Based on record review and interview during the recertification survey conducted 3/11/2024-3/13/2024 the facility did not ensure they established and maintained 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 diseases and infections for 11 of 11 residents (Residents #1, 106, 107, 108, 109, 110, 111, 112, 113, 114, and 115) reviewed. Specifically, the facility did not have an infection prevention control program including standards, policies and procedure that were current, specific to the resident population, and reviewed at least annually. Findings include: The policy Infection Prevention Manual revised 6/24/22 to add the Centers for Medicare and Medicaid Services (CMS) updated requirements for vaccine reporting for all hospital and Transitional Care Unit specific data. The surveillance activities reflect regulatory mandates and internal infection control risk assessments performed annually. Results of the Hospital Surveillance activities are reported to the infection prevention committee at least quarterly. The policy Antimicrobial Stewardship revised 6/27/2023 documented the hospital has adopted a statement of leadership commitment for antibiotic stewardship. The institutional leadership is committed to embracing and executing the Centers for Disease Control and Prevention's core elements of Hospital Antibiotic Stewardship. Hospital Leadership has identified a physician and a pharmacy champion who are responsible for stewardship outcomes. The Transitional Care Unit Policy and Procedure Manual Table of Contents dated 3/13/2024 did not include policies for infection control. The facility did not have an individual infection prevention plan, antibiotic stewardship program, and infection control policies that were specific to the needs of the residents on the Transitional Care Unit. The 8/2023 facility assessment documented professional Transitional Care Unit support services shared with the hospital included infection prevention. The Infection Prevention Program of the hospital will provide a safe hospital environment through a comprehensive multidisciplinary Infection Prevention Program. The focus of the program is to improve patient care by disease prevention in patients and hospital team members. The Director of Infection Prevention acts as the Infection Prevention Officer for the hospital. During the entrance conference interview on 3/11/2024 at 7:08 AM, the Director of Patient Safety and Quality stated the Infection Preventionist was the Director of Infection Prevention #8 and was shared with the hospital. During an interview on 3/11/2024 at 7:56 AM, registered nurse/covering Unit Manager #11 stated they were not aware of a separate Infection Preventionist, and it was possible that a clinical leader (registered nurse) was the Infection Preventionist for the unit. During an interview on 3/11/2024 at 8:02 AM, the Administrator stated there was no full time Infection Preventionist designated for the Transitional Care Unit, as there were only 20 beds. There was a nurse assigned to the unit, but the Director of Infection Prevention for the whole hospital was also located on this campus. During an interview on 3/13/2024 at 6:49 AM, the Director of Patient Safety and Quality stated the Transitional Care Unit, like all other units in the hospital, had their own policies, but they followed the hospital policies. During an interview on 3/13/2024 at 9:20 AM, registered nurse/ Unit Manager #2 stated the Infection Preventionist for the Transitional Care Unit was registered nurse/Infection Preventionist #9 and they were not dedicated to the Transitional Care Unit, as they were responsible for additional units in the hospital. They stated registered nurse/Infection Preventionist #9 was available for their unit on a part time basis. During an interview on 3/13/2024 at 10:29 AM, registered nurse/Infection Preventionist #9 stated they had been assigned the Infection Preventionist on the Transitional Care Unit within the last year. They stated they were on the unit at least 4 times a week and they reported to the Director of Infection Prevention #8 who was responsible for the infection prevention program for the hospital. The hospital had an infection exposure plan that applied to the Transitional Care Unit. They did not believe there was a specific documented infection prevention plan for the Transitional Care Unit. The unit influenza and pneumonia vaccine policies and masking policy were found under the general hospital infection control policies. There was a Transitional Care Unit policy for COVID-19 infection control because they did not keep the COVID-19 positive patients on the Transitional Care Unit. They stated the antibiotic stewardship for the Transitional Care Unit was lumped into the hospital's antibiotic stewardship program. The Nurse Managers were not involved with antibiotic stewardship, it included pharmacy, physicians, and the Director of Infection Prevention. During an interview on 3/13/2024 at 11:35 AM, registered nurse/Unit Manager #2 stated the Transitional Care Unit policies should be updated every 2 years. The Transitional Care Unit had a COVID-19 infection plan and policy. The standard for the Transitional Care Unit policy review was the hospital standard of every 2 years. There were no Transitional Care Unit policies for infection prevention. They stated registered nurse/Infection Preventionist #9 was their Infection Preventionist and was utilized hospital wide. During an interview on 3/13/2024 at 1:59 PM, the Administrator stated Director of Infection Control #8 oversaw both hospital campuses and registered nurse/Infection Preventionist #9 covered this campus including the Transitional Care Unit. There were specific policies for the Transitional Care Unit, including specific policies for infection control because the long-term care regulations differ from the acute hospital care regulations. It was important to have specific infection prevention policies to address how staff would need to respond differently to the infection process in long term care versus hospital acute care. The policies were reviewed every 2 years. 10 NYCRR 415.19(a)(1); 400.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted 12/28/21-12/29/21, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety for 1 of 2 kitchen areas (main kitchen). Specifically, the facility failed to remove expired food items and maintain clean surfaces in the main kitchen. Findings include: The facility policy Food and Supply Storage revised 1/2022 documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Fresh date or other approved labeling system. Products are good through the close of business on the date noted on the label. Refer to the Food Storage Chart in this policy to determine discard dates for food items. During an observation in the main kitchen on 12/28/21 at 9:35 AM, the following was observed: - the dairy cooler contained a 5-pound (lb) bag of mozzarella cheese with a printed date of 10/20/21 on the package and delivery sticker date of 12/1/21, and a 16-ounce (oz) container of milk with a use by date of 12/24/21. - the cook's cooler contained a tray of hash browns, a large, covered metal container of pancake mix, and a small, covered metal container of an unidentified item that were not dated. - a drink cooler near the steam table contained a 6 oz Lactaid milk with an expiration date of 12/27/21, an 8 oz chocolate milk with an expiration date of 12/24/21 and a 4 oz Mighty Shake (nutritional supplement) with a use by date of 12/18/21. - cooler #4 contained a 5 lb container of sour cream with a use by date of 12/27/21. There was a cardboard sheet of 27 oz cans of sliced chili with stickered delivery dates of 3/21/21. The stickers blocked the expiration date on each individual can. There was a metal container with slices of roast beef with an orange sticker labeled use by 12/27/21. - the storage room had 5 cardboard boxes of paper products sitting directly on the floor. During the observation the Food Service Director stated that the 5 lb bag of mozzarella, 16 oz of milk, 6 oz Lactaid, 8 oz chocolate milk, and the 4 oz Mighty Shake were outdated and needed to be removed. The Food Service Director stated the items in the cook's cooler were placed in the cooler each morning, so they knew the items had been from that morning. They stated the roast beef should have been thrown away and the chili was good for one year after the delivery date and they could not tell what the expiration date was because of the sticker blocking the date. During an observation in the main kitchen on 12/28/21 at 9:35 AM there were 2 steam tables turned on and warming up. The shelving underneath one steam table had significant dried spillage of white/blue matter on the full length of the shelf, and the second steam table had dried white matter on almost the entire length of the shelf. During the observation, the Food Service Director said the steam tables were in prep and would be wiped down. During an observation in the main kitchen on 12/28/21 at 10:06 AM, the following was observed: - a small cooler near the preparation area and storage room had a metal container covered with plastic wrap with cut up slices of ham that had a use by date of 12/27/21. - a second small cooler had a large plastic container of olives with an open date of 10/26 and use by date of 12/27/21. - the gluten free freezer contained chicken patties that expired 5/4/21 and an open box of [NAME] (not labeled with an opened date) with an expiration date of 12/2020. - there were two cardboard box sleeves of frozen pre-made desserts with expiration dates of 8/2021. During the observation, the Food Service Director stated, the olives should have been removed. They stated the chicken patties box was not open, and they had removed the [NAME] box from the freezer. During an observation of the main kitchen on 12/29/21 at 10:53 AM, the 5 lb sour cream with use by date of 12/27/21 remained in cooler #4. There were also nine 27 oz cans of diced green chilis with the delivery date sticker removed from one of the cans and a best by date of 10/2021. The Food Service Director stated the spare food was mixed in with regular supplies and was checked monthly. During an interview with the Food Service Director on 12 /29/21 at 11:49 AM, they stated it was the storeroom clerk's responsibility for checking dates on food items. When the storeroom clerk was not available, the chefs and/or lead cooks would take that responsibility. The Director would walk through weekly or every couple of weeks. Any outdated milk products could make a resident sick. Staff should have been using the best by dates on cans and not placing stickers over these dates on the chili cans. The chili cans should have been discarded at the end of 10/2021. The undated pancake mix and hash browns were part of the breakfast cart for that day and would have been used that morning. The Food Service Director stated frozen food items were not allowed to be out of date and should have been checked. The frozen food items were not used often. The dishwasher was asked to clean the steam table and shelf below. The whole area should have been cleaned by the end of the night eat day and would be checked daily during the kitchen walk through. During an observation on 12/29/21 at 12:35 PM of the gluten free freezer, there was an apple cobbler frozen dessert with a package date of 2/19/21 and a received date of 6/16/21; individual bags with receive date of 6/23/20 and a date on the box of 8/18/20, 25 or more chocolate chip cookies with a receive date of 6/9/20 and 48 chocolate chip cookies with a receive date of 7/3/20. During an interview with the Food Service Director on 12/29/21 at 12:40 PM, they stated frozen items, even if expired, should be immediately discarded. During an interview with lead cook #4 on 12/29/21 at 1:38 PM, they stated they were covering as the stock person was off. When they were covering the stock room, they would check expiration dates, rotate stock, and would check best by dates on cans when placing received by labels on the cans and they would ensure these dates were not covered over. The cook stated if an item was found outdated, the item would be discarded. They were not aware of any outdated items. 10NYCRR 415.14(h)