dated 5/27/18 (food can be kept no longer than 3 days); - salmon, chicken [NAME] and chicken parmesan were post dated to 6/2/18. (Foods must be dated on the date it was placed in the refrigerator). The unit Licensed Practical Nurse present at the time of the observation was interviewed on 5/31/18 at 3:31 PM and stated he was a new employee and was not familiar with the facility policy regarding storage of food in the unit refrigerators. The Food Service Director (FSD) at was interviewed on 5/31/18 at 3:35 PM and stated that foods should be thrown out after 24 hours. He further stated he had notices posted on the refrigerators and that he was not aware that the notices were removed. When asked about the post dated food items, the FSD did not provide an explanation. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a recertification survey, the facility did not provide timely rehabilitation services for 1 of 1 resident (#86) reviewed for rehabilitation services. Specifically, resident #86 did not receive Physical Therapy/Occupational Therapy evaluation and treatment as recommended and ordered by the physician. The findings include: Resident #86 was admitted to the facility on [DATE] and has diagnoses and conditions including Diabetes Mellitus, Muscle Weakness, and Seizure. The 3/25/18 Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) indicated that the resident's BIMS score (Brief Interview for Mental Status) was 15 out of 15 which suggested that resident was cognitively intact; required supervision of one person for bed mobility, transfers, and eating; extensive assistance of one staff for toilet use; and received scheduled and as needed pain medications with frequent complaints of moderate pain. A consult with rheumatology dated 4/10/18 included a recommendation to start therapy for frozen shoulder; a 4/11/18 physician prescription included Physical Therapy for 12 weeks with a diagnosis of adhesive capulitis, was followed with a nursing note which included the resident to come back from an appointment and a new order for physical therapy for 12 weeks for frozen shoulder and physiotherapy; a 5/8/18 nursing note documented the resident was seen by the physician and ordered PT/OT evaluation and treatment; a 5/23/18 physician order for evaluation and treatment 5 times a week for 4 weeks; and a 5/23/18 Occupational Therapy Standardized Assessment was completed. The resident was interviewed on 5/23/18 at 9:38 AM and she stated that the physician in the community had discussed with her the need for therapy but it had not been started in the facility since admission. She said she did not know why she had not been provided therapy. The resident stated she had asked the Therapy Director once or twice before about receiving therapy and had been told that she was not aware of any physician recommendation. She stated she asked her facility physician about receiving therapy and he told her that he had put an order in the computer since May 2018. The resident stated she has pain constantly on the right shoulder and finds it very difficult to move her arm. The Therapy Director was interviewed on 5/25/18 at 10:48 AM and she stated that the resident had always asked for therapy because she said she had a lot of chronic pain. She said she was not informed by the physician to start therapy. She said the resident had been functionally stable and she could not justify putting her on therapy. The Therapy Director stated she first needed documentation showing a functional decline in order for a resident to be considered for therapy. Recently she was told by the resident that she was having increased difficulty with ambulating, and toilet use. She stated she spoke with the nursing staff and they decided to put her on therapy but not until 5/23/18 (see above physician's order dated 5/8/18 to start evaluation and treatment). The Therapy Director further stated that when a resident goes out to an appointment and comes back with a recommendation for therapy, she follows up with the physician to make sure the referral was correct and then the resident is seen. She was unable to provide documented evidence addressing follow up with the consulting physicians recommendations and orders. The physician was interviewed on 5/25/18 at 1:19 AM and stated that after the recommendations from an outside physician were received, the Therapy Director and her staff should evaluate and make a determination if therapy would benefit the resident. The physician stated further that he had put in an order for an evaluation dated 5/8/18 and that he did not know why there was a delay with the therapy evaluation and treatment. The Unit 2 charge nurse was interviewed on 5/25/18 at 3:10 PM and stated that she obtained and placed an order for a PT/OT evaluation and treatment on 5/8/18 and did not know why the resident has not had an evaluation and treatment since that time. She further stated that whenever the resident needs to move her arms she cringes including when the nurses give her medications. She said she does not think the resident's pain is chronic and that the painful shoulders might be the reason the resident was having trouble wiping herself after bowel movements. 415.16(a)

Based on observations, record reviews and interviews conducted during a recertification survey, the facility did not follow proper hand hygiene to prevent cross contamination for 2 of 6 residents (#103 and #45) observed during medication pass. Specifically, the medication nurses did not follow proper hand hygiene during preparation of medications and between residents during medication pass. The findings are: The current Facility Medication Administration Competency Form indicated that staff has to perform hand hygiene appropriately prior to administering medications, and perform hand hygiene before and after resident contact, contact with medical equipment and whenever exiting a resident's room and before returning to the medication cart. 1. During a medication pass on Unit 3 on 5/31/18 at 9:11 AM, a Licensed Practical Nurse (LPN #1) was observed to open and close an inhaler for resident #99. She then placed the inhaler back into the medication cart. She then proceeded to resident #103, prepared his medications and administered them. She did not follow proper hand hygiene protocol to disinfect her hands at anytime during the preparation and administration of the medications between the residents. LPN #1 was interviewed immediately after the observation and she stated that she usually cleans her hands between residents during medication administration. She stated she did not have a hand sanitizer on her medication cart during medication pass. LPN #1 stated she had a small hand sanitizer on her person but did not use it during the medication administration. 2. During a medication pass on Unit 3 on 5/31/18 at 10:00 AM, LPN #2 prepared and then administered medications to resident #45. She then proceeded to obtain the medications of resident #27, placed them on top of the medication cart, and administered the medications to resident #27. LPN #2 was not observed to perform proper hand hygiene at anytime during and in between the preparation and administration of the medications between the residents. LPN #2 was interviewed following the medication pass. She stated that she had forgotten to clean her hands between residents during medication administration and that she usually does not forget. 415.19(b)(1)