**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that comprehensive person-centered care plans with measurable goals and interventions were reviewed and revised for 1 of 5 Residents (Resident #63) reviewed for unnecessary medications. Specifically, (1) A Pharmacy Drug Review was conducted for Resident #63 and revealed a drug-drug interaction of concurrent use of Aspirin and Fluoxetine medication may increase the risk of bleeding and to monitor the resident; (2) There was no documented evidence the residents' care plans were reviewed and revised to reflect the drug-drug interactions as identified by the Pharmacist; (3) There was no evidence these changes were communicated among the nursing staff for ongoing monitoring; and (4) There was no documented evidence that Resident #63 was monitored for bleeding, side effects/adverse effects of the medications. The findings are: 1. Resident # 63 is a [AGE] year-old who was admit to the facility on 6/14/2021 with diagnoses and conditions including Depression, Anxiety Disorder, Schizophrenia, and Heart Failure. According to the 6/22/2021 5-Day Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition, and required extensive staff assistance with activities of daily living (ADLs). Physician Orders dated 6/14/2021 included orders for Resident # 63 to receive Abilify 5mg tablet oral daily at 5PM for Anxiety Disorder, Aspirin 81mg chewable tablet oral daily at 10AM for Heart Failure, and Fluoxetine 40mg capsule oral daily at 10AM for Major Depressive Disorder. A Care Plan (CP) titled At Risk for Bleeding was initiated on 6/15/2021. The CP listed the medication ASA 81mg chewable tablet oral daily. Goals included signs and symptoms of minor bleeding would be detected early. Interventions included, but not limited to monitor for any signs and symptoms of bleeding, increase bruising, and notify the physician for any increase bleeding or abnormal labs. A Psychotropic Drug Use Care initiated on 6/15/2021 listed medication Fluoxetine 40mg capsule oral daily and Abilify 5mg oral daily. Goals included the resident would be free of complications associated with the use of psychotropic medication. Interventions included to assess and evaluate for effectiveness and/ or adverse reaction on an ongoing basis, and to monitor for signs and symptoms of complication and report to the physician. A Pharmacy Drug Review was conducted on 6/24/2021. The Pharmacist documented concurrent use of the Aspirin and Fluoxetine medication may increase the risk for bleeding and to monitor the resident. Further review of the above At Risk for Bleeding Care Plan, as well as other Care Plans revealed they were not updated with the Pharmacist drug-drug interaction information. There was no documented evidence that the resident was monitored for bleeding as recommended by the Pharmacist or monitored for the ongoing use of the medication's effects/ side effects, or adverse reactions. Nurses Progress Notes 6/14/2021 to 7/6/2021 revealed no documented evidence of medication effects/adverse reaction, bleeding, or documentation of the pharmacist recommendation of the drug-drug interaction between the medications as described above. The Medication Administration Record (MAR) from 6/24/2021 to 7/24/2021 was viewed in the presence of Registered Nurse (RN #1) on 7/1/2021 at 12:05PM and revealed Resident #63 had orders for Aspirin 81mg chewable tablet daily at 10AM and Fluoxetine 40mg capsule oral daily at 10AM daily. There was no evidence that the above pharmacy drug-drug interaction recommendation to monitor the resident were transcribed to the MAR to alert the nurses of the risk of bleeding from these medications. RN #1 was asked if the information was documented on a treatment record to which h/she replied the resident had no treatment record. In an interview with the Director of Nursing (DON) on 7/1/2021 at 11: 50AM, h/she stated it was the nursing staff responsibility to make sure the pharmacist recommendations, as indicated above, were documented on the resident's care plan for the staff to follow up. In an interview with RN #1 on 7/1/2021 at 12:05PM regarding the above pharmacy review, h/she stated that pharmacy medication reviews are done monthly. If the information was for nursing, such as monitoring for bleeding, the information would be documented on the resident's care plan for the nurses to monitor. RN #1stated that the pharmacy drug-drug interaction recommendations should have been documented on the resident's care plan. RN #1 was asked who was responsible to initiate and update residents' care plans. H/She stated that the nurses, including the Director of Nursing, were responsible for initiating and updating residents' care plans. During a follow up interview with RN #1 on 7/06/21 at 3:48 PM, h/she stated that there was no documentation that the staff were monitoring the resident for bleeding. It should have been done. The nurses were responsible for monitoring and documenting in the Progress Notes. 415.11 (c) (2) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation conducted during a recertification survey, it could not be ensured that the facility provided care and treatment in accordance with professional standards of practice. Specifically, the facility did not ensure that a change in skin condition was reported and treated timely for 1 of 1 resident (Resident #7) reviewed for skin conditions (non-pressure). The finding is: The facility policy and procedure titled Skin Care/Personal Grooming, dated 1/15/2002 and revised 12/2014 documented: Certified Nursimg Assistant (CNA) responsibility during AM bed bath, shower, or tub bath, inspects resident's skin for any redness, dryness, cracking, etc. Report any finding to Nurse. Licensed Nurse responsibility: Checks and cleans skin as necessary .Report any changes to the Nurse Manager/Supervisor, MD/Nurse Practitioner. Resident #7 was admitted on [DATE] with diagnoses including Bipolar disorder, Major Depressive Disorder, and Alzheimer's disease. The significant change Minimum Data Set (MDS: an assessment tool) dated 8/20/2020 documented moderately impaired cognition for decision making, one unhealed stage 3 Pressure ulcer, Skin and ulcer treatments included: pressure reducing device for chair and bed, turn and positioning program, Nutrition or hydration intervention, pressure ulcer/injury care, and application of ointments/medications other than to feet. A subsequent Quarterly MDS dated [DATE] documented severely impaired cognition for decision making, and skin and ulcer treatments: pressure reducing device for chair and bed, turn and position program, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet. The Resident's Comprehensive Care Plan (CCP) documented risk for skin breakdown related to Braden score ( a skin risk assessment) of 13, limited mobility, and history of previous skin breakdown. Interventions included: monitor for any kind of skin breakdown and report to MD (medical doctor) / NP (nurse pracitioner). Surveyor observation on 6/29/21 at 2:15 PM revealed a small round area, visually estimated to be .5 inch in diameter with a yellowish center, on the resident's left upper forearm. The 6/25/21 physician's orders included: Skin check on shower days, every week on Wednesdays and Saturdays 7 am-3pm. Following surveyor inquiry, new orders were noted dated 7/2/2021 Mupirocin 2% topical ointment apply to topical route 2x/day to lesion and left arm, diagnosis follicular disorder, unspecified and consult with Physician. An interview with Registered Nurse #1 on 7/2/21 at about 3:50 PM revealed: RN #1 was not aware of a skin issue on the resident's left upper forearm. At that time, RN and Surveyor went to speak with Resident #7 and RN #1 observed the resident's left forearm with Surveyor present. Surveyor again observed a small round area about .5 inch in diameter with a yellowish center on the resident's left upper forearm, however the area surrounding the yellowish center was now observed to be slightly reddened. RN #1 reported that h/she had not observed the skin change previously, had not been notified of it, and further revealed h/she would be calling the Resident's doctor. Certified Nurse Aide (CNA #1) was interviewed on 7/06/21 at 9:28 AM and reported: H/She was assigned to Resident #7 last month 6/2021, h/she noticed a change to resident's forearm just above the wrist (CNA #1 identified area by pointing to her own left wrist), could not recall which side, h/she observed a black spot on Wednesday 6/30, h/she tried to report it to the RN #1, and RN #1 was busy so h/she did not get to tell him/her, and did not recall providing care to resident after that. CNA #1 further stated that h/she checked the resident's skin daily in the morning and if h/she sees something, h/she calls the nurse right away to look at. CNA #2 was interviewed on 7/06/21 10:13 AM reported: H/She is assigned to Resident #7 for this month 7/2021 and does a skin check every morning when washing the resident and during showers. Further reported that on 7/1/21 the resident had something on her left arm, like a little pimple, could recall what color, (CNA #2 identified site of pimple by pointing to her own left arm above watch strap), h/she did not report to the nurse and h/she should have, but h/she was just coming over to the assignment and assumed it had been reported. In a follow up interview on 7/6/2021, RN #1 reported that h/she had not been notified by CNA of any change in skin condition and it was the responsibility of the CNA to report any skin changes to the RN. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that facility staff accurately measured a resident's fluid intake to maintain proper hydration and health. Specifically,fluid restriction related to abnormal lab values was not followed for one of one resident (Resident #64) reviewed for hydration. Facility staff members did not accurately measure the resident's fluid intake during a recent lunch observation. The findings are: Resident #64 was admitted to the facility on [DATE] with diagnoses including Major Depression, Diabetes Mellitus, and Renal Insufficiency. According to the 6/16/2021 admission Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition and required extensive staff assistance with activities of daily living (ADLs). A Medical Nutrition Therapy Care Plan initiated 6/16/2021 and updated on 6/23/2021, documented the resident was at risk for altered nutrition/hydration status. The resident was on fluid restriction of 1500ml/day. Goals included the resident would be free from signs/symptoms of dehydration, such as high blood urea nitrogen (BUN) and or electrolytes. Interventions included to assess intake and to monitor for signs and symptoms of dehydration. Physician Orders dated 6/17/2021 had orders for regular diet with thin liquids, fluid restriction of 1500cc/day with reference to the Medication Administration Record (MAR) for the breakdown of the fluids. A Nursing/Dietary Fluid Restriction Sheet, dated 6/17/2021, showed the breakdown of the resident's fluid intake between the nursing and dietary staff as follow: -Nursing 7A-3PM shift =120ml, 3PM-11PM =120ml, 11PM-7AM = 60ml, (Total 300ml) -Dietary Breakfast: 4 oz milk (120ml), 8 oz coffee (240ml), 4 oz juice (120ml) = 480ml total fluid., Lunch: 4 oz tea (120ml), 2 oz milk (60ml) = 180ml total., Dinner: 4 oz tea (120ml), 2 oz milk (60ml), 4 oz soup (120ml) = 300ml total., 2 PM snack: 4 oz juice (120ml), 8PM snack: 4 oz juice (120ml), (Total 1,200ml), (Total fluid in 24 hours = 1500ml). Physicians' Progress Notes dated 6/18/2021 revealed the resident had a low sodium level of 128 with plans to restrict fluids. Nutrition Progress Note dated 6/23/2021 documented the resident's labs of 6/10/2021 showed abnormal sodium level of 128. The resident was placed on 1500ml fluid restriction as follow: -Nursing , 7A-3PM shift =120ml, 3PM-11PM =120ml 11PM-7AM = 60ml, (Total 300ml) -Dietary , Breakfast = 480ml, Lunch = 180ml, Dinner = 300ml, 2 PM snack =120ml, 8PM snack = 120ml, (Total fluid in 24 hours = 1500ml). During a lunch meal observation on 6/29/21 at 1:38 PM, a dietary worker poured unmeasured milk and tea in cups that were not calibrated for Resident #64 who was on 1500ml of fluid restrictions in a 24-hour period. Similar cups to the ones the resident was served with were compared and revealed the cup that the milk was served in was engraved with 9 oz size at the bottom and contained approximately 120ml milk or more. The cup with the tea was almost full of approximately 240ml of fluid. The cup had no measurements. The resident's lunch meal ticket dated 6/29/2021 stated fluid restriction with special instructions to give half a cup of tea and 2 oz of milk. In an attempt to correct the excessive fluid that was served to the resident, Registered Nurse (RN #1) poured off some of the fluids of both cups without using a measuring device for accuracy. During an interview with Registered Nurse (RN #) on 6/30/2021 at 1:50PM, h/she stated that the dietary department was responsible to make sure the resident's fluids were measured correctly. The fluids should have been measured by the dietary server when preparing the resident's meal trays. RN #1 said h/she was aware of the resident's fluid restrictions. H/She stated that h/she had noticed that the dietary server had poured an excessive amount of milk and tea in the cups that were not calibrated. RN #1 stated that the fluids the dietary server poured into the cups were way too much. H/She stated that was why h/she had to pour off some of the fluids, based on her judgement of what the amount should have been in each cup. RN #1 was asked why h/she had poured off the fluids based on her judgement, instead of getting calibrated cups to measure the fluids accurately. H/She stated that h/she did not want to leave the dining area. An interview was conducted with the Dietary Aide (DA), on 7/1/2021 at 1:45PM, related to the inaccurate amount of fluid that h/she had served the resident on 6/29/2021. H/She stated that h/she was aware the resident was on fluid restriction, but not the overall total. The resident should have received 4oz of coffee or tea, and 2 or 4 oz of milk. H/She stated that h/she thought h/she had poured the correct amount of fluid on that day, even though h/she did not use a measuring cup. The DA stated that h/she realized that h/she had poured an excess amount of fluid in the resident's cups after h/she was counseled by her manager. H/She stated h/she did not measure the fluids because h/she did not have a measuring cup. The DA stated that h/she should have used the measuring cups to serve the resident's fluids. The DA stated that h/she did not inform her manager that the measuring cups were not available. H/She stated there was documentation of the fluid breakdown between nursing and dietary, but h/she did not look at it on that day. The DA stated that h/she should have looked at it daily during serving of meals. H/She stated that the dietary aides who serve the meals are responsible to make sure the fluids are measured correctly. H/She stated that on that day, the resident got an excess amount of approximately 2 oz over the required amount. The DA said the fluid restriction information was documented on the resident's meal ticket. In an interview with the Registered Dietician (RD) on 7/2/2021 at 12:19PM, h/she stated that the resident was on 15000ml fluid restrictions related to low sodium levels. The resident's fluid breakdown included 4oz of juice at 2PM and 4oz at 8PM. H/She stated the staff are supposed to be measuring the resident's fluids. Measuring cups are available. The RD stated that h/she was informed that the dietary worker gave the resident excessive fluid. H/She stated that dietary and nursing are responsible to make sure the resident's fluids are measured accurately. The server was in-serviced about the incident. An interview with the assigned CNA #3 on 7/2/2021 at 12:38PM revealed the resident was on fluid restriction. H/She stated that the food servers are responsible for measuring the fluids before putting it on the tray; the nursing staff is responsible for double checking to make sure the fluids are accurate. The resident's fluid restriction is documented on the meal tickets. The tickets tell how much fluid is required with each meal. The resident's fluids are broken down between nursing and dietary. 415.12 (i) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that the irregularities identified by the Pharmacist were communicated to the resident's primary medical doctor and acted upon. Specifically, monitoring of the Resident's blood levels of Lithium did not occur in accordance with the physician's orders. This was evident for 1 (Resident #7) out of 5 residents reviewed for Unnecessary Medications. The finding is: An undated facility policy and procedure titled Drug Regimen Review revealed: The consultant pharmacist reviews the physician's orders, lab test result, nurse's notes, physician's notes, and resident's background in performing drug regimen reviews of each resident on a monthly basis; identifies a possible irregularity during the resident's monthly drug regimen review; reports irregularity on a two-part drug regimen review form; completes the upper portion of the form supplying the following information: Date drug regimen review written, Resident's name and room number, prescribing physician's name; provides a brief statement as to recommendation, signs and dates the form, retains a copy in binder, and original copy is placed in MD communication book on unit. The Attending Physician/Nurse Practitioner (NP) documents response to the pharmacist's comments in the area provided. Resident #7 was admitted on [DATE] with diagnoses including Bipolar disorder, Major Depressive Disorder, Alzheimer's disease A significant change Minimum Data Set (MDS: an assessment tool) dated 8/20/2020 documented moderately impaired cognition for decision making, and antidepressant medication was administered 7/7 previous days. A subsequent Quarterly MDS dated [DATE] documented severely impaired cognition for decision making, and antidepressant medication was administered 7/7 previous days. The Comprehensive Care Plan (CCP) titled Actual / Potential Drug Related Complications secondary to use of psychotropic drug as demonstrated by : Medication used: Lithium Carbonate 300 mg 3x/week Monday/Wednesday/Friday, Lithium Carbonate 300 mg once daily, Mirtazapine 15 mg 7.5 mg once daily. Updated 6/17/21: Seroquel 25 mg daily at HS. Goal: Resident will be free from complications associated with the use of psychotropic medication daily x 90 days. Interventions included: monitor lab results per MD order. Care Plan progress notes dated 10/30/20, 11/14/20, 2/20/21, 5/20/21, and 6/17/21 did not address Lithium levels. Observations of Resident #7 revealed on 6/29/21 at 01:53 PM Resident #7 was sitting in dining room waiting for lunch, became tearful, face sad, making soft distressed sounds. Resident self-calmed after a couple of minutes, then again became tearful with sad facial expression, this time with more audible distressed sounds. Staff responded by asking resident what was wrong, no explanation offered by resident, and staff explained to Resident that she was going to get her lunch for her and resident calmed. Physician's order dated 6/25/21 included: Lithium level every 3 months, Lithium carbonate 300 mg , 1 capsule by oral route 3x/week M/W/F at 10:00 AM dx bipolar d/o, current episode depressed, mild. Lithium carbonate 300 mg , 1 capsule daily at 8 pm dx bipolar d/o, current episode depressed, mild. Review of the record revealed: Lab reports for Lithium levels were completed on 8/11/2020, 1/21/2021, and 5/27/2021. A time frame of 5 months elapsed between Lithium level of 8/11/2020 and 1/21/2021. A time frame of 4 months elapsed between Lithium levels of 1/21/21 and 5/27/21. Upon Surveyor request to the Director of Nursing (DON) ([NAME]) for Resident #7's Medication Regimen Review (MRR) for the past six months, DON responded by providing a copy of the Pharmacy Consulting Services Quality Assurance Performance Improvement Material report for all facility residents from 1/20/21 through 6/24/21. Resident #7 was noted by the Pharmacist in that report as follows: Critical Elements- Lab orders not on file: 11/2020 Lithium level Critical Element Irregularity noted: Lab order is not on file. 4/2021 Lithium Level (ordered every three months). Additionally, the DON provided a copy of the Consultant Pharmacist Medication Regimen Review Accountability Record which was specific to Resident #7, and documented the following: 1/20/21: QA findings forwarded to Director of Nursing: Check 11/2020 Lithium level., 2/17/21: Medication Regimen Reviewed: Lithium 1/21/21, 5/26/21: QA findings forwarded to Director of Nursing: Check 4/2021 Lithium level. There was no documented evidence that: The Physician was notified of the irregularities and that Lithium levels were not being checked in accordance to the Physician's orders. , Any action had been taken to address the irregularities. A telephone interview of the Medical Director/resident's primary medical doctor (PMD) on 07/02/21 at 10:10 AM revealed: in regard to MRR recommendations for the DON to check labs: if the labs were done and MD documented them, then it is not necessary to inform the MD. If the labs were not done the MD should be notified. Interview of the DON conducted on 07/06/21 at 2:30 PM revealed: for Quality Assurance (QA) issues on the MRR, the following actions are taken: For lab reports not on file: the DON gets a copy of the QA from MRR and gives it to the nurse going on shift, usually the 3-11 shift. The nurse makes sure the lab is there. If the lab is not there, nursing will ensure the lab is done. There is no documentation of this action. In a follow up interview later that afternoon, the DON revealed that no Lithium level was found for 11/2020 and 4/2021. The Registered Nurse (RN #2, 3-11 shift) ) was interviewed on 7/6/2021 at 4:35 pm and reported that h/she was not aware of the missed/late Lithium levels for Resident #7, and further reported that if h/she had been aware h/she would have called the lab and if the lab was delayed would call MD. The Registered Nurse (RN #1, 7 am -3 pm shift) was interviewed on 7/6/2021 at 4:45 PM and reported h/she was not aware of late/missed Lithium levels for Resident #7, and further reported that if h/she was aware h/she would have called the MD. A follow up interview of the Pharmacy Consultant was conducted 7/6/2021 at 4:50 PM and revealed: no MRR irregularity was sent to MD regarding the late/missed lithium levels, and further revealed that MD received the QA form which documented the missing Lithium levels. 415.18 (c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that facility staff provided ongoing monitoring of a resident for medication effect, side effects, adverse reaction, or any associated behavioral effects of the medication. Specifically, 1of 5 residents (Resident # 63) reviewed for unnecessary medication revealed no evidence of ongoing monitoring for the use of an antipsychotic medication, Abilify, used to treat Anxiety Disorder. Additionally, a Pharmacy Drug Review revealed a drug-drug interaction of increased bleeding between Aspirin and Fluoxetine (anti-depressive medication). There was no evidence that the resident was monitored for bleeding as recommended by the pharmacist. The findings are: Resident # 63 is a [AGE] year-old who was admit to the facility on 6/14/2021 with diagnoses and conditions including Depression, Anxiety Disorder, Schizophrenia, and Heart Failure. Physician Orders dated 6/14/2021 included medication orders for Abilify 5mg tablet oral daily at 5PM for Anxiety Disorder, Aspirin 81mg chewable tablet oral daily at 10AM for Heart Failure, and Fluoxetine 40mg capsule oral daily at 10AM for Major Depressive Disorder. A Care Plan (CP) titled At Risk for Bleeding was initiated on 6/15/2021. The CP listed the medication ASA 81mg chewable tablet oral daily. Goals included signs and symptoms of minor bleeding would be detected early. Interventions included, but not limited to monitor for any signs and symptoms of bleeding, increase bruising, and notify the physician for any increase bleeding or abnormal labs. A Psychotropic Drug Use Care initiated on 6/15/2021 listed medication Fluoxetine 40mg capsule oral daily and Abilify 5mg oral daily. Goals included the resident would be free of complications associated with the use of psychotropic medication. Interventions included to assess and evaluate for effectiveness and/ or adverse reaction on an ongoing basis, and to monitor for signs and symptoms of complication and report to the physician. According to the 6/22/2021 5-Day Minimum Data Set (MDS; a resident assessment and screening tool), the resident had moderate impaired cognition, and required extensive staff assistance with activities of daily living (ADLs). A Pharmacy Drug Review was conducted on 6/24/2021. The Pharmacist documented concurrent use of the Aspirin and Fluoxetine medication may increase the risk for bleeding and to monitor the resident. Nurses Progress Notes 6/14/2021 to 7/6/2021 revealed no documented evidence of behavior monitoring, medication effects/adverse reaction, bleeding, or documentation of the pharmacist recommendation of the drug-drug interaction between the medications as described above. The Medication Administration Record (MAR) from 6/24/2021 to 7/24/2021 was viewed in the presence of Registered Nurse (RN #1) on 7/1/2021 at 12:05PM and revealed Resident #63 currently ordered for Aspirin 81mg chewable tablet daily at 10AM and Fluoxetine 40mg capsule oral daily at 10AM daily. There was no evidence that the above pharmacy drug-drug interaction and recommendation to monitor the resident were transcribed to the MAR to alert the nurses of the risk of bleeding from these medications. RN #1 was asked if the information was documented on a treatment record to which h/she replied the resident had no treatment record. In an interview with the Director of Nursing (DON) on 7/1/2021 at 11: 50AM, h/she stated that it was the nursing staff responsibility to make sure the pharmacist recommendations, as indicated above, were documented on the resident's care plan for the staff to follow up. In an interview with RN #1 on 7/1/2021 at 12:05PM regarding the above pharmacy review, h/she stated that pharmacy medication reviews are done monthly. If the information was for nursing, such as monitoring for bleeding, the information would be documented on the resident's care plan for the nurses to monitor. RN #1stated that the pharmacy drug-drug interaction recommendation should have been documented on the resident's care plan. During a follow up interview with RN #1 on 7/06/21 at 3:48 PM, h/she stated that there was no documentation that the staff were monitoring the resident for bleeding and behavior. They should have been done. The nurses were responsible for monitoring and documenting in the Progress Notes. 415.12(1)(2)(i)

Based on observation and staff interview during the Life Safety Recertification survey, the facility did not ensure all applicable state codes were met. Specifically, the facility did not install a carbon monoxide detector in accordance with section 915 of the 2015 edition of the International Fire Code, as adopted by New York State and contained in the NYS Uniform Code Supplement Section 915.3, which requires carbon monoxide detection in buildings with fuel-burning appliances. The finding is On 06/29/21 at approximately 11:10 AM, a tour of the nursing unit revealed one gas dryer located in a closet at the end of the corridor near resident room F213. Further observation at this time revealed a carbon monoxide detector was not installed in the closet where the gas dryer was located or throughout the corridor near the gas dryer. In an interview at this time, the Maintenance Director stated carbon monoxide detection will be installed in the corridor. 10 NYCRR: 415.29 (a)(2), 711.2 (a)(1); 42 CFR: 483.70 (b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9

Based on record review and staff interview, the facility did not ensure that a Legionella Risk Assessment and Water Management Plan was provided in accordance with Section 483.80. Specifically, the facility did not ensure that the Legionella Program was assessed at least annually. The findings are Record review of the facility's Legionella Program revealed a document titled Water Management Plan - The Knolls 1/15/2020 Prepared by Sound Water Treatment, Inc. Revised January 2020. Additional record review at this time revealed the DOH-5222 document was also dated January 15,2020. In an interview on 06/30/21 at approximately 12:40 PM, the Maintenance Director stated that the Legionella Program should be reviewed annually. 483.80(a)(1)(2)(4)(e)(f)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure proper storage of food in accordance with professional standards for food safety. Specifically, 1) perishable foods were not labeled and dated, 2) foods were not discarded by use by date, and 3) dry goods were not stored in closed containers. .A facility policy and procedure titled Labeling and Dating, dated 2/5/11 and last revised on 11/4/20202, included but was not limited to: All food items must be labeled with either a manufacturers label or handwritten label. Twice a day the dining services manager on duty will check all perishables for proper covering, labeling, and dating .It is also the responsibility of other production staff and employees to discard outdated foods and beverages as assigned or noted by management. The findings are: Observations and interviews conducted during the initial tour of the kitchen on 06/29/21 at 10:04 AM revealed: 1) The following unlabeled, undated, and expired dairy foods were stored in the walk-in produce refrigerator: An opened, 2.32-pound package of muenster cheese labeled with a prep date of 6/17/21, a use by date of 6/19/21, and was held 10 days past the use by the date. An opened 2.81-pound package of yellow american cheese labeled with a prep date 6/17/21, use by date 6/19/21, and was held 10 days past the use by date. An opened 1.9-pound package of blue cheese labeled with a prep date 6/21, use by date 6/23/21, and was held 6 days past the use by date. An opened 1.48-pound package of goat cheese labeled with a prep date 6/21/2011, use by date 6/23/21, and was held 6 days past the use by date. An opened .85-pound package of shredded mild cheddar cheese labeled with a received by date 6/7/21 was not labeled with an opened date or use by date. An opened .9-pound package of mozzarella cheese was unlabeled/undated. Cook #1 was interviewed on 6/29/21 at 10:34 AM and reported that all staff are responsible to check used by dates and discard expired foods, but it is primarily the responsibility of the Managers. The Regional Manager (responsible for covering the kitchen at the time of the tour) was interviewed on 6/29/21 at 10:48 AM and reported: When a product is brought in by a company it should be labeled with a receiving date. If a boxed product containing multiple bags of that product is then opened, the received date, as well as the use by date found on the product box, should be carried over to each individual bag. If an item is stored in the freezer and is later pulled to thaw in the refrigerator, it should be labeled with a pull date and a use by date. If a product is opened it should be labeled with a prep date and a use by date. At that time, the Regional Manager stated that h/she would discard the above items. 2) The following unlabeled and undated frozen were stored in the walk-in freezer: 4.6-pounds of cod wrapped in in plastic wrap dated 4/1/21, no received date or use by date. 2.33-pounds of breaded cod stored in a clear plastic bag dated 4/4/21, no received date or use by date. 1.18-pounds of frozen breaded fish stored in a blue bag, unlabeled and undated. 3. The following unlabeled and undated raw meat and poultry items were stored in a walk-in refrigerator: A defrosted to touch, 10-pound package of raw ground beef labeled with a received date of 6/21/21, no pull date or use by date 9.7-pounds defrosted to touch, raw Chicken thighs stored in a 1/3 pan, volume exceeded top of pan, wrapped in plastic wrap, labeled frozen 6/12/21, no pull date or use by date 2 defrosted to touch, raw pork loin, approximately 6.5 pound each, labeled with received date 5/21/21, no pull date or use by date. Cook #2 was interviewed on 6/29/21 at 10:38AM at that time and reported that she had pulled the ground beef, chicken thighs, and pork loin from the freezer last night, she usually would label these with a pull date , but she did not have any labels. [NAME] #2 did not produce documentation (i.e. a pull log) to support her statement. The Regional Culinary Manager was interviewed on 6/29/21 at 10:38AM and reported the fish, ground beef, chicken thighs, and pork loin would be discarded. #4. Observation of dry food storage on 6/30/21 at 10:43 AM in Dining Room Food Service/Pantry area revealed: The following food items were not stored in closed containers : single serving cold cereal, individual portions of saltines, graham crackers, cookies, breakfast syrup, grape jelly, and individual sugar packets. The [NAME] President of Operations Food Service was interviewed on 6/30/21 at 10:43AM and reported that the dry foods would be stored in closed containers. An interview conducted with the Food Service Director on 07/06/21 01:24 PM revealed his/her expectation fo dating and labeling were: Everything that is consumable should be dated on received date. If multiple items come in one box, the received date can be on the box. Then, if the cooks take out part of the item and some items remain, then the received date should be labeled on the remaining items. Items that are pulled from the freezer should be labeled with a pull date, the guidance for use by date varies, and there is a listing on the freezer and walk in refrigerators which will indicate how long the items can be held for under refrigeration. When asked if there should be any other labeling besides the pull by date for the frozen foods, FSD reported there might be a use by date. For products such as cheese, if the cheese stays in the box the received date will be on the box, if individual bags of cheese are used staff must label all bags with the same received date as on the box. If the cheese is opened it is labeled with an opened date, the expiration date must be checked on the refrigeration guidance sheet and should cheese labeled with a discard date. For frozen items that are partially used, i.e. an opened bag of frozen breaded fish fillets, these should be labeled with received by date, an opened date, and a discard date. 415.14(h)