Based on observation and interviews during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and Grill Room (resident café). Specifically, equipment and food preparation area floors were not clean. This is evidenced by: During an observation in the main kitchen on 8/20/2024 at 9:42 AM, the cooking line shelving, ceiling fan, floor under and behind the cooking line equipment, floor in dry storage room, fire extinguishers, and kitchen fire suppression system canister and pull station were soiled with food particles or thick dust; additionally, the bulk container of liquid thickener was not labeled. During an observation in the Grill Room resident café on 8/20/2024 at 10:12 AM, the knife rack and floor under and behind the cooking line equipment were soiled with food particles. During an interview on 8/20/2024 at 10:56 AM, [NAME] #1 stated that they would have the soiled items, areas found in the kitchen and Grill Room would be cleaned and added to the cleaning list. During an interview on 8/20/2024 at 12:21 PM, Administrator #1 stated that they would discuss with the dietary and maintenance departments regarding the soiled areas found in the kitchen and Grill Room. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on observation and interviews during the recertification survey, the facility did not dispose of refuse properly for the outdoor grease collection bin. Specifically, the exterior of outdoor grease collection bin was heavily soiled with a black build-up. This is evidenced by: During an observations on 8/20/2024 at 9:49 AM, the exterior of the grease recycling bin (located in the garbage compactor area) was heavily coated with a black build-up of spilled over grease; flies were hovering around the bin. During an interview on 8/20/2024 at 10:56 AM, [NAME] #1 stated that they would have the grease bin cleaned. During an interview on 8/20/2024 at 12:19 PM, Administrator #1 stated that they would discuss with the dietary and maintenance departments on how the grease bin should be properly filled and kept clean. 10 New York Codes, Rules, and Regulations 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) personal items were stored in double locked cabinet with controlled substances for 4 out of 4 medication carts reviewed, and for 1 out of 2 medication storage rooms reviewed. This is evidenced by: The facility's Medication Storage Policy revised on 5/2024 documented, all medications would be stored in a clean and sanitary environment, in a locked cabinet, cart or medication room would be accessible only to authorized personnel, as defined by facility guideline. Bulk Medications or multi-use vials would be labeled with the date opened and date that would expire per manufacturer recommendations. These medications would be discarded according to manufacturer's expiration date. The facility's Medication Administration Policy: General revised 5/2024, documented PROCEDURE: 4 a: Read the Electronic Medication Administration Record. Carefully note the name, dose, amount of medication on hand, scheduled time, and expiration date. During an observation on 8/21/2024 at 11:35 AM, the refrigerator located in the pharmacy next to the [NAME] unit, contained an open bottle of Tuberculin Purified Protein Derivative with no open and or expiration date. During an observation on 8/21/2024 at 11:40 AM on [NAME] Unit, Cart #1 contained 1 Lispro and 1 Novolog open vials of insulin, opened 8/19/24 and 8/20/2024 respectively, with no expiration dates. Licensed Practical Nurse #3 stated they were not aware of pharmacy grid of medications with shortened expiration dates. During an observation on 8/21/2024 at 11:55 AM on Stockade Unit Medication Room, Narcotic Box side 2 contained 2 wallets and $3 cash in an envelope. Both belonging to residents. Medication cart # 2 contained open bottles of Timolol and Latanoprost eye drops with no expiration dates after opening. During an observation on 8/22/2024 at 8:50 AM on Stockade Unit, Cart #1 contained 1 open bottle of Artificial tears with no expiration date. During an observation on 8/22/2024 at 9:31 AM on Woodlawn unit, Cart #1 contained. 1 opened bottle of Systane eye drops with no open or expiration dates. During an observation on 8/22/2024 at 9:49 AM, Cart #2 contained 1 vial of Aspart insulin with no expiration date. Licensed Practical Nurse # 1 verbalized expiration was 28 days after opening insulin. During an interview on 8/21/2024 at 12:43 PM, Administrator #1 stated all residents have locked drawers in their room for personal items. Also, the facility had a safe located in their office to keep resident valuables. Families and leadership were made aware safe was available. During an interview on 8/22/2024 at 2:57 PM, Director of Nursing #1 stated the Medication Nurse was responsible for labeling open and expiration dates on multi vial dose medicine. Director of Nursing #1 and Assistant Director #1 stated they were aware of safe in administrator's office but did not know if other floor nursing staff were aware. During an interview on 8/26/2024 at 10:02 AM, Nurse Educator #1 stated nursing competencies included two days of orientation including Medication Administration. Medication administration audit was completed upon hire. Annual nurse competencies have been initiated beginning this year, 2024. The Medication Nurse was responsible for checking open and expiration dates prior to administering medication. The overnight Medication Nurse generally organized medication cart, checks for dates and cleanliness. Stock medications were labeled with open dates, and the expiration was preprinted on the stock medication bottle. 10 New York Codes, Rules, and Regulations 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for (2) (Resident #'s 12 and #76, of two (2) resident's care plans reviewed for an ambulation program. Specifically for Resident #'s 12 & #76, the facility did not ensure the comprehensive care plan (CCP) for the resident's ambulation program was consistently implemented. This is evidenced by: The facility Policy and Procedure P&P titled, Care Plan: Development and Management last reviewed 3/2021, documented the purpose of the policy was to create and develop comprehensive care plans to provide effective person-centered care. The facility was unable to provide a P&P for the Nursing Unit Ambulation Program. The facility P&P titled, ADL documentation, CNA (Certified Nurse Assistant) reviewed 2/2021 documented the CNA who has completed the resident care will be responsible for documenting the level of care the resident received during their shift. It documented the CNA would notify the nurse of any concerns regarding refusals or change in ability. Nurses would evaluate the resident and determine appropriate interventions during each instance of refusal of when goals were not met and nurses notes would include the identified issue and interventions tried. Resident #12: Resident #12 was admitted to the facility with the diagnoses of heart failure, diabetes, and osteoarthritis. The Minimum Data Set (MDS-an assessment tool) dated 11/19/2021 documented the resident was without cognitive impairment. The resident was alert and oriented. It documented the resident required one-person physical assistance with ambulation. The CCP for Activities of Daily Living (ADL) Performance Deficit, revised 11/5/2021 documented an intervention for the resident to be walked in the corridor with limited assistance of one person for up to forty feet twice daily. Additionally, an intervention documented the resident would be provided with the nursing unit ambulation program as scheduled. The Follow Up Question Report (used by staff to document care provided) for Resident #12 dated 1/17/2022 through 2/17/2022 documented: Walk in Corridor with limited assistance of one staff for up to forty feet twice daily: A response of Not Applicable was documented on 1 day shift out of 32 opportunities and 10 evening shifts out of 32 opportunities. A distance of greater than 40 feet was documented for 14 out of 32 day shift opportunities and 7 out of 32 evening shift opportunities. Nursing Progress Notes dated 1/17/2022 through 2/17/2022 did not include documentation of resident refusal or inability to ambulate per CCP. During an interview on 2/18/2022 at 1:18 PM, Resident #12 stated they are not consistently ambulated on the evening shift. Resident #12 stated they were ambulated on the day shift only yesterday. Resident #76: Resident #76 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, heart failure, and rheumatoid arthritis. The Minimum Data Set (MDS-an assessment tool) dated 1/7/2022, documented the resident was cognitively intact, and required extensive assistance of one-person assistance with ambulation. During an interview on 2/17/2022 at 10:15 AM, Resident #76 stated they were not consistently ambulated twice daily. Resident #76 stated the staff told them they did not have time to ambulate them twice a day, mostly on the evening shift. The CCP for ADL/ Mobility last revised on 7/23/21 documented an intervention for the resident to be walked in the corridor with extensive assistance and one person for sixty feet. Additionally, an intervention documented the resident would be provided the nursing unit ambulation program as scheduled. The Follow Up Question Report (used by staff to document care provided) for Resident #76 dated 1/17/22 through 2/17/22 documented for: Walk in Corridor with extensive assistance of one staff sixty feet twice daily: A response of Not Applicable on 17 out of 32 opportunities evening shift opportunities. A distance of thirty feet or less was documented for 9 out of 32 [NAME] shift opportunities and 8 out of 32 evening shift opportunities. Nursing Progress Notes dated 1/17/22 through 2/17/22 did not include documentation of resident refusal or inability to ambulate per CCP. Interviews During an interview on 2/23/22 at 10:37 AM, Licensed Practical Nurse (LPN) #1 stated residents should be ambulated by Certified Nurse Assistants (CNA) once or twice daily as scheduled on the CNA tasks. LPN #1 stated if the task could not be performed or the resident refused the CNA should let the nurse know, the resident reapproached, and a nursing note would be written. During an interview on 2/3/22 at 11:08 AM, CNA #2 stated they regularly cared for Resident #12 and Resident #76, and they did not refuse ambulation. CNA #2 stated she did not know why a CNA would document NA for ambulating a resident. During an interview on 2/23/22 at 11:23 AM, Registered Nurse Unit Manager (RNUM) #1 stated the resident should be ambulated as scheduled usually once or twice per day. RNUM #1 stated the CNA tasks were assigned in the electronic record and when a resident was tasked for ambulation on the day and evening shift then the CNA would know to ambulate the resident that frequency. RNUM #1 stated a CNA would be expected to tell the nurse when a resident refused, or an ambulation program scheduled was not completed. The RNUM #1 stated they were not aware CNAs were documenting Not Applicable for ambulation on Resident #12 and #76. During an interview on 2/23/22 at 11:38 AM, the Director of Nursing (DON) stated staff should provide ambulation per the resident's CCP. The DON stated a facility report was run daily and included the level of assistance needed, how far a resident was to be ambulated and the frequency the ambulation should occur. The DON stated they would expect the care plan would be implemented and staff would not document Not Applicable for a resident with a care planned ambulation program. 10NYCRR415.4(b)(1)(i)

Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. Specifically, resident room wardrobes were not secured and could topple over on three (3) of four (4) resident units. This is evidenced as follows. During observations on 02/18/2022 from 1:00 PM to 3:30 PM, the wardrobes in resident room numbers 101, 105, 117, 111, 119, 121, C-3, C-4, 201, 203, 204, 205, 207, 209, 211, 217, 218, 221, 233, 310, and 329, were not attached to the wall and could easily topple. During an interview on 02/18/2022 at 3:10 PM, the Director of Maintenance stated that while unaware wardrobes were not attached, perhaps at times, to help residents, staff or family members will try to move wardrobes by pulling on a wardrobe and dislodging the screws attaching it to the wall. During an interview on 02/18/2022 at 5:24 PM, the Administrator and Director of Nursing stated that they were unaware that wardrobes were not secured, all wardrobes are now being secured, and at present the facility does not have problematic residents that wander in and out of rooms. 10 NYCRR 415.12(h)(1)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, food contact and non-food contact equipment in the main kitchen were not clean, and beverages and plastic serving utensils were stored under sink waste lines. This is evidenced as follows. The food preparation areas were inspected on 09/24/2019 at 8:49 AM. Ten cutting boards on the storage rack in the main dining were covered in food debris, the exhaust fan guards in the walk-in cooler were covered in dust, exhaust fan guards over the grill line covered were covered with grease, and the floor under the grill line was covered in grease. Soda cans and plastic serving wares were stored under the sink waste line in C-wing resident unit kitchen. The Director of Dining Services stated in an interview on 09/24/2019 at 9:28 AM, that staff can do a better job of cleaning the cutting boards, exhaust fans, and wall behind the grill line. Additionally, he will follow up with the nursing staff to ensure that food and plastic utensils are not stored under waste lines in the nourishment kitchens. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.90, 14-1.110, 14-1.170

Based on record review and staff interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility policy does not provide information on safe reheating of food and a procedure to ensure facility staff assisted dependent residents in accessing and consuming the food. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 09/25/2019. The policy did not include information regarding holding temperatures and reheating procedures for foods and did not include a procedure to ensure staff-dependent residents in accessing and consuming the food. The Director of Dining Services stated in an interview on 09/25/2019 at 2:15 PM, that the policy for food brought to residents does not include procedures for reheating and storing food at proper temperatures and does not include guidelines on how residents will access food brought to them.