**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 05/19/2025 to 05/23/2025, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and all drugs and biologicals were stored in locked compartments with access limited to authorized personnel for two (2) (Elmgrove and [NAME] East Hall) of four (4) medication carts and one (1) (Elmgrove) of two (2) medication rooms reviewed. Specifically, medications were left unattended by staff, +expired medications were stored in medication carts and medication rooms, and an unlabeled and undated tube of Medihoney (a treatment used for wounds) was stored in a medication cart. The findings include: Review of the undated facility policy Medication Storage revealed medications would be stored in their original packaging. Antiseptics, disinfectants, and germicides used in any aspect of a resident's care must have legible, distinctive labels that identify the contents and the directions for use. The facility would not use discontinued, outdated, or deteriorated medication and those medications would be returned to the dispensing pharmacy or destroyed. Review of the facility policy Administration of Medication, dated March 2018, documented during administration of medications no medications are kept on top of the cart. 1. During an observation on 05/22/2025 at 11:28 AM, a medication cart sitting outside resident room [ROOM NUMBER] had a medicine cup on top of the cart that contained two (2) unidentified medications. There was no staff in sight. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated the medication cup should have been secured in the medication cart. 2. During an observation and interview on 05/22/2025 at 11:05 AM on [NAME] East Hall, a medication cart contained four (4) amoxicillin capsules (an antibiotic) with an expiration date of 04/10/2025 and a 15 milliliter tube of Medihoney (wound treatment) that was unlabled with resident identifyers or open date on it. During an immediate interview with Licensed Practical Nurse #4 and Licensed Practical Nurse #1, Licensed Practical Nurse #4 stated they were unsure who was responsible for checking expiration dates on medications. Licensed Practical Nurse #1 stated all nurses should be checking for expiration dates when giving medications. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated the safest practice for a house stock (items which a facility routinely keeps on hand) treatment stored in a common area would be to label it with a resident's name (who the treatment was prescribed for). 3. During an observation on 05/22/2025 at 10:44 AM in the Elmgrove Unit medication room there were three (3) boxes of Fast Acting Dairy Aid (used to treat lactose intolerance), two (2) boxes were unopened (32 capsules each) with an expiration date of March 2025 and one (1) box was opened (number of capsules unknown) with an expiration date of February 2025. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated night shift nurses are responsible for monthly audits of medication rooms and carts. Night shift nurses should pull all expired medications and send them back to pharmacy for disposal. The expired medications should have been caught on a monthly audit. 10 NYCRR 415.18(d) 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 05/19/2025 to 5/23/2025, for one (1) (Resident #17) of three (3) residents reviewed, the facility did not ensure a paid feeding assistant provided dining assistance only for residents who have no complicated feeding problems. Specifically, Unit Assistant #2 provided eating assistance to Resident #17, who was diagnosed with dysphagia (difficulty swallowing). The findings includes: Review of the facility's training manual Assisting with Nutrition and Hydration in Long-Term Care (used for paid feeding assistant training), dated 2004, included federal regulations prohibited paid feeding assistants from assisting residents who have more complicated problems, such as lung aspirations (accidental inhalation of food into the respiratory tract), difficulty swallowing, residents with feeding tubes or intravenous feedings. Dysphagia which means difficulty swallowing and paid feeding assistants would not be assigned to feed residents who had dysphagia. Resident #17 had diagnoses including dysphagia, vascular dementia, and dyskinesia of the esophagus (muscles in the esophagus do not function properly leading to difficulty in moving food and liquids from the throat to the stomach). The Minimum Data Set (a resident assessment tool), dated 02/12/2025, documented Resident #17 had severe cognitive impairment, was dependent on staff for eating, and was on a mechanically altered diet. During an observation and interview on 05/21/2025 at 12:19 PM, Unit Assistant #2 was assisting Resident #17 with lunch in the main dining room. The resident had a divided plate that contained pureed food items (veggie burger, tomato soup, and broccoli). Resident #17 coughed occasionally throughout the meal. During an interview at this time, Unit Assistant #2 stated the food was thickened (thickened consistency to prevent choking). Review of Resident #17's lunch meal ticket (ticket that comes with the meal that includes what is being served and assistance required) revealed the resident was a feed (required assistance from staff to complete the meal), received a pureed vegan diet, and nectar thickened fluids. Review of the resident's current Comprehensive Care Plan (last revised 11/12/2024) included interventions for staff to supervise and assist Resident #17 as needed for meal consumption. Review of current physician's orders, dated 02/07/2025, included a regular diet, pureed texture, and nectar (thickened liquid) consistency. Review of the facility document List of residents eligible for assistance and who are currently receiving assistance from paid feeding assistants, received on 05/19/2025, included Resident #17. Review of the facility document Name of staff who have successfully completed training for paid feeding assistants and who are currently assisting selected residents with eating meals and/or snacks, received on 05/19/2025, included Unit Assistant #2. Review of Unit Assistant #2's employee file revealed a completed Nursing Home Training Program for Paid Feeding Assistant Skills and Knowledge Checklist dated 06/29/2022. In a nursing progress note, dated 02/06/2025, Licensed Practical Nurse #2 documented Resident #17 was fed by staff, used straws with thin liquids, had a pureed diet, staff must be aware to cue the resident not to talk while drinking or eating, and the resident often coughed with liquids during the day's meal. In a nursing progress note, dated 02/06/2025, Licensed Practical Nurse #6 documented Resident #17 had difficulty with swallowing medications and during dinner. The Unit Assistants were reminded to use a spoon for safer results and to let the writer know if there were continued issues. During an interview on 05/22/2025 at 11:42 AM, Unit Assistant #2 stated in their role (as feeding assitant), they guide or assist residents with their meals and their training included assisting residents with eating. Unit Assistant #2 stated they could assist residents with pureed or mechanically soft diets and there were not any residents they could not assist. They stated Resident #17 received thickened liquids and if the resident were to cough or choke, they would back off (on giving more food or drink). During an observation on 05/22/2025 at 12:20 PM, Unit Assistant #2 was assisting Resident #17 with their lunch meal in the dining room. There was a divided plate that contained pureed food items (veggie burger, tomato soup, and green beans). During an interview on 05/22/2025 at 12:54 PM, Licensed Practical Nurse #2 stated the nurses, Certified Nursing Assistants, and trained Unit Assistants could assist residents with meals. For the staff that had undergone the feeding assistant training, there were no restrictions on residents that they could assist including residents that had swallowing difficulties and mechanically altered diets or fluids. During an interview on 05/22/2025 at 3:40 PM, the Nurse Educator stated the Unit Assistants undergo feeding assistant training with their orientation. The state requirement included feeding assistants should not be assisting residents with swallowing difficulties, and they told the feeding assistants this during their training. The Nurse Educator stated the feeding assistants should not be assisting residents who had mechanically altered diets or altered liquid consistencies. During an interview on 05/23/2025 at 9:22 AM, the Director of Nursing stated most of the feeding assistants were unit assistants that had gone through the training, along with some other non-clinical staff. The Director of Nursing stated they would look to the nurses and the nurse managers to guide which staff (including feeding assistants) should assist which residents with their meals. The Director of Nursing stated they believed the feeding assistants could assist residents with swallowing difficulties since there are varying levels. When asked if they were aware the regulation included paid feeding assistants could not assist residents with difficulty swallowing, the Director of Nursing stated they may have known but it had been a while. 10 NYCRR 415.14

Based on interviews and record review conducted during the Recertification Survey from 05/19/2025 to 05/23/2025, the facility did not maintain a quality assessment and assurance committee that consisted of, but not limited to, the Medical Director or their designee. Specifically, the facility could not provide documented evidence the Medical Director or their designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a regular basis. The finding includes: Review of the facility's undated Quality Assurance and Performance Improvement Program Overview revealed a list of members who attend the Quality Assurance Meeting and did not include the Medial Director or their designee. Review of the facility document Quality Assurance Members 2025 revealed members included, but were not limited to, the Medical Director. Review of the facility's Quality Assurance Attendance Log from May 2024 to May 2025 revealed the Medical Director and/or their designee did not attend three (3) of the five (5) meetings held. During an interview on 05/22/2025 at 4:19 PM, the Assistant Administrator stated they did not know that either the Medical Director or a designee was required to attend the meetings. 10 NYCRR: 415.27(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey, the facility did not provide influenza and/or pneumococcal immunizations as required or appropriate for one of five residents reviewed. Specifically, the facility was unable to provide evidence that Resident #44, who was eligible for the vaccine, had been offered, declined and/or educated regarding Pneumococcal immunization during their admission. This is evidenced by the following: The undated facility policy, Pneumococcal Immunization included that unless contraindicated, pneumococcal immunizations are highly recommended for all residents of the facility per the facility's protocol. The policy included that all new resident admissions would have their vaccine history checked with their community medical provider prior to admission to the nursing home. Routine physician admission orders would include the pneumococcal vaccine on admission if they (resident) had not had it or were out of the recommended window of being immunized, unless contraindicated by a medical provider. The policy included that the resident and/or representative would be provided a current Vaccine Information Statement (VIS- a document providing information about the pneumococcal vaccine), and the nurse would document in the medical record the date the information was provided to the resident and/or representative. The signed immunization consent or declination forms would be filed in the resident's medical record. A resident's immunization record should be documented in the 'Immunization' section of the electronic medical record and would be reviewed periodically to ensure that vaccination(s) were current. Resident #44 is a [AGE] year-old resident of the facility admitted in 2022, with diagnoses that included vascular dementia, macular degeneration, and anxiety. The Minimum Data Set Resident Assessment that was provided by the facility and dated 2/14/24, revealed Resident #44 was severely impaired cognitively and that their pneumococcal vaccine was not up to date. The question asking the reason why the vaccine had not been received was left blank. Review of Resident #44's immunizations in the electronic health record revealed Resident #44 received a Pneumococcal Polysaccharide vaccine (PPSV23) on 5/22/2002. Review of physician orders since the resident's admission did not reveal any evidence that a pneumococcal vaccine had been administered since the 2002 vaccine. Review of the facility's 'Immunization Worksheet,' on 3/13/24 revealed Resident #44 had received a Pneumococcal Polysaccharide vaccine 23 (PPSV23) on 5/22/2002. On 3/12/24 Resident #44 received the Pneumococcal Conjugate vaccine (PCV) 13 or 20 vaccine (after surveyor intervention and resident representative consent). Additionally, seven residents were highlighted on the spreadsheet that indicated the residents were eligible for a pneumococcal vaccination. The facility could not provide evidence that Resident #44 or their representative were offered, accepted, or declined the pneumococcal vaccine since the resident's admission to the facility prior to the survey. During an interview with the Director of Nursing/Infection Preventionist and the Director of Staff Education (previous Infection Preventionist until January 2024) on 3/12/24 at 1:03 PM, the Director of Staff Education stated that residents' immunizations are reviewed on admission and if eligible the vaccine is offered. The Director of Staff Education said a spreadsheet is used to keep track of residents' immunizations and due dates for revaccinations, dependent on which vaccine they were previously administered and when. The Director of Nursing/Infection Preventionist stated they could not find any evidence that Resident #44 (including information from their representative) had been offered the pneumococcal vaccine since their admission in 2022. The Director of Staff Education said that during the COVID-19, there was changing guidance on not administering different immunizations too closely (timeframe) together and more spaced out and that there had also been issues with obtaining the vaccines. The Director of Nursing/Infection Preventionist stated (after review of the immunization worksheet) they identified additional eligible residents with outdated pneumococcal immunizations. During an interview on 3/13/24 at 8:54 AM, the Medical Director stated the Infection Control Officer (Infection Preventionist) was responsible for auditing residents' immunization records ensuring that all residents' immunizations are up to date and inform them if not. The Medical Director stated if a resident had received the Pneumococcal Polysaccharide Vaccine 23 prior, they would encourage the resident to be re-vaccinated, but that the resident (or their representative) did have the right to refuse. The Medical Director stated that based on their previous pneumococcal immunization in 2002, Resident #44 could have received the pneumococcal vaccine when admitted to the facility in 2022. The Medical Director stated they had not been aware of any supply issues obtaining the vaccines in 2022 or 2023. 10 NYCRR 415.19 (a)(3)

Based on observations, interviews, and record reviews, conducted during the Recertification Survey completed on 6/3/22, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were cold foods prepared on-site and held for greater than seven days, expired/outdated food products not discarded, food items undated, unlabeled and/or stored uncovered, lack of hair restraints in food preparation areas, and cleaning tools were not stored in a manner to prevent contamination of food, utensils, or equipment. This is evidenced by the following: 1. Observations in the presence of the Dining Manager during the initial brief tour of the main kitchen on 5/31/22 from approximately 8:48 a.m. to 9:30 a.m., included the following: a) Three 3-gallon tubs of ice cream were stored uncovered, in the ice cream freezer. b) Hair restraints were not available for use and one staff member working in the kitchen was observed not wearing a hair restraint. c) One-gallon containers of Caesar dressing, Catalina dressing and barbeque sauce, a five-gallon container of sour cream, and a half-gallon container of fat free milk were open and undated in the double glass-door cooler. d) A container of sauce prepared on-site and located in double glass-door cooler was dated 44 days prior. e) An open container of coconut milk located in the double-glass door cooler was marked with an expiration date of November 2021. f) A container of cheese sauce was uncovered in the walk-in refrigerator. g) A container of what was identified by the Dining Manager as meatballs was unlabeled, undated, and uncovered. h) A partial block of what was identified by the Dining Manager as deli turkey was open, undated, and unlabeled in the walk-in refrigerator. i) A large tray of chicken chowder and a small container of chicken sauce in the walk-in refrigerator were marked as prepared 9 days earlier. j) A large tray of what was identified by the Dining Manager as Swedish meatballs in sauce and another large tray pan of what was identified by the Dining Manager as meat sauce were unlabeled and undated in the walk-in refrigerator. k) A clear bag of what was identified by the Dining Manager as pastry dough was unlabeled and undated in the walk-in freezer. Additionally, a large box of single serve cheese pizzas, beef patties, tater tots, veggie burgers, pizza dough and frozen penne were open and undated in the walk-in freezer. l) Bags of elbows, bow-tie pasta, spaghetti, couscous, and rice were open and undated in the dry storage area. m) Brooms and upright dustpans were stored abutting an open rack of clean dishes and equipment that included an immersion blender. 2. Observations in the presence of the Executive Chef during a follow-up visit to the main kitchen on 6/2/22 from approximately 11:02 a.m. to 12:10 p.m. included the following: a) Hair restraints were not available for use and a kitchen staff member was observed without a hair restraint. b) Three 3-gallon tubs of ice cream were uncovered, in the ice cream freezer. c) Two small containers of sausage were uncovered in the double glass-door cooler. d) Nine bags, each containing eight bread rolls, located on the bread rack were marked with a 'best by' date 10 days prior. e) A small container of meatballs marked as being prepared 9 days earlier, was located in the walk-in refrigerator. f) The container of cheese sauce was uncovered in the walk-in refrigerator. g) The large tray of what was previously identified by the Dining Manager as Swedish meatballs in sauce and another large tray pan of what was previously identified by the Dining Manager as meat sauce, which were previously unlabeled and undated remained in the walk-in refrigerator unlabled and undated. h) Large bags of ravioli and fish patties were open, unlabeled, and undated in the walk-in freezer. The previously identified pastry dough, large box of single serve cheese pizzas, tater tots, pizza dough and frozen penne remained in the walk-in freezer open and undated. i) A small container of cooked rice was marked as being prepared 20 days earlier and located in the cooler under the cooks' prep area. j) Small containers of what were identified by the Executive Chef as tofu and barbeque sauce were outside of their original packaging, unlabeled and undated, in the cooler under the cooks' prep area. k) Brooms and upright dustpans were stored abutting an open rack of clean dishes and equipment that included an immersion blender. 3. During an interview on 6/2/22 at 11:15 a.m., the Executive Chef stated that the foods should have been covered, labeled, and dated on the day the food was made and that there was a five-day rotation on prepared foods. The Executive Chef stated that foods older than that should have been thrown out. The Executive Chef stated there was a lot of new staff that probably didn't understand the process. The Registered Dietitian and Director of Food Service were not available for interview. No written policies were provided for review with regard to holding, storage, labeling, or discarding food items. 10NYCRR: 14-1.31(a), 14-1.42, 14-1.43(e), 14-1.72(c), 14-1.172 U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance