Based on observations, interviews, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, for one (Resident #13) of two residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two medication errors for 26 opportunities resulting in a medication error rate of 7.7 percent. Specifically, during an observation of medication administration Resident #13's physician's orders were not followed for the administration of one medication and a second medication was administered without a prescribed dose included in the physician's order. This is evidenced by the following: The Medication Error Protocol, dated February 2020, documented in part that the nursing staff and medical provider shall try to prevent medication errors and adverse consequences and shall strive to identify and manage them appropriately when they occur. An example of a medication error includes orders received from a medical provider not transcribed promptly or accurately. 1. Resident #13 had diagnoses that included Parkinson's disease, atrial fibrillation (irregular, rapid heart rate that can cause poor blood flow), and type two diabetes. The Minimum Data Set Resident Assessment, dated 12/16/2024, documented the resident was cognitively intact. Review of current physician's orders as of 01/16/2025 revealed midodrine five milligrams one time daily for orthostatic blood pressure (blood pressure that changes from sitting to standing) with parameters to hold the medication for a systolic blood pressure greater than 90 and a Vitamin B12 tablet in the morning. There was no dose listed for the Vitamin B12. During an observation of medication administration on 01/16/2025 at 9:37 AM, Licensed Practical Nurse #2 obtained and documented Resident #13's blood pressure of 124/82. Licensed Practical Nurse #2 then administered the midodrine five milligrams and the Vitamin B12 at a dose of 1000 micrograms. During an interview on 01/16/2025 at 11:37 AM, Licensed Practical Nurse #2 stated the midodrine five milligrams should be held if Resident #13's systolic blood pressure was greater than 90. When Resident #13's blood pressure was reviewed at this time, Licensed Practical Nurse #2 stated they should not have given the medication. Additionally, Licensed Practical Nurse #2 stated if a physician's order did not include a dose, a note should be entered in the medical provider's log making them aware that the order was incomplete, and the medication should not be given until the medical provider verified the order. Licensed Practical Nurse #2 generated the list of medications that had been administered revealing the Vitamin B12 medication had been given without a dose ordered by the medical provider. During an interview on 01/16/2025 at 11:49 AM, Nurse Practitioner #1 stated the nurse should check the parameters and if the parameters indicated to hold the medication for a systolic blood pressure greater than 90, and the resident's blood pressure was 124/82, the medication should not have been given. The Nurse Practitioner stated if documentation showed that the medication had been held enough times, they would reach out to the family and discuss the possibility of discontinuing it. Nurse Practitioner #1 stated all physician's orders should have a dose included and nursing staff should not proceed without a dose. Nurse Practitioner #1 stated it was an error on their end, and the nurse administering the medication should have brought it to their attention. During an interview on 01/16/2025 at 3:25 PM, the Director of Nursing stated the nurse should check the resident's blood pressure, read the physician's order, and follow the ordered parameters. The Director of Nursing stated they were not aware there were physician's orders that did not have a dose included because upon entering an order, the system should not allow you to save the documentation if the order was incomplete. The Director of Nursing stated the nurse should have called the medical provider to verify the order prior to giving the medication. 10 NYCRR 415.12(m)(1)

Based on observations, interview, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, the facility did not maintain the kitchen in accordance with professional standards for food service safety. Specifically, an exhaust hood and filters were dirty, and a dishwashing machine was not functioning properly to sanitize dishware. The findings are: Record review of the undated daily cleaning lists revealed there was no documented cleaning of the kitchen exhaust hood and filters. During observations on 1/14/2025 at 8:55 AM and again on 1/15/2025 at 12:00 PM, the exhaust hood and filters above the cooking range in the main kitchen had visible accumulation of grease and dust. During an interview at this time, the Kitchen Supervisor stated their vendor comes in to clean the hood once a year in September, and staff should clean the hood as well when it needs it. During observations on 01/14/2025 at 8:47 AM, a low temperature dishwashing machine in the main kitchen was not functioning as designed. The label on the machine read wash at 120 degrees Fahrenheit and rinse at 120 degrees Fahrenheit with chlorine sanitization. Further observations included the chlorine sanitizer did not inject into the dish machine while in operation and the Kitchen Supervisor had to manually depress the dispenser button to introduce sanitizer into the machine. During an interview at this time, the Kitchen Supervisor stated they just noticed the sanitizer was not automatically dispensing during a cycle and needed to manually activate the dispensing unit to add sanitizer. During observations on 01/15/2025 at 12:06 PM, the low temperature dishwashing machine in the main kitchen was not functioning properly. The chlorine sanitizer did not automatically dispense during a cycle and the dispensing line was observed to be leaking sanitizer when activated manually. During an interview at this time, the Kitchen Supervisor stated the dish washer was still not functioning properly and the vendor had yet to get back to them. The Kitchen Supervisor also stated that when manually operating the sanitizing dispenser, they noticed the hose was leaking sanitizer so that would need to be addressed, and may be why sanitizer measurements were erratic. The Kitchen Supervisor also stated that instead of having to manually use the dispenser and measure sanitizer levels each time, it was decided to use disposable utensils and plates and wash with the three-bay sink until the dish machine could be addressed. 10NYCRR: 415.14(h), 14-1.95, 14-1.96(c), 14-110(d), 14-113(a), 14-1.175(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review conducted during the Recertification Survey completed 6/2/23 to 6/7/23, it was determined that for one of one kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, dish machine sanitizer levels were inadequate, and temperature controlled for safety (TCS) foods were not held at proper temperatures. The findings are: 1. Observations and interviews during the initial tour of the main kitchen on 6/2/23 between 8:30 a.m. and 10:00 a.m. included a [NAME] brand low-temperature mechanical dish washing machine. When tested after running, the sanitizer (chlorine based) level was zero. In an interview at this time the food service director (FSD) stated that the dish machine is checked every day but not this morning and they keep a log but could not readily locate them. The FSD also stated that they would call their vendor. 2. Observations and interviews during the follow-up visit to the main kitchen on 6/5/23 between 11:50 a.m. and 1:30 p.m. included a 'Nor-Lake' refrigeration unit full of beverages, including: a gallon of milk (a TCS food) at 50 degrees (°) Fahrenheit (F) and a half-gallon of chocolate milk (a TCS food) at 47°F, both of which were located on the bottom shelf of the cooler. During an interview at this time the FSD stated that the milk was placed into the cooler at 11:00 a.m. The surveyor verified that the ThermoWorks Thermapen One digital thermometer was accurate using the ice-point method. The thermometer read 32°F after being placed in a cup of ice water. 3. On 6/7/23 at 12:15 p.m., monthly records of the dish machine were provided for review via email. The logs for January through June of 2023 included that before each meal dietary aides should check the dish machine using test strips, and chlorine should read 50-100ppm (parts per million). The dish machine logs on 6/1/23 included: 'isn't coming out' and 'not working', and the logs for breakfast on 6/2-6/4/23 did not include a check mark or any other indication that the sanitizer level was between 50 and 100ppm. 10NYCRR: 415.14(h), 14-1.31(c), 14-1.40(a), 14-1.44, 14-1.112, 14-1.113

Based on interviews, and record review conducted during the Recertification Survey, completed on 12/22/21, it was determined that for one (wing one) of two wings reviewed for medication storage, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, the Controlled Substance Record sheets which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift narcotic count were not completed to validate the correct controlled substance count. This is evidenced by the following: The facility policy and procedure for Accounting for Narcotic Medications dated July 2011 documented that the facility will ensure that narcotic medications are properly accounted for in compliance with regulatory requirements and standard of practice. At each shift change or change of incoming nurse responsible for passing medications, all narcotics are counted by the incoming and outgoing licensed nurses and the correct count attested to on the Narcotic Count Verification form. The outgoing and incoming nurses must visualize the Index prior to beginning the count, as well as during the count to assure that each resident has the appropriate medications. If a discrepancy is found at any time during a count with the Resident Index form and the Narcotic Count Sheet, the supervisor will be notified, and an investigation will begin. During medication storage review on 12/22/21 at 9:33 a.m., the wing one shift-to- shift narcotic count sheets revealed multiple missing signatures to verify that the narcotic counts were properly completed by two nurses. From 10/3/21 to 10/29/21 there were 19 missing signatures, from 11/1/21 to 11/30/21, there were 18 missing signatures and from 12/1/21 to 12/22/21, there were 4 missing signatures. During an interview on 12/22/21 at 9:40 a.m., the Licensed Practical Nurse (LPN) said staff are expected to sign off the narcotic count at each shift to ensure the narcotic count is correct. The LPN said there should be no unsigned areas on the narcotic sheets. During an interview on 12/22/21 at 9:53 a.m., with the Director of Nursing (DON) and the Administrator, both stated that they were not aware the narcotic count sheets were not always signed off by both oncoming and outgoing staff. The DON said that they have not done audits of the narcotics sheets since they had started working at the facility several months prior. The Administrator stated that it is the policy of the facility for staff to sign off the narcotic sheets for each shift. 10NYCRR 415.18(b)(1)(2)(3)