Every finding on record at Ross Center For Nursing And Rehabilitation

Based on observations, interviews, and record review, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was identified during the Kitchen Task. Specifically, during follow-up kitchen tours on 01/15/2026 and on 01/16/2026, the walk-in freezer temperatures were observed to be 26 degrees Fahrenheit (the food safety requirement should be at or below zero (0) degree Fahrenheit). Additionally, one (1) of the three (3) evaporator fans in the walk-in freezer were not operational. The finding is: The facility policy and procedure titled Food Storage dated 01/13 documented all perishable foods are stored in either refrigerators maintained at 41 degrees [Fahrenheit] or below, or freezers at zero (0) degree [Fahrenheit], or below respectively. A reliable thermometer shall be installed and maintained in all refrigeration and freezer units and monitored on a daily basis. The United States Food and Drug Administration Refrigerator and Freezer Storage Chart dated March 2018 documented freezing [temperature] of zero (0) degree Fahrenheit (-18 degree Celsius) keep food safe indefinitely. During an interview on 01/13/2026 at 9:37 AM, the Director of Food Services stated that there was no equipment that was non-operational, except for a broken lock on the chemical room door. The Director of Food Services stated there were no outstanding work orders for any kitchen equipment, including all refrigeration units. During a follow-up kitchen tour with the Director of Food Services on 01/15/2026 at 9:53 AM, the outside thermometer gauge of the walk-in freezer indicated a temperature of 20 degrees Fahrenheit. A free-standing thermometer inside the walk-in freezer indicated temperature of 26 degrees Fahrenheit. Three (3) overhead evaporator fans were observed; the fan on the left was not operational. The middle fan and the fan on the right were spinning. The walk-in freezer temperature log for January 2026 indicated the temperature on 01/15/2026 at 6:00 AM was -10 degrees Fahrenheit. During an interview on 01/15/2026 at 9:53 AM, the Director of Food Services stated that they were not aware of the walk-in freezer temperature issue. The Director of Food Services stated that the walk-in freezer temperature should be maintained at zero (0) degree Fahrenheit or below. The Director of Food Services was not certain why the temperature was out of range. The Director of Food Services stated they were aware that the walk-in-freezer overhead fan on the left was not working and thought that the fan turned off as part of the unit defrosting process and they did not submit any repair order for the evaporator fan. During a follow-up kitchen tour with the Director of Environmental Services on 01/15/2026 at 02:45 PM, the outside thermometer gauge for the walk-in freezer indicated a temperature of 12 degrees Fahrenheit. A free-standing thermometer inside the walk-in freezer indicated temperature of 22 degrees Fahrenheit. The Director of Environmental Services stated the walk-in freezer temperature was out of range because the door was not shut properly. During a follow-up kitchen tour with the Director of Food Services and the Director of Environmental Services on 01/16/2026 at 09:37 AM, the outside thermometer gauge for the walk-in freezer indicated a temperature of 14 degrees Fahrenheit. A free-standing thermometer inside the walk-in freezer indicated temperature of 26 degrees Fahrenheit. The evaporator fan on the left was still off while the middle fan and the fan on the right were spinning. During an interview on 01/16/2026 at 09:40 AM, the Director of Environmental Services stated that the fans were on alternate cycles for defrosting and there were always only two fans that were spinning at the same time. The Director of Environmental Services stated they considered the evaporator fans operational. The Director of Environmental Services stated a technician has been called to service the walk-in freezer. During an interview on 01/16/2026 at 12:24 PM, the technician from servicing company stated the walk-in freezer should be maintained at zero (0) degree Fahrenheit or below to keep the food frozen solid. The technician stated the walk-in freezer compressor (a machine responsible for compressing refrigerant to cool the freezer) required additional refrigerant (a special fluid that absorbs heat from one area and releases it in another) due to pressure changes. The technician stated the freezer temperature was elevated because of inadequate refrigerant fluid. The technician stated the evaporator fans circulated air inside the freezer. The technician stated a non-operational fan will impact areas inside the walk-in freezer where there may be lack of air flow, causing ice buildup and gradual increase in temperature. The technician stated the evaporator fan on the left was off during their inspection and they (the technician) found loose connecting wire. The technician stated they tightened the wire, and the fan is now operational. The technician stated all three fans should be running simultaneously during non-defrosting cycle. The technician stated they were not called for servicing the walk-in freezer prior to today, 1/16/2026. 10 NYCRR 415.5(e)(1)(2)

Based on record review and staff interviews, the facility did not immediately inform the resident's Physician when there was a significant change in the resident's physical, mental, or psychological status (that is, a deterioration in health, mental, or psychological status in either life threatening conditions or clinical complications). This was identified for one (1) (Resident #84) of two (2) residents reviewed for Nutrition. Specifically, on 12/15/2025 Resident #84 was identified with an undesired significant weight loss of 5% in one month, and on 1/16/2026 an undesired significant weight loss of 10.2% in 3 months. There was no documented evidence that the resident's Physician was notified of the resident's significant weight loss.The finding is: The facility's policy titled, Resident Change in Condition last revised in 10/2025 documented should a resident experience a medical change in condition that indicates an emergency of acute illness, it is the expectation that the Registered Nurse on duty will perform a full assessment of the resident and document such change in the medical record and notify the Physician of such changes. Upon determining that a change in the resident's condition has occurred, the licensed nurse on duty will promptly notify the Registered Nurse Supervisor on duty and make him/her aware. A change in condition may include but is not limited to: A significant change in the resident's physical/emotional, mental condition. Resident #84 had diagnoses that included hypertension (abnormally high blood pressure) and type 2 diabetes mellitus (a form of diabetes mellitus characterized by high blood sugar, insulin resistance, and lack of insulin). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making with long- and short-term memory problems. The Minimum Data Set documented the resident's height was 63 inches and weight was 121 pounds. The resident had no weight loss of 5% or more in the last month or a loss of 10% of more in the last six (6) months and was not on a physician-prescribed weight-loss regimen. The Dietary Progress Note dated 12/11/2025, written by Registered Dietitian #1, documented: Resident noted with a 5.4 pounds decrease in weight in one month (4.5% change in usual body weight). The 12/11/2025 weight was 112.8 pounds. The recent weight trends were as follows: 06/2025 weight: 120.2 pounds, 09/05/2025 weight: 121 pounds, and 11/07/2025 weight: 118.2 pounds.The Dietary Progress Note dated 12/15/2025, written by Registered Dietitian #1, documented: Weekly weight available (today)- 112.2 pounds, which is consistent with the monthly weight of 112.8 pounds that was taken on 12/11/2025. The resident triggered significant weight loss (5%) this month.During an interview on 01/16/2026 12:30 PM, Registered Dietitian #1 stated the resident's weight on 12/29/2025 was 104 pounds, which they never entered into the electronic medical record because it reflected an 8.2 pounds weight loss since 12/15/2025 and wanted a reweight. Registered Dietitian #1 stated they requested a reweigh of the resident to confirm the accuracy of the 104 pound weight; however, there was never any weight taken for resident after 12/29/2025. During an interview on 01/16/2026 at 1:00 PM, Registered Dietitian #1 stated they did not notify the Physician of Resident #84's significant weight loss because they were waiting for the resident to be reweighed. During an interview on 01/16/2026 at 2:50 PM, Registered Nurse #2 stated they did not know that Resident #84 had a significant weight loss, otherwise they would have notified the Physician of the weight loss for further work up. During an interview on 01/20/2026 at 1:05 PM, the Medical Director stated when a resident has a significant weight loss, the resident's Primary Physician/Medical Provider should be notified by the Registered Dietitian or the Unit Nurse. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on interviews and record review (Incident # 2677700), the facility did not ensure each covered individual report immediately, but not later than two (2) hours, to the administration of the facility and to the New York State Department of Health after the allegation was made. This was identified for one (1) (Resident #116) of two (2) residents reviewed for Abuse. Specifically, on 11/23/2025 at 2:00 AM, Resident #116 reported a verbal abuse allegation to Licensed Practical Nurse #5. Registered Nurse #2 was made aware of the abuse allegation and did not report the incident to the facility administration until 11/24/2025, 24 hours after the allegation was made.The finding is:The facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property, last reviewed 06/22/2018, documented verbal abuse as any use of oral, gestured or written languages which uses degrading or derogatory terms towards residents. Mental abuse is defined as but not limited to harassment which was threats of punishment, mental anguish or mental illness. Section six (6) of the policy on reporting documented that the Director of Nursing Services or designee is responsible for reporting all alleged violations and all substantiated incident to the New York State Department of Health and to all other agencies as required. The policy did not indicate specific timeframes to for all reportable incidents including but not limited to allegation of abuse, suspicion of crime, and serious/non serious injuries.Resident #116 was admitted with diagnoses that included fracture of the left ulna (one of two long bones in the forearm), fracture of the left humerus (one of two long bones in the forearm) and multiple fractures of the ribs (curved bones that round from the back to the chest). The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. The resident exhibited no behavioral symptoms at the time of the assessment.The Comprehensive Care Plan for Abuse dated 11/17/2025 documented Resident #116 was at risk for abuse and neglect. Interventions included to observe resident for unusual skin marks, discoloration, ecchymosis and report promptly, to investigate accident as needed (PRN) and to in-service staff on abuse and neglect.The Comprehensive Care Plan for Behavioral Symptoms related to Fabrication/Accusatory Behavior dated 12/01/2025 documented Resident #116 exhibited verbal behavioral symptoms related to fabricating and accusing others. The behavioral symptoms are noted to put the resident at significant risk for physical illness or injury. Interventions included to assess for unrecognized need and preferences, to separate from others when agitated. The care plan did not document specific dates and events of accusatory behaviors.A review of the facility's Accident and Incident Report dated 11/23/2025 documented that on 11/23/2025 at approximately 2:00 AM Resident #116 reported to Licensed Practical Nurse # 5 that someone wanted to hurt their arm. Licensed Practical Nurse # 5 reported the allegation to Registered Nurse #2. Registered Nurse # 2 initiated the Accident and Incident report. The Assistant Director of Nursing Services signed for the Director of Nursing Services on 11/24/2025 and notified the New York State Department of Health.A written statement by Licensed Practical Nurse # 5 dated 11/25/2025 documented that during the 11/22/2025 to 11/23/2025 overnight shift, Resident #116 reported that an aide from the previous shift made a statement about breaking the resident's already injured hand. The resident expressed fear regarding this comment. Licensed Practical Nurse # 5 provided assurance of safety and reported the allegation to the Registered Nurse supervisor immediately.A statement from Resident #116, written by the Assistant Director of Nursing Services, dated 11/24/2025 documented that the incident occurred between 3:00 PM to 4:00 PM on Saturday (11/22/2025). Resident #116 stated they had an argument with a person with a red wig whom Resident #116 had seen on the unit before. Resident #116 said something derogatory to this person, and the discussion escalated into an argument. Resident #116 stated that the person grabbed their arm and said, let me break your arm again and see how you like it. Resident #116 did not identify the person by name.The undated investigative summary, written by the Assistant Director of Nursing Services, documented that on the morning of 11/24/2025 they were notified by the Unit Manager/Supervisor that on Sunday 11/23/2025 at approximately 2:00 AM, Resident #116 reported that a short [in stature] Certified Nursing Assistant with a red wig told Resident #116 that they will hurt the resident's arm even more after Resident #116 used slur words towards the Certified Nursing Assistant. Law enforcement and the New York State Department of Health were notified. The alleged perpetrator (Certified Nursing Assistant #6) was removed from the schedule. The facility concluded there was no cause to believe abuse occurred.The Nursing Home Facility Incident Report documented the abuse allegation was submitted to the New York State Department of Health on 11/24/2025 at 4:55 PM.A review of Resident #116's medical record indicated there was no documented evidence about the abuse allegation made by Resident #116.Resident #116 was discharged from the facility on 12/27/2025 and was unavailable for interview and observation.During an interview on 01/15/2026 at 11:17 AM, Licensed Practical Nurse #5, who reported the allegation on 11/23/2025, stated that they reported the allegation made by Resident #116 to Registered Nurse # 2 immediately. Licensed Practical Nurse # 5 stated that they did not recall any details of the incident at this time.During an interview on 01/15/2026 at 12:03 PM, Registered Nurse # 2, who was the nursing supervisor on 11/23/2025 during the night shift (11:00 PM-7:00 AM), stated Licensed Practical Nurse # 5 reported to them (Registered Nurse # 2) of Resident #116's allegation of abuse around 2:00 AM on 11/23/2025. Registered Nurse # 2 stated that they immediately interviewed Resident #116 who stated that a staff member from the previous shift (3:00 PM-11:00 PM) verbally threatened to hurt their (Resident #116) arm after Resident #116 and the staff member got into an argument. Registered Nurse # 2 stated that Resident #116 denied being physically hurt. Registered Nurse # 2 stated that they did not immediately report the incident to the Director of Nursing Services or the Assistant Director of Nursing Services because they were focused on ensuring the resident's wellbeing and that the alleged perpetrator was not assigned to the resident anymore. Registered Nurse # 2 stated that they notified the Assistant Director of Nursing Services on the morning of 11/24/2025 which was more than 24 hours after the allegation was brought to their attention. Registered Nurse # 2 stated they should have reported Resident #116's abuse allegation to the Director of Nursing Services or the Assistant Director of Nursing Services but it went over my head.During an interview on 01/15/2026 at 12:32 PM, Certified Nursing Assistant #6, who was Resident #116's assigned Certified Nursing Assistant on 11/22/2025 during the evening shift (3:00 PM-11:00 PM), stated that they did not get into any argument with Resident #116 during the shift. Certified Nursing Assistant #6 stated Resident #116 did not use derogatory language towards them. Certified Nursing Assistant #6 stated they provided all care to Resident #116 that evening when the resident was in bed and did not encounter the resident in the bathroom at 4:00 PM on 11/22/2025. Certified Nursing Assistant #6 stated that they did not verbally threaten to make resident's injured hand hurt more and they did not physically hurt the resident.During an interview on 01/15/2026 at 01:54 PM, the Assistant Director of Nursing Services stated Registered Nurse # 2 should have immediately notified them or the Director of Nursing Services to seek guidance on how to proceed with the investigation. The Assistant Director of Nursing Services stated they were made aware of the incident on Monday (11/24/2025) morning. The Assistant Director of Nursing Services stated they did not report the incident to New York State Department of Health within two hours because they only needed to report incident that resulted in serious harm within two hours and had four (4) to 24 hours to report any abuse and neglect incident without serious injury. The Assistant Director of Nursing Services stated they were not aware that all alleged abuse must be reported within two hours after the allegation was made.During an interview on 01/15/2026 at 03:01 PM, the Director of Nursing Services stated they were on vacation and were not involved in the reporting and investigating of the incident for Resident #116. The Director of Nursing Services stated that Registered Nurse # 2 should have contacted either the Administrator, the Director of Nursing Services, or the Assistant Director of Nursing Services immediately when the incident was first reported. The Director of Nursing Services stated any abuse or neglect allegation with visible injury must be reported to the New York State Department of Health and law enforcement within an hour and those that did not result in injuries must be reported to the New York State Department of Health within four (4) to 24 hours. The Director of Nursing Services stated they were not aware that all alleged abuse must be reported within two hours after the allegation was made regardless of absence of physical injuries. The Director of Nursing Services stated that they were involved in developing and reviewing the facility's Abuse policy and the policy did not include reporting timeframe requirements for all reportable incidents.During an interview on 01/15/2026 at 03:32 PM, the Administrator stated Resident #116's allegation of abuse should have been reported immediately to the Director of Nursing Services or the Assistant Director of Nursing Services on 11/23/2025 and reported to the New York State Department of Health within two hours after the abuse allegation was made. The Administrator stated that they were involved in developing and reviewing the facility's Abuse policy and the policy did not include reporting timeframe requirements for all reportable incidents. The Administrator stated that the policy should have included the timeframe requirements for all reportable incidents.During an interview on 01/20/2025 at 03:40 PM, the Medical Director stated they were involved in developing and reviewing the facility's Abuse policy. The Medical Director stated that current facility policy on Abuse did not include reporting timeframe requirements for all reportable incidents. The Medical Director stated that they expected all abuse allegations to be reported to the New York State Department of Health immediately but did not know the specific timeframe that was required for abuse allegations or for all other reportable incidents.10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews, the facility did not ensure that a comprehensive person-centered care plan was implemented to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #37) of two (2) residents reviewed for Position and Mobility. Specifically, Resident #37 required use of a pillow for the lower extremities to prevent direct contact of the boney prominences (knees) due to contractures as per the resident's plan of care. On multiple observations, the resident was observed without the use of the pillow in between the knees.The finding is:The facility policy titled Management and Treatment of Pressure Ulcers dated 12/2024 documented interventions to use devices, such as pillows and foam wedges to prevent direct contact between bony prominences and consult with the Physical Therapist for the positioning devices.The facility policy titled Assistive/Adaptive and Preventative/Positioning Devices dated 02/2025 documented a knee separator to be used to prevent knee contractures and maintain skin integrity. The use of preventative/positioning devices will be indicated in the Comprehensive Care Plan and on the Certified Nursing Assistant accountability record.Resident #37 was admitted with diagnoses that included metabolic encephalopathy (brain dysfunction caused by a chemical imbalance leading to confusion, memory problems or coma), major depressive disorder (mood disorder causing sadness, loss of interest and impacts daily functioning), and type 2 diabetes mellitus ( a condition where the body has too much sugar in the blood). The Quarterly Minimum Data Set assessment dated [DATE], documented that Brief Interview for Mental Status score could not be completed as the resident was rarely/never understood. The Quarterly Minimum Data Set assessment documented Resident #37 had limitations in range of motion to their lower extremities bilaterally (both sides). A Comprehensive Care Plan for Activities of Daily Living dated 01/23/2025 last revised on 01/12/2026 documented interventions that included to place a pillow between the lower extremities in and out of bed.The Resident Nursing Instructions (resident care instructions for Certified Nursing Assistant) effective 05/14/2025, documented to place a pillow in between the lower extremities in and out of bed.A rehabilitation screening form dated 12/29/2025 documented Resident #37 had significant bilateral hip and knee contractures.A physical therapist note dated 01/09/2026 documented Resident #37 had severe fixed bilateral lower extremity contractures with limited range of motion. The knee abduction wedge was not tolerated and the Physical Therapist recommended to use a pillow in between the lower extremities.During an observation on 01/13/2026 at 1:15 PM, Resident #37 was in a Geri chair in their room. Both legs were noted to be contracted. There was no pillow or cushion in between the resident's knees. During an observation on 01/15/2026 at 7:34 AM, Resident #37 was in a Geri chair in their room. Both legs were noted to be contracted. There was no pillow or cushion in between the resident's knees. During an observation on 01/16/2026 at 7:40 AM, Resident #37 was in bed. There was no pillow in between the resident's knees, and no pillow was seen lying around the bed or on the floor. During an interview and observation on 01/16/2026 at 09:58 AM, the 7:00 AM-3:00 PM shift Certified Nursing Assistant #1 stated Resident #37 had a habit of pulling the pillow out from their knees. Certified Nursing Assistant #1 stated they would replace the pillow and would notify the nurses about the resident's behavior. Certified Nursing Assistant #1 then went into Resident #37's room. The resident was observed in bed with no pillow in between their legs. Certified Nursing Assistant #1 stated they checked the resident this morning during their morning rounds and thought the pillow was placed in between the resident's legs.During an interview on 01/16/2026 at 10:06 AM, Registered Nurse Unit Manager #1 stated they knew that Resident #37 had a behavior of pulling the pillow out. Registered Nurse Unit Manager #1 stated they did not document the resident's behavior and did not update the resident's care plan.During an interview on 01/20/2026 at 12:24 PM, the Director of Nursing Services stated the resident's plan of care should have been followed. The use of the pillow for Resident #37 was for comfort and to prevent the contracted knees from rubbing together and causing a pressure ulcer. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews, the facility did not ensure the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #84) of two (2) residents reviewed for Nutrition. Specifically, on 12/11/2025, Registered Dietitian #1 documented Resident #84 as having a weight loss of 5.4 pounds in one-month (a 4.5% decrease in the resident's usual body weight) and recommended weekly weights for four (4) weeks to further assess the accuracy of the resident's weight trends. On 12/15/2025, Registered Dietitian #1 documented Resident #84 triggered for an undesired significant weight loss (5% in one month). The weekly weights were not completed as per the recommendations, and no new dietary interventions were put in place. On 1/16/2026, Resident #84's weight reflected an additional loss of 4 pounds (3.57%) in one month and an undesired significant weight loss of 10.2% in 3 months. The finding is: The facility's policy titled, Significant Weight Change, last reviewed 11/25/2025, documented the Clinical/Registered Dietitian will track and evaluate resident weights on a monthly basis. All residents with a significant weight change greater than 5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months will be reviewed by the Clinical/Registered Dietitian. The Clinical/Registered Dietitian will use clinical judgement with assessing weight loss and may, including, but not limited to, monitor weekly weights and follow up with all interventions/recommendations as needed. Resident #84 had diagnoses that included hypertension (abnormally high blood pressure) and type 2 diabetes mellitus (a form of diabetes mellitus characterized by high blood sugar, insulin resistance, and lack of insulin). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making with long and short term memory problems. The Minimum Data Set documented the resident's height was 63 inches and the weight was 121 pounds. The resident had no weight loss of 5% or more in the last month or a loss of 10% of more in the last six (6) months and was not on a physician-prescribed weight-loss regimen. The Physician's Order dated 07/03/2024 and last renewed on 01/19/2026 documented for the resident to receive a no added salt, low concentrated sweets diet and a thin liquid consistency.The Physician's Order dated 07/11/2024 and last renewed on 01/19/2026 documented for the resident to receive mechanical soft food consistency.The Physician's Order dated 09/05/2025 and last renewed on 12/22/2025 documented for the resident to receive Boost Glucose Control 0.07 gram-0.8 kilocalorie/milliliter oral liquid (a nutritional supplement) 240 milliliters by oral route once daily. This order was discontinued on 01/16/2026.The Dietary Progress Note dated 12/11/2025, written by Registered Dietitian #1, documented: Resident noted with a 5.4 pounds decrease in weight in one month (4.5% change in usual body weight). The 12/11/2025 weight was 112.8 pounds. The recent weight trends were as follows: 06/2025 weight: 120.2 pounds, 09/05/2025 weight: 121 pounds, and 11/07/2025 weight: 118.2 pounds. Registered Dietitian #1 recommended weekly weights for four (4) weeks to further assess accuracy of the weights.The Comprehensive Care Plan entitled Nutritional Status, initiated on 07/05/2024, documented as an intervention including obtaining weekly weights for four (4) weeks. The weekly weight intervention was initiated on 12/11/2025.The Dietary Progress Note dated 12/15/2025, written by Registered Dietitian #1, documented: Weekly weight available (today) of 112.2 pounds. Consistent with monthly weight of 112.8 pounds taken on 12/11/2025. The resident triggered for a significant weight loss (5%) this month and weekly weights were in progress. Review of the Weight Monitoring in the electronic medical record on 01/16/2026 at 11:25 AM revealed no documented evidence of the resident being weighed since 12/15/2025.During an interview on 01/16/2025 at 11:40 AM, Registered Dietitian #1 stated the last weight they had gotten for the resident was 104 pounds on 12/29/2025 which they had not entered into the resident's electronic medical record because it had been over an eight (8) pound weight loss since the resident's last weight of 112.2 pounds taken on 12/15/2025. Registered Dietitian #1 stated before they documented the resident's weight in the electronic medical record, they requested a reweight from Registered Nurse #2; however, the weight was never obtained. During an observation on 01/16/2026 at 11:45 AM Registered Nurse #2 and Certified Nursing Assistant #3 weighed Resident #84. The resident's weight was recorded as108.2 pounds. During an interview on 01/16/2026 at 1:00 PM, Registered Dietitian #1 stated they were not aware if the facility had a policy to address significant weight loss. Registered Dietitian #1 stated if a resident on their unit had a significant weight loss, they would verbally tell the Registered Nurse Unit Managers about the weight loss and also discuss it in morning report. Registered Dietitian #1 stated they could not recall if they had discussed Resident #84's significant weight loss in morning report. They had requested the weekly weights for Resident #84 from Registered Nurse #2; however, the weekly weights were not completed. Registered Dietician #1 stated they did not notify the Physician of Resident #84's significant weight loss because they were waiting for the resident to be reweighed. During an interview on 01/16/2026 at 2:50 PM, Registered Nurse #2 stated they were aware the resident was supposed to be weighed weekly. Registered Nurse #2 stated Registered Dietitian #1 requested the resident to be reweighed; however, the resident was not reweighed because the nursing unit staff did not obtain the weight. Registered Nurse #2 stated the nursing staff should have obtained the resident's weekly weight and reweighed the resident when requested by the Dietician. Registered Nurse #2 stated they were not aware that the resident had a significant weight loss, otherwise they would have notified the Physician of the weight loss for further interventions and work up. The Physician's Order dated 01/16/2026, written by Physician Assistant #1, documented to increase Boost Glucose Control 0.07 gram-0.8 kilocalorie/milliliter oral liquid (a nutritional supplement) to 240 milliliters by oral route two (2) times per day for unspecified protein-calorie malnutrition.During an interview on 01/20/2026 at 1:05 PM, the Medical Director stated when a resident has a significant weight loss, the resident's Primary Physician/Medical Provider should be notified by the Registered Dietitian or the Unit Nurse. The Primary Physician/Medical Provider would assess the resident, review the resident's weight trend, consider ordering oral nutritional supplementation, and possibly order a calorie count. During an interview on 01/20/2026 at 4:05 PM, the Director of Nursing Services stated Registered Dietitian #1 should have reported difficulties obtaining the resident's weekly weights. The Director of Nursing Services stated weights should be obtained the same day they were requested. The Director of Nursing Services stated once a month a Weight Loss Meeting is held to determine the cause of the residents' weight loss and the residents' Physicians are notified to see if they want to order any blood work for the resident and order weekly weights if appropriate. The monthly weight loss meeting was not conducted in December 2025, because they were on vacation. The Director of Nursing Services stated Registered Dietitian #1 had only been working at the facility for a few weeks and were not informed about the monthly Weight Loss Meeting. The Director of Nursing Services stated the facility did have a policy addressing Significant Weight Changes and was unsure why Registered Dietitian #1 was not aware of that. 10 NYCRR 415.12(i)(1)

Based on observations, record review, and interviews the facility did not ensure that parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (1) (Resident #117) of one (1) resident reviewed for Antibiotics. Specifically, Resident #117 had a physician's order to infuse Ceftriaxone (antibiotic) medication; however, the route of infusion was not specified in the order. During multiple occasions, Resident #117 was observed with a Peripheral Intravenous Catheter in their left hand. There was no physician's order for the assessment and care of the intravenous catheter.The finding is: The facility policy titled initiation and management of intravenous therapy revised on 10/2025 documented a valid order from a licensed practitioner for Intravenous fluids authorizes nursing staff to initiate peripheral access as necessary to carry out the prescribed treatment. A separate order for peripheral intravenous insertion is not required, unless otherwise specified by facility policy or the type of vascular access. Resident #117 was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and dementia. The Minimum Data Set assessment documented the resident had severely impaired cognition. The Minimum Data Set was not completed and did not include information regarding intravenous antibiotic use as the resident was recently admitted to the facility. The care plan for Urinary Tract Infection dated 01/12/2026 documented interventions including to administer medications as ordered, maintain infection control practices through proper handwashing, monitor for signs and symptoms of side effects of antibiotics. The physician's order initiated on 01/12/2026 documented Ceftriaxone 1Gram /100 milliliter normal saline, infuse 1 gram once daily every day at 9:00 AM for seven (7) Days for Urinary tract infection. The order did not include the route of the medication administration. A review of the medical record revealed there were no physician orders and documentation that care and monitoring for signs and symptoms of infection of the intravenous site was provided. During the screening observation on 1/13/2026 approximately 11:00 AM, the resident was in their bed with an intravenous catheter in the left forearm. There was no medication being infused via the intravenous catheter.During an observation on 1/14/2025 at approximately 9:00 AM, Resident #117 was observed in bed with an intravenous catheter in their right arm. The resident was receiving an intravenous antibiotic medication. During the interview on 01/15/2026 at 08:23 AM, Licensed Practical Nurse#3 stated that all intravenous medications must have order for intravenous line access. Licensed Practical Nurse #3 stated the Registered Nurse supervisor was responsible for entering the physician's order and inserting intravenous access sites. Licensed Practical Nurse#3 stated they did not realize there were no physician orders for flushing the Intravenous line and monitoring the site for signs and symptoms of infection. Licensed Practical Nurse#3 stated they flush all intravenous lines sites before and after they administer the medications to make sure the Intravenous line is patent and functioning. During an interview on 01/15/2026 at 08:33 AM, Registered Nurse Unit Manager#3 stated residents who receive intravenous medications must have a physician's order for inserting the intravenous access line, flushing the line with normal saline, and to check the site for signs and symptoms of infection. Registered Nurse Unit Manager#3 stated they did not realize there were no physician orders for the insertion of the intravenous line access and its maintenance. Registered Nurse Unit Manager#3 stated it was the admission Nurse and the Unit Manager's responsibility to enter the physician's orders in the resident's medical record. During an interview on 01/15/2026 at 09:54 AM, Registered Nurse Supervisor #4 stated on 01/12/2026 they completed the admission assessment for Resident #117. Registered Nurse Supervisor #4 stated they reviewed the hospital discharge medications and obtained the physician's orders from Physician Assistant #1. Resident #117 required Intravenous antibiotic infusion for a Urinary Tract Infection. Registered Nurse Supervisor #4 stated they inserted the intravenous line access, flushed the line with normal saline to maintain the patency, and monitored the intravenous site for skin integrity but they forgot to initiate the orders on 01/12/2026. During an interview on 01/15/2026 at 10:15 AM, Physician Assistant #1 stated the admission nurse called them on the night of 01/12/2026 and reviewed Resident #117's hospital discharge medications. Physician Assistant #1 stated there was no need for separate orders for the insertion of the intravenous line access or routine care and monitoring because it is implied, and the nurses automatically know that it should be done. Physician Assistant #1 stated the initiation of the intravenous line is the nurses' responsibility and they assume that nurses know to flush and monitor the intravenous line. During an interview on 01/20/2026 at 11:36 AM, the Medical Director stated the physician's order for intravenous infusion of antibiotics implies that there is an intravenous access line; therefore, there is no need for a separate physician's order to insert the intravenous access line. The Medical Director stated the intravenous line should be flushed with normal saline to maintain the patency and integrity of the line. The intravenous line site should be monitored for signs and symptoms of infection and infiltration. The Medical Director stated they assumed the nurses were doing the care without a physician's order and there was no need for physician orders. The Medical Director stated they were not aware of the regulatory requirements for parenteral fluids. During an interview on 01/20/2026 at 12:34 PM, the Director of Nursing Services stated separate physician's orders for intravenous line access, flushing the line with normal saline and monitoring the site for signs and symptoms of infection are not needed because the tasks should be included in the physician's order for intravenous medication. The Director of Nursing Services stated the facility's policy indicated that the nursing staff do not need a physician's order for intravenous line access. 10 NYCRR 415.12(k)(2)

Based on interviews and record review, the facility did not ensure that residents were assisted in obtaining routine Dental Care. This was identified for one (1) (Resident #5) of one (1) resident reviewed for dental care. Specifically, Resident #5 was not seen by a Dentist since their admission to the facility in June 2024. The finding is:The facility's policy titled, Dental Services, last reviewed 10/2025, documented residents will be seen and evaluated by the Dentist upon admission, annually, as requested by the resident and/or representative, and as needed with a significant change of condition. The policy did not state if a physician's order was required for a resident to be seen by a Dentist.Resident #5 had diagnoses which included hypertension (abnormally high blood pressure) and type 2 diabetes mellitus (a form of diabetes mellitus characterized by high blood sugar, insulin resistance, and lack of insulin). The 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision making. The resident had no broken or loose fitting full or partial denture and no mouth or facial pain, discomfort, or difficulty with chewing.During an interview on 01/13/2026 at 11:15 AM, Resident #5 stated they had dentures in the community. Resident #5 stated when they came to the facility, they did not have their upper and lower dentures, and they were never seen by a Dentist since being admitted to the facility. Resident #5 stated they would like to have their dentures replaced.A review of the resident's medical record revealed no documented evidence that the resident was ever seen by a Dentist.The physician's order dated 01/16/2026 documented for the resident to have a Dental Consultation in house, as needed.During an interview on 01/20/2026 at 11:35 AM, the Assistant Director of Nursing Services stated they did not know why Resident #5 was never seen by a Dentist since being admitted to the facility. The Assistant Director of Nursing Services stated the resident was originally admitted to the facility as a short-term rehabilitation resident and then became a long-term care resident at which time the resident should have been seen by a Dentist. During an interview on 01/20/2026 at 1:20 PM, Registered Nurse #2 stated all consultations, including consultations by the Dentist, require a physician's order. Registered Nurse #2 stated they had obtained a physician's order on 01/16/2026 when they realized the resident was never seen by a Dentist. Registered Nurse #2 stated they keep a list to keep track of when each resident's annual Dental examination is due; however, Resident #5 was not on their list because they were never seen by a Dentist. During an interview on 01/20/2026 at 3:50 PM, the Medical Director stated a physician's order is required for a dental consult and that should have been documented in the facility's Dental Policy. During an interview on 01/20/2026 at 4:20 PM, the Director of Nursing Services stated that Resident #5 was never seen by a Dentist, and it was an oversight. The Director of Nursing Services stated they will reevaluate the facility's Dental policy to address the need for a physician's order for a dental consultation.10 NYCRR 415.17(a-d)

Based on observation, record review, and interviews the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (1) (Resident #88) of six (6) residents reviewed for Medication Administration Task. Specifically, during the medication administration task, Licensed Practical Nurse #1 removed a calcium /vitamin D3 tablet (vitamin supplement) from a blister pack with their bare hands. Licensed Practical Nurse #1 broke the tablet in half and put the two halves of the tablet in the souffle cup and proceeded to offer the medication to Resident #88.The finding is:The facility policy titled Medication Administration last reviewed/revised 12/2025, documented pills should not be handled with fingers. Pour directly from blister packs into souffle cup.Resident #88 was admitted with diagnoses that included Parkinson's disease (a progressive brain disorder that damages neurons leading to problems with movement), congestive heart failure (the heart muscle does not pump blood effectively), and dementia (decline in mental abilities). The Quarterly Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment.A physician's order dated 07/11/2025 and last renewed on 12/10/2025 documented calcium 315 milligram/vitamin D3 6.25 microgram tablet, give one tablet by oral route once daily for deficiency in vitamins.During an observation of the Medication Administration Task on 01/15/2026 at 8:50 AM, Licensed Practical Nurse #1 removed the calcium 315 milligram-vitamin D3, 6.25 microgram tablet, from the blister pack with their bare hands. Licensed Practical Nurse #1 then broke the tablet in half and placed the two halves in a souffle cup. Licensed Practical Nurse #1 then proceeded to administer the same medication to Resident #88. During an interview on 01/15/2026 at 8:53 AM, Licensed Practical Nurse #1 stated they should have put on gloves and should not have touched the medication tablet with bare hands. Licensed Practical Nurse #1 stated the calcium tablet was a large pill and not easy to swallow so they wanted to break the tablet in half to make it easy for the resident to swallow.During an interview on 01/15/2026 at 9:14 AM, Registered Nurse Unit Manager #1 stated the medication nurse should not have handled any medications with bare hands. If they needed to break or crush a medication, they should have put on gloves or put the tablet in a tablet bag to crush the medication. Registered Nurse Unit Manager #1 stated that handling medications with bare hands is an infection control concern.During an interview on 01/15/2026 at 2:58 PM, the Director of Nursing Services stated the nurses should wear gloves when handling medications. The Director of Nursing Services stated to prevent contamination and spread of infections; the nurses must not handle the medication tablets with their bare hands.10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and interviews the facility did not ensure call systems were accessible to each resident while residents were in their rooms. This was identified for one (1) (Resident #57) of one (1) resident reviewed for call systems. Specifically, during multiple observations, Resident #57 was observed in bed, and the call bell was out of their reach.The finding is:The facility policy titled Call Bells last revised on 12/2025, documented to have a call bell at the bedside within reach. The purpose of the call bell is to provide the resident with a method of communication to assist in meeting needs in a timely manner.Resident #57 was admitted with diagnoses that included cerebral infarction (brain tissue dies due to lack of blood, oxygen, and nutrients), dementia (a decline in thinking skills due to damaged blood vessels in the brain), and epilepsy (a neurological disorder that causes seizures, loss of consciousness and unusual behavior). Minimum Data Set assessment dated [DATE], documented that a Brief Interview for Mental Status score could not be completed as the resident was rarely/never understood. The Minimum Data Set assessment documented Resident #57 was dependent on staff for activities of daily living.The Comprehensive Care Plan, titled Falls: at risk for falls, dated 04/11/2022, and last reviewed and revised 12/15/2025, documented interventions that included to place the call bell within reach at all times.During an observation on 01/13/2026 at 10:11 AM, Resident #57 was observed in their room, in bed sleeping. The call bell was observed hanging on the wall and was out of the resident's reach.During an observation on and on 01/13/2026 at 1:08 PM, Resident #57 was observed in their room, in bed resting. The call bell was observed hanging on the wall and was out of the resident's reach.During an observation on 01/20/2026 at 7:01 AM, Resident #57 was observed in their room, in bed awake. The resident was not interviewable. The call bell was observed on the floor, behind the nights stand, and was out of the resident's reach. During an interview and observation on 01/20/2026 at 7:06 AM, Licensed Practical Nurse #2 stated the call bell should be within the resident's reach. The Certified Nursing Assistants should check on the placement when they are doing their rounds. Licensed Practical Nurse #2 stated Resident #57 could use the call bell to call for assistance. Resident #57's call bell was observed on the floor, behind the nightstand. Licensed Practical Nurse #2 picked up the call bell, wiped it clean, and clipped the call bell onto the bed cover, within the resident's reach.During an interview on 01/20/2026 at 7:10 AM, Registered Nurse Unit Manager #1 stated the Certified Nursing Assistants, and the nurses were responsible to ensure the call bell is within reach of the resident. The 11:00 PM-7:00 AM shift Certified Nursing Assistants should have made rounds before leaving this morning and should have seen the call bell was out of reach. During an interview on 01/20/2026 at 12:26 PM the Director of Nursing Services stated the Certified Nursing Assistants, Licensed Practical Nurses, and the Nurse Supervisors are responsible to ensure that each resident has a call bell within reach to ensure that the resident could call staff for assistance. 10 NYCRR 415.29

Based on observations, record review, and staff interviews during the Abbreviated Survey case #NY00368340 and initiated on 1/15/2025, the facility did not ensure that residents have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely, including that the physical layout of the facility maximizes resident independence and does not create a safety risk. This was identified for 8 of 18 residents reviewed for Quality of Care. Specifically, a complaint was received reporting that the East unit of the facility was freezing cold affecting all the residents on that unit. The finding is: The facility's policy titled; 'Cold Weather Emergency' updated 1/16/2025 documented under Plan A Residents are to be checked and temperatures are to be taken immediately on all residents. All rooms are to have adequate supply of blankets. If temperatures are below 70 degrees Fahrenheit resident's temperatures will be taken every four hours. An observation tour was conducted on 1/15/2025 at 10:45 AM on the East and [NAME] unit. Multiple residents were observed in their beds, some residents were covering with four blankets. Electrical space heaters were noted in 5 resident's room. Residents were sitting in the hallway wearing thick robes, sweatshirts with hoods on their heads. During an interview with Resident #8 on 1/15/2025 at 2:39 PM they stated they have Arthritis, and they are always cold. Resident #8 stated their legs stiffens up and makes it difficult for them to go to Physical Therapy. During an interview with Resident #2 on 1/15/2025 at 10:48 AM, they stated staff will not turn up the heat when they complain about being cold. The resident also stated they believe the heat goes off at nights because it gets so much colder. Resident #2 stated they do not eat in the main dining area because it's too cold and they would rather eat in their room, which is also cold but not as cold of the dining room. During an interview with Resident #10 on 1/15/2025 at 3:01 PM they stated they shiver until they fall asleep at night. They also stated that they put boxes in front of their bedroom window to prevent the draft at night when they are in bed. Resident #10 stated that it is cold all day but worse at night. During an interview with Resident #11 on 1/15/2025 at 3:10 PM they stated they spoke to the Administrator, (does not recall their name), about being cold. The Resident stated they have Bronchitis and Arthritis, and the cold affects their legs and makes it difficult in Physical Therapy. The resident stated that the Administrator brought a space heater in their room. Resident #11 stated even with the space heater they are still cold. The facility did not have documented evidence they had identified that resident's room temperatures were at a safe and comfortable range. The facility could not provide any documentation that room temperatures were monitored to ensure comfortability. During an interview on 1/16/25 at 1:54 PM the Director of Maintenance stated that the windows in some of the rooms caused drafts in the winter. The Director of Maintenance further stated that plastics are placed over the windows to seal and prevent draft. The Director of Maintenance acknowledged that residents still complained of lack of heat and those residents were provided with space heaters. The Director of Maintenance also stated that the East and North Units have an older heating system and need repairs. The repairs are expensive and will take a long time. During an interview with the Administrator on 1/16/2025 at 4:48 PM and 5:42 PM they stated that they were not aware that there were room temperatures below 70 degrees. They stated that when residents complained that they were cold they were offered space heaters and room changes. The Administrator stated that they were not aware that the heating units in some rooms were not radiating heat. During an interview with Registered Nurse #2 on 1/15/2025 at 5:05 PM they stated some of the residents complained of being cold at night. Registered Nurse #2 stated that sometimes they would set up a space heater at the nursing station and have the residents gather around the heater and close the double doors to the unit to try to keep the unit warm. Registered Nurse #2 stated they told Maintenance regarding the issues with the heat. 10 NYCRR 483.10 (i)(1)

S483.90 The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. (d) Space and equipment. The facility must (2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. (b) Equipment. The nursing home shall maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. (j) Housekeeping. (1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but limited to buildings, utilities, fixed equipment, resident care equipment and furnishings. Based on observations, interviews, and record review conducted during the Abbreviated Survey (Complaint NY00368340), the facility failed to maintain their heating system in proper working conditions and to adequately maintain the residents' rooms windows to provide a healthy, functional, and comfortable environment for residents, personnel and the public in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29. Specifically: 1.Hot water coil heating system in several resident rooms and a shower room were not delivering heat. 2.Portable heating units were observed in use in some resident rooms. 3.Three out of four resident's shower rooms were not provided with any type of heating system. 4.Residents rooms' windows were not properly maintained to prevent air drafts. 5.There was no maintenance system in place to ensure that the building and utilities were maintained in good repair and safe operating condition to protect the health and safety of residents, personnel and the public. This resulted in causing temperatures in residents' rooms, shower rooms and common areas in three of three nursing units to fall below the required range. The findings are: On 01/16/2025, from approximately 10:00 AM to 12:30 PM, and again from 3:45 PM to 4:30 PM temperatures observed in resident rooms, shower rooms, corridors, and staff and visitor restrooms were below State and Federal required ranges. Temperatures at resident rooms in the East and North units were observed between 63 - 69 degrees Fahrenheit. Temperatures in the shower rooms in East, [NAME] and North units were 64 - 65 degrees Fahrenheit. Temperature in the rehabilitation gym was at 67.1 degrees Fahrenheit, dining/activities room was 66 degrees Fahrenheit. Corridors in the North unit at 65 degrees Fahrenheit. In addition, some residents' rooms were observed with air drafts coming from windows and heating coil units not working at all or not working properly to maintain the temperature at required levels. Observations included, but not limited to the following: East unit: -room [ROOM NUMBER]: Temperature 69 -70 F. observed with bottom window frame covered with a towel and a portable heater in use. -room [ROOM NUMBER]: Temperature range 63 - 65 F. Residents' window observed covered with plastic and blue tape around the edges. Air draft felt coming from the window opening. A portable heater observed in use. -room [ROOM NUMBER]: observed with plastic cover outside the window and a portable heater in use. -room [ROOM NUMBER]: temperature 68 F. The Director of Maintenance(DOM), who was present at the time of observation stated that the unit needs the motor changed, they don't remember the last time the motor was changed and that everything is done in house. -room [ROOM NUMBER]: window covered with towels. -room [ROOM NUMBER]: 67.4 F. -room [ROOM NUMBER]: 66 F, heat not blowing off from the unit. -room [ROOM NUMBER]: 68. 2 F. -room [ROOM NUMBER]: temperature 70 F - 71.4 F and 70.3 - 69.8 F towels observed in the windows, draft coming from the windows gaskets. -room [ROOM NUMBER]: 70 F, windows covered with plastic. -Shower room: 64.9 F. There is no heating system installed. North unit: -room [ROOM NUMBER]: Room at 70.9 F. Toilet observed at 53 F. -room [ROOM NUMBER]: 63.5 F. Air draft coming from the window. A portable heater observed in use. The heating coil unit observed covered with resident's clothes, and the other unit observed shut off. -room [ROOM NUMBER]: A portable heater observed in use in 44A, the temperature registered at 74 F, and in 44B the temperature registered at 69 F, the resident on side 44 B stated that they like the room to be cold. -room [ROOM NUMBER]: 69 - 70 F, window covered with plastic. -room [ROOM NUMBER]: 67 F. Unit not working properly. The DOM stated that the unit needs motor replacement. -room [ROOM NUMBER]: 67F. Heating coil unit observed to be off. -room [ROOM NUMBER]: 66 F. Heating coil unit's motor in disrepair. - Shower room: 64 F. Heating coil unit not working. The DOM stated that they will replace the motor of the unit. -Corridor 64.9 F - 67.1. West Unit -Shower room [ROOM NUMBER] - 65.9 F. -Shower room [ROOM NUMBER] - 61.7 F The DOM stated that there is no heat system in the above shower rooms. Common Areas: -Rehab gym: 67.1 F - Activities room/dining room: 66 - 67 F. Air draft coming from the bottom of the heating coil units. The DOM stated that they can close the bottom of the heating coil units. -The staff restroom located by the lobby: 44 F. -The visitors' restroom: 42F. On 01/16/25 at approximately 12:15 PM, the Director of Maintenance (DOM) was interviewed and stated the following: -They were not aware that the resident rooms and common areas were below regulatory temperature ranges. -They have not received any complaints from residents or staff. -They do not take air temperatures every day. -The heating system for the East and North units comes from the boiler to the heating coil units in resident rooms, and in corridors is through air handlers. -The heating system at the facility in the East and North units has not been changed since they began working at the facility in 2013. -They changed the motor of the unit that provides heat to the corridor in the North Unit about a year ago. Further stating that the motor usually last 3 - 4 years. -Residents can shut on / off the heating coil units by themselves. -Residents can open the windows by themselves. -They do not do frequent windows checks; they check the windows on as needed basis and check to see if the windows are cracked or broken. -There is no heating system in the showers rooms of the [NAME] and North units. -They do not have a regular maintenance schedule, and everything is done on as a needed basis. -Environmental rounds are done once per month, and they are done to check what is wrong or not working, but they do not document it. -They have put plastic covers on some resident room's windows to prevent the air drafts, and that they have replaced the motor in some of the coil heating units. On, 01/16/25 at approximately 12:53 PM, the Administrator stated that they did provide portable space heaters to residents that request it to make them more comfortable, not because there were any issues with the heating system, and did not know that there was a problem with the heating system, The Administrator further stated that they have not received any complaints from residents; some residents like to have the heat off and some other residents open the windows; that are residents that like to have their rooms colder and others warmer. On 01/16/25 at approximately 4:30 PM, the Director of Maintenance (DOM) stated that they will check the windows for air drafts and will cover them with plastic from the outside, will continue to replace the motors in the malfunctioning coil heating units, and will take a look at the options to install heat in residents' shower rooms. Further stating that all repairs will be done in house as they do have available parts for the heating coil units in the basement. On 01/16/25 at approximately 5:45 PM, document review of the temperature logs, revealed that air temperatures were only taken in two separate instances, both related to heating complaints made to the Department of Health. First instance, intake NY00362610, temperatures taken only on 12/01/2024 - 12/03/2024 - 12/04/24- 12/05/24 records temperatures range at 71.2 -78 F. And, second instance, intake NY00368340, the DOM provided the logs for temperatures taken on 01/10/25 -1/13/25 - 1/14/25 records temperatures range at 72.2 - 77.1 F. The DOM stated that they don't have a temperature policy, and that is something that they are going to incorporate, in addition to take daily air temperatures and create an air temperature log. On, 01/17/25 at approximately 10:05 AM, the Director of Maintenance stated that the plumbing company was scheduled to be at the facility that day in the afternoon to check on the heating system; residents from some of the affected rooms were moved to another rooms, and for the residents that stayed in their rooms extra blankets were provided, the windows were covered with plastic on both sides , further stating that they will check for air draft in windows, will caulk them and strip from outside; they will try to do the repairs in house, and if not possible will outsourced. And that they will install split units or electric ceiling panel heaters in the shower rooms. Further stating that the motor in the heating coil unit in room [ROOM NUMBER] was already replaced. On 01/17/25 at approximately 2:30 PM, the Administrator stated that they are doing repairs to the heating coil units, insulating windows, replacing motors, making sure there is no obstructions on the heating coil unit; they reached out to a boiler vendor to look at the heating system to see why this particular rooms are not working. He stated that believes the HVAC system is checked quarterly for the whole facility, and that there has to be a log on maintenance, and that there are no maintenance logs for the windows. He stated that they can call on the same day to install duct less heat units on the residents' showers. On 01/17/25, at approximately 2:50 PM, the DOM, provided a HVAC service log dated 10/05, 10/06, 1/23, and 6/3,the logs did not include the year, the DOM stated that it was from last year. The logs indicate locations on the [NAME] unit, but did not record anything on the East and North units. No other maintenance records were provided to indicate regular inspection and maintenance of the facility's heating system for all three nursing units. On 01/17/25, at approximately 5:07 PM, document review of the facility's work orders provided from 10/02/24 to 01/13/25, specifies that the heat was put on 11/8/24, no additional information contained within the document specifies the check and maintenance of heating coil units in resident rooms or residents' rooms' windows checks. On 01/31/25, at approximately 10:45 AM, document review of the facility's policy named Cold Weather Emergency, with an updated date 01/16/25. The policy states that a Plan A will be established for any room where the temperature drops below 70 F. And a Plan B if the temperature drops below 60 F. Plan A states the following actions for Housekeeping staff: The department will check all windows for drafts. Curtains or drapes will be drawn to minimize drafts and air flow. Sealing of air leaks will be called to the attention of the Maintenance Department. And, for Maintenance staff: The department staff will check all heating units for maximum productivity on notification of air leaks in or around windows or doors, sealant will be used by the maintenance department of effectuate stoppage. The room will be temperature-checked on a one-hour basis. Under Departmental Responsibilities Under Both Plans: Housekeeping must go to each room to check all windows and drapers are closed tightly and drafts sealed. Maintenance Department is to check units to ascertain that all systems are functioning adequately, each heating unit is to be checked individually throughout the building. The policy did not indicate how temperatures should be taken and documented. On 01/31/25, at approximately 11:25 AM, document review of the Plumbing, Heating and Cooling vendors invoice dated 01/20/25 detailed a service call, but no scope of the work provided and or needed to the heating system was included. In addition, no manufacture specifications for the coil heating units were provided for review. S483.90(d) (2) 415.29(b), (j) (1)

Based on observations, interviews, and record review during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not ensure each resident was served food and drink that was palatable, attractive, and at a safe and appetizing temperature. This was identified for ten (Resident #9, Resident #10, Resident # 14, Resident # 39, Resident #50, Resident #72, Resident #77, Resident #91, Resident #94, and Resident #103) of eleven residents during the Resident Council meeting; one (Resident #102) of four residents reviewed for food, and one (Resident #48) of sixteen residents reviewed during the dining task. Specifically, during the resident council meeting held on 10/28/2024 ten of eleven residents in attendance complained the hot meals were served cold. On 10/30/2024 during the lunch meal service observations, the lunch meal temperatures for the hot food items were observed to be below 135 degrees Fahrenheit. The finding is: The undated facility policy titled Food Temperatures documented temperatures of all food items will be taken and properly recorded prior to service each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items may not fall below 135 degrees Fahrenheit after cooking unless it is an item that is to be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit prior to serving. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures such as hot or cold carts, pellet systems, insulated plate bases, domes, etc. Food sent to the units for distribution will be transported and delivered to the unit storage areas to maintain temperatures at or above 135 degrees Fahrenheit for hot foods. Resident #102 was admitted with diagnoses that included status post left hip Periprosthetic Fracture (around the internal prosthetic). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #48 was admitted with diagnoses including a Left Clavicle (the collar bone) Fracture, Type 2 Diabetes Mellitus, and Protein-Calorie Malnutrition. The Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. The Resident Council meeting was conducted on 10/28/2024 at 11:15 AM. Ten of eleven residents during the group interview complained that they were served cold food during meals that should have been served hot. A review of the Resident Council minutes from 4/2024 to 10/2024 revealed during the Resident Council meeting on 5/2024 there was a concern with meal trucks arriving on the units and the staff not handing out meal trays. No concerns were documented in the Resident Council minutes regarding hot foods that were served cold during meals. During an interview on 10/28/2024 at 11:31 AM, Resident #48 stated the hot foods were served cold and that the food was lousy. During an interview on 10/28/2024 at 11:05 AM, Resident #102 stated they received cold food that should have been served hot during meals. On 10/30/2024 during the lunch meal service, three test trays were requested for three of three units in the facility (Unit North, Unit East, and Unit West): The last unit meal truck of two meal trucks for Unit [NAME] arrived on the unit at 12:20 PM. The last meal tray was observed to be served at 12:30 PM. The test tray temperatures were taken at 12:20 PM in the presence of the Dietician. The temperature readings for both the vegetables and noodles were 122 degrees Fahrenheit. The last lunch meal truck of two meal trucks for Unit East arrived on the unit at 12:29 PM. The last meal tray was served at 12:44 PM. The test tray temperatures were taken at 12:44 PM in the presence of Licensed Practical Nurse #3. The temperature readings for both the noodles and the carrots were 113 degrees Fahrenheit, and the temperature reading for the Chicken meal was 128 degrees Fahrenheit. The lunch meal truck for Unit North arrived on the unit at 12:35 PM. The last meal tray was served at 12:41 PM. The test tray food temperatures were taken at 12:41 PM in the presence of the Dietician. The temperature reading for carrots was 115 degrees Fahrenheit, and the temperature reading for the noodles was 95 degrees Fahrenheit. During an interview on 11/1/2024 at 9:28 AM, the Ombudsman stated the residents had complained about cold food for about two or three months during the Resident Council meetings and they spoke with the Director of Recreation to determine if there was a plan to address the residents' concerns. The Ombudsman stated the Director of Recreation told them they (the Director of Recreation) would speak with the Director of Nursing Services regarding the concerns. The Ombudsman did not realize the residents' concerns regarding the food temperatures were not included in the Resident Council minutes because they did not request or receive a copy of the Resident Council minutes. During an interview on 11/1/2024 at 3:55 PM, the Food Service Director stated they knew the Resident Council's concerns about hot meals being served cold. The Food Service Director stated they monitor the hot food temperatures on the tray line in the kitchen for every meal; however, the food temperatures were not monitored on the units during meals. The meal temperature concern was discussed during the morning meetings with the administrative staff (Department Heads). The Food Service Director stated they brought up helpful solutions during these morning meetings such as closed, insulated food trucks and a pellet system but nothing was done. The Food Service Director stated they could not recall the last time Quality Assurance was completed regarding food temperatures. During an interview on 11/1/2024 at 4:04 PM, the Director of Recreation stated they attended Resident Council meetings and were responsible for recording the meeting minutes. The cold food concern was discussed during the Resident Council meetings for the past three months. The Director of Recreation stated this concern should have been documented in the Resident Council minutes. During an interview on 11/1/2024 at 4:14 PM, the Dietician stated they were aware of the residents' concern regarding receiving hot food at cold temperatures during meal services. The Dietician stated they recommended distributing meal trays before distributing coffee to shorten the distribution time. The Dietician stated they also recommended utilizing methods such as insulated food trucks or a pellet system as these would be helpful to maintain hot food temperatures of at least 135 degrees Fahrenheit; however, these recommendations were never implemented. During an interview on 11/1/2024 at 4:19 PM, the Director of Nursing Services stated they were aware of the Resident Council members' concerns related to hot food items being served cold. This concern was also discussed during morning meetings. The Director of Nursing Services stated they completed multiple observations of the nursing staff during breakfast and lunch meals on different units and they did not identify concerns regarding the length of time the staff distributes meal trays on the units. 415.14(d)(1)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not distribute and serve food in accordance with professional standards for food service safety. This was identified during the kitchen facility task; for ten (Resident #9, Resident #10, Resident # 14, Resident # 39, Resident #50, Resident #72, Resident #77, Resident #91, Resident #94, and Resident #103) of eleven residents during the Resident Council meeting; for one (Resident #102) of four residents reviewed for food, and for one (Resident #48) of sixteen residents reviewed during the dining task. Specifically, 1) The cold water dishmachine used for dishwashing did not hold the proper temperature of 140 degrees Fahrenheit as recommended by the manufacturer. 2) during the resident council meeting held on 10/28/2024 ten of eleven residents in attendance complained about the meal temperature and were served cold food that should have been served hot. On 10/30/2024 during the lunch meal service, three (Unit North, Unit East, Unit West) of three units meals temperatures for the hot food items were below 135 degrees Fahrenheit. The findings are: 1) The facility's undated policy titled Dishwashing Procedures documented that all dishes, utensils, and trays are to be washed and sanitized appropriately. Procedures include but are not limited to: Running a test tray through the machine; and checking the wash and the rinse temperature gauges. The wash temperature-120 degrees Fahrenheit or above and the rinse temperature-140 degrees Fahrenheit or above. If the temperature [reading] is not appropriate, notify the Food Service Director and/or Maintenance. When the [dishwashing] machine is not working appropriately, disposables will be used. Under the General Operating Instructions for the dishmachine, the policy documented that the water temperature should be 140 degrees Fahrenheit and to report to the Supervisor if the temperature is lower or higher than 140 degrees Fahrenheit. The facility's undated policy titled Dish Machine Log documented that the water temperature of the dishmachine should be at 120 degrees Fahrenheit. Check the temperature at each meal and record on the log sheet. Report any discrepancies to the Food Service Director immediately. The dishmachine was observed being operated by Dietary Aide #1 on 10/29/2024 at 10:20 AM, in the presence of the Food Service Director. The temperature gauge on the dishmachine read 110 degrees Fahrenheit for the Wash and 110 degrees Fahrenheit for the Rinse cycle. During an interview on 10/29/2024 at 10:20 AM, the Food Service Director stated the dishmachine used by the facility was a low-temperature dishmachine. The chemical sanitizer is used each time the dishmachine is run. With the chemical sanitizer, the low-temperature machine's Wash and Rinse temperature had to be 120 degrees Fahrenheit to sanitize effectively. During an interview on 10/29/2024 at 10:20 AM, Dietary Aide #1 stated they were using the dishmachine to wash the dishes from the facility's Breakfast meal. Dietary Aide #1 stated when they started the dishmachine that morning, the temperature gauge was at 120 degrees Fahrenheit for Wash and Rinse cycle. The dishmachine Temperature Log sheet for October 2024 was reviewed on 10/29/2024 at 10:30 AM. For the entire month of October, the breakfast, lunch, and dinner, the dishmachine temperature readings were 120 degrees Fahrenheit including the temperature reading for the Breakfast meal on 10/29/2024. The dishmachine was observed being operated by Dietary Aide #1 on 10/29/2024 at 10:50 AM, in the presence of the Food Service Director. The temperature gauge on the dishmachine read 95 degrees Fahrenheit for the Wash and 95 degrees Fahrenheit for the Rinse cycle. During an interview on 10/30/2024 at 12:25 PM, the Director of Environmental Services stated they were aware that sometimes the water supplied to the dishmachine runs at a low temperature and the hot water mixing valve had to be adjusted. During an additional interview on 10/30/2024 at 12:35 PM, the Food Service Director stated they would periodically check the temperature of the dishmachine themselves. The Food Service Director stated that when the temperature of the dishmachine did not reach the desired temperature, the residents would be served their meals on disposable plates, cups, and utensils or all plates, cups, and utensils would be washed by hand in the three-compartment sink. During an interview on 10/30/2024 at 3:35 PM, the President of the vendor company that supplied the sanitizing solution for the dishmachine stated the Wash temperature of the dishmachine should be at 120 degrees Fahrenheit and the Rinse temperature at 140 degrees Fahrenheit for the chemical to effectively sanitize the dishes. During an interview on 11/1/2024 at 3:40 PM, the Administrator stated they knew there were temperature issues with the dishmachine but for the most part, the temperature of the dishmachine was hitting 120 degrees Fahrenheit. The Administrator stated that the facility had used disposable plates, cups, and utensils when the the dishmachine water temperature was too low. 17585 2) The undated facility policy titled Food Temperatures documented temperatures of all food items will be taken and properly recorded prior to service each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures such as hot or cold carts, pellet systems, insulated plate bases, domes, etc. Food sent to the units for distribution will be transported and delivered to the unit storage areas to maintain temperatures at or above 135 degrees Fahrenheit for hot foods. The Resident Council meeting was conducted on 10/28/2024 at 11:15 AM. Ten of eleven residents during the group interview complained that they were served cold food during meals that should have been served hot. During an interview on 10/28/2024 at 11:31 AM, Resident #48 stated the hot foods were served cold and that the food was lousy. During an interview on 10/28/2024 at 11:05 AM, Resident #102 stated they received cold food that should have been served hot during meals. On 10/30/2024 during the lunch meal service, three test trays were requested for three of three units in the facility (Unit North, Unit East, and Unit West): The last unit meal truck of two meal trucks for Unit [NAME] arrived on the unit at 12:20 PM. The last meal tray was observed to be served at 12:30 PM. The test tray temperatures were taken at 12:20 PM in the presence of the Dietician. The temperature readings for both the vegetables and noodles were 122 degrees Fahrenheit. The last lunch meal truck of two meal trucks for Unit East arrived on the unit at 12:29 PM. The last meal tray was served at 12:44 PM. The test tray temperatures were taken at 12:44 PM in the presence of Licensed Practical Nurse #3. The temperature readings for both the noodles and the carrots were 113 degrees Fahrenheit, and the temperature reading for the Chicken meal was 128 degrees Fahrenheit. The lunch meal truck for Unit North arrived on the unit at 12:35 PM. The last meal tray was served at 12:41 PM. The test tray food temperatures were taken at 12:41 PM in the presence of the Dietician. The temperature reading for carrots was 115 degrees Fahrenheit, and the temperature reading for the noodles was 95 degrees Fahrenheit. During an interview on 11/1/2024 at 3:55 PM, the Food Service Director stated they knew the Resident Council's concerns about hot meals being served cold. The Food Service Director stated they monitor the hot food temperatures on the tray line in the kitchen for every meal; however, the food temperatures were not monitored on the units during meals. The meal temperature concern was discussed during the morning meetings with the administrative staff (Department Heads). The Food Service Director stated they brought up helpful solutions during these morning meetings such as closed, insulated food trucks and a pellet system but nothing was done. The Food Service Director stated they could not recall the last time Quality Assurance was completed regarding food temperatures. During an interview on 11/1/2024 at 4:14 PM, the Dietician stated they were aware of the residents' concern regarding receiving hot food at cold temperatures during meal services. The Dietician stated they recommended distributing meal trays before distributing coffee to shorten the distribution time. The Dietician stated they also recommended utilizing methods such as insulated food trucks or a pellet system as these would be helpful to maintain hot food temperatures of at least 135 degrees Fahrenheit; however, these recommendations were never implemented. During an interview on 11/1/2024 at 4:19 PM, the Director of Nursing Services stated they were aware of the Resident Council members' concerns related to hot food items being served cold. The Director of Nursing Services stated they completed multiple observations of the nursing staff during breakfast and lunch meals on different units and they did not identify concerns regarding the length of time the staff distributes meal trays on the units. 10 NYCRR 415.14(h)

Based on record review and staff interviews, during the re-certification survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure food served to the residents was at acceptable temperature parameters for three of the three resident units. Cross Reference F 804 Food and Nutrition Services F 812 Food and Nutrition Services The finding is: The undated facility policy titled Food Temperatures documented temperatures of all food items will be taken and properly recorded prior to service each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items may not fall below 135 degrees Fahrenheit after cooking unless it is an item that is to be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit prior to serving. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures such as hot or cold carts, pellet systems, insulated plate bases, domes, etc. Food sent to the units for distribution will be transported and delivered to the unit storage areas to maintain temperatures at or above 135 degrees Fahrenheit for hot foods. The Resident Council meeting was conducted on 10/28/2024 at 11:15 AM. Ten of eleven residents during the group interview complained that they were served cold food during meals that should have been served hot. A review of the Resident Council minutes from 4/2024 to 10/2024 revealed during the Resident Council meeting on 5/2024 there was a concern with meal trucks arriving on the units and the staff not handing out meal trays. No concerns were documented in the Resident Council minutes regarding hot foods that were served cold during meals. On 10/30/2024 during the lunch meal service, three test trays were requested for three of three units in the facility (Unit North, Unit East, and Unit West): The last unit meal truck of two meal trucks for Unit [NAME] arrived on the unit at 12:20 PM. The last meal tray was observed to be served at 12:30 PM. The test tray temperatures were taken at 12:20 PM in the presence of the Dietician. The temperature readings for both the vegetables and noodles were 122 degrees Fahrenheit. The last lunch meal truck of two meal trucks for Unit East arrived on the unit at 12:29 PM. The last meal tray was served at 12:44 PM. The test tray temperatures were taken at 12:44 PM in the presence of Licensed Practical Nurse #3. The temperature readings for both the noodles and the carrots were 113 degrees Fahrenheit, and the temperature reading for the Chicken meal was 128 degrees Fahrenheit. The lunch meal truck for Unit North arrived on the unit at 12:35 PM. The last meal tray was served at 12:41 PM. The test tray food temperatures were taken at 12:41 PM in the presence of the Dietician. The temperature reading for carrots was 115 degrees Fahrenheit, and the temperature reading for the noodles was 95 degrees Fahrenheit. During an interview on 11/1/2024 at 9:28 AM, the Ombudsman stated the residents had complained about cold food for about two or three months during the Resident Council meetings and they spoke with the Director of Recreation to determine if there was a plan to address the residents' concerns. The Ombudsman stated the Director of Recreation told them they (the Director of Recreation) would speak with the Director of Nursing Services regarding the concerns. The Ombudsman did not realize the residents' concerns regarding the food temperatures were not included in the Resident Council minutes because they did not request or receive a copy of the Resident Council minutes. During an interview on 11/1/2024 at 3:55 PM, the Food Service Director stated they knew the Resident Council's concerns about hot meals being served cold. The Food Service Director stated they monitor the hot food temperatures on the tray line in the kitchen for every meal; however, the food temperatures were not monitored on the units during meals. The meal temperature concern was discussed during the morning meetings with the administrative staff. The Food Service Director stated they brought up helpful solutions during these morning meetings such as closed, insulated food trucks and a pellet system but nothing was done. The Food Service Director stated they could not recall the last time Quality Assurance was completed regarding food temperatures. During an interview on 11/1/2024 at 4:04 PM, the Director of Recreation stated they attended Resident Council meetings and were responsible for recording the meeting minutes. The cold food concern was discussed during the Resident Council meetings for the past three months. The Director of Recreation stated this concern should have been documented in the Resident Council minutes. An Interview was conducted on 11/1/2024 at 3:00 PM with the Administrator and they stated they were doing the best they could with serving residents food at an acceptable temperature. 10 NYCRR 415.26

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's cold food concern identified on three of three units observed during the dining task. Specifically, multiple complaints were brought up during Resident Council meetings that hot meals were being served cold; however, the Quality Assurance Performance Improvement Committee did not address, review, analyze, and act on available data on the identified issue to make improvements and to ensure improvements are sustained. Cross Reference: F 804 Food and Nutrition Services F 812 Food and Nutrition Services The finding is: The facility's undated Quality Assurance Performance Improvement Plan documented that the purpose of the Quality Assurance Performance Improvement is to provide quality care and cost-effective services to meet the individual needs of the residents they serve, through innovation and continuous improvement in the delivery of care. The purpose of the Quality Assurance Performance Improvement (QAPI) is to evaluate resident experiences of the services provided to determine how the experience can be improved. Quality Assurance Performance Improvement includes all members of each service. Decisions are made based on the evaluation of all input from residents, families, healthcare practitioners, caregivers, and other stakeholders. A Review of the Quality Assurance and Performance Improvement (QAPI) meeting agenda for 8/21/2024 revealed no documented attempts to address, review, analyze, and act on complaints regarding the hot meals being served cold, to make improvements, and to ensure improvements are sustained. A review of the Resident Council Meeting Minutes dated 8/2024 to October 2024 revealed that the residents' complaints about cold food were not reflected in the minutes. During an interview on 11/1/2024 at 3:55 PM, the Food Service Director stated they were aware of the concerns of hot meals being served cold. The concerns were brought up during the Resident Council meetings within the past three months. The Food Service Director stated that the food temperatures were not monitored on the units during meals. The concern of cold food was discussed during the morning meetings with the administrative staff (Department Heads). The Food Service Director stated they could not recall the last time Quality Assurance was completed regarding food temperatures. During an interview on 11/1/2024 at 4:04 PM, the Director of Recreation stated they attended Resident Council meetings and were responsible for recording the meeting minutes. The cold food concern was discussed during the Resident Council meetings for the past three months. The Director of Recreation stated this concern should have been documented in the Resident Council minutes. During a telephone interview on 11/01/2024 at 5:52 PM, the Director of Nursing Services stated they were part of the Quality Assurance and Improvement Program (QAPI) Committee, and attended the meetings on a quarterly. They were aware of the complaints related to the hot meals being served cold. These complaints were brought up during multiple Resident Council Meetings. The Director of Nursing Services stated food temperature complaints were not discussed in the Quality Assurance and Process Improvement Committee meetings because the issue was addressed in morning reports. 10 NYCRR 483.75 (a)(2)(h)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored and the written description of the facility policy to implement advance directives were followed. This was identified for one (Resident #18) of two residents reviewed for advance directives. Specifically, Specifically, the facility did not ensure that Resident #18's advance directives (their preferred code status in the event of cardiac or pulmonary arrest) were accurately identified per their wishes. The finding is: The facility's policy titled Identification of Residents with Advanced Directive dated [DATE], documented the staff should identify the resident's advanced directives status by utilizing the electronic medical record and residents' hard (paper) chart. Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that tells others the resident's wishes regarding life-sustaining treatment. It is designed to communicate the individual's wishes about a range of life-sustaining and resuscitative measures. Residents who are already in a facility who have their advanced directives changed by request of self or representative will have the updated information entered on the electronic medical record, physicians' orders, and form placed in the appropriate section of the hard chart. Medical Orders for Life-Sustaining Treatment (MOLST) healthcare workers such as social workers, nurses, medical doctors, nurse practitioners, and physician assistants will identify a resident who has an advanced directive by checking the emergency medical record for residents order that states advanced directive, checking the hard chart for the pink or white copy of Medical Orders for Life-Sustaining Treatment (MOLST) that identifies the resident or the Health Care Proxy's wishes for advance directive form placed in the appropriate section of the hard chart. Resident #18 was admitted to the facility with diagnoses including Lymphedema (swelling due to built-up of lymph fluid), Atrial Fibrillation, and Heart Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status of 12, which indicated the resident had moderately impaired cognition. A Comprehensive Care Plan titled Advanced Directives dated [DATE] documented both the Do Not Resuscitate and the Cardiopulmonary Resuscitation (CPR) as Resident#18's advanced directives. The physician's order for advance directive dated [DATE] documented Full Code (Cardiopulmonary Resuscitation). A Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE] documented Full Code (Cardiopulmonary Resuscitation). Resident#18 was observed on [DATE] at 1:37 PM in their room sitting in a wheelchair. The resident was not wearing an identification band. There were two identification bands attached to the left side of Resident #18's wheelchair. One of the Identification Bands had a red dot and the second Identification band had no dots. During an interview on [DATE] at 1:37 PM, Resident #18 stated they did not like to wear an identification band and that is why there were identification bands on their wheelchair and walker. Resident #18 stated they wished for Do Not Resuscitate and then changed their wishes in [DATE] and wanted to be resuscitated if their heart stopped. During an interview on [DATE] at 2:00 PM, Licensed Practical Nurse #4 confirmed Resident #18 was not wearing an identification band and had two different identification bands attached to Resident #18's wheelchair. Licensed Practical Nurse #4 stated the resident refuses to wear their Identification band. Licensed Practical Nurse #4 stated the red dot on the identification band indicated that Resident#18 wished for Do Not Resuscitate. Licensed Practical Nurse #4 stated they check for Resident#18's identification band every shift and sign for it on the Medication Administration Record to indicate the presence of the identification band. Licensed Practical Nurse #4 stated they did not realize the resident had two different identification bands attached to the wheelchair. During an interview on [DATE] at 3:40 PM, Social Worker #2 stated when a resident's advance directive status is changed they are responsible for ensuring correctly identified advance directive status is reflected on the resident's identification band. For Do Not Resuscitate, the identifier is a red dot that is placed on the resident's identification band. When a resident rescinds their Do Not Resuscitate status, then the Identification band should be replaced and should not have a red dot. During an interview on ,d+[DATE]//2024 at 3:45 PM, the Director of Nursing Services stated it was not acceptable that Resident #18 had two identification bands on Resident #18's wheelchair. The Director of Nursing Services stated the facility does not use the red dots on the identification band to indicate the resident's advance directive status. They stated none of the facility policies include using the red dots as an identifier for the resident's advance directive status. The Director of Nursing Services stated if a nurse found a resident unresponsive they must confirm the resident's advanced directive status by checking the physician orders and the Medical Orders for Life-Sustaining Treatment (MOLST) form. 10 NYCRR 415.3 (e) (2)(iii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure that each resident was provided with a comfortable and homelike environment. This was identified on one (East Unit) of three resident units during the environmental tour. Specifically, the hot water temperatures were not maintained within an acceptable range and were noted below the required range of 90 degrees-110 degrees Fahrenheit in the resident areas. The finding is: 42 CFR 483.470 (d)(3) PART 483-REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES 483.470 Condition of Participation: Physical environment. (d) Standard: Client bathrooms. The facility must ensure: (3) In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 Fahrenheit. New York State Rules and Regulations, Article 2 Medical Facility Construction, Part 713- Standards of Construction for Nursing home facilities, Section 713-1.9- Mechanical requirements, (m) Domestic hot water systems shall provide adequate hot water at each outlet at all times. Hot water temperature at fixtures used by residents shall not exceed 110 degrees Fahrenheit. The facility's Policy and Procedure for Hot Water dated 7/2013 documented that each resident's sink/faucet is tested for a proper temperature of 90-113 degrees Fahrenheit. Each faucet is checked on a daily basis during the Maintenance Department's preventive maintenance room checks. This includes testing of hot water, with the range noted above. If the temperature is not within the correct range, the Maintenance Department staff immediately adjusts the temperature to be within the appropriate range. During the initial tour of the facility on 10/29/2024 between 10:00 AM to 11:00 AM, on the East unit, Residents # 102 and Resident # 39 complained the water in their rooms and showers were cold the last few weeks. This has been brought to the Maintenance Department's attention and nothing has been done. Resident # 102 stated they had to take showers on another unit because the shower in their room did not have hot water. The hot water was felt by touch and found to be cool. On 10/30/2024 at 12:52 PM, the hot water temperature for the sink was tested in Resident # 102's and Resident #39's rooms. The Director of Environmental Services was present during the observations. The sink water temperature in Resident # 102's and Resident #39's rooms was found to be cool to the touch. The water temperature was measured at 79 degrees Fahrenheit. The hot water in both resident room sinks was running for at least four minutes before the temperature reading was obtained. During an interview on 10/30/2024 at 12:52 PM, the Director of Environmental Services stated hot water temperatures are checked daily and a water temperature log is maintained on each unit. The Director of Environmental Services stated they were not aware of any hot water temperature issues, if they were made aware of any temp below 90 degrees Fahrenheit, they would have adjusted the boiler temperature. During an observation on 10/30/2024 at 3:00 PM, the hot water temperature for the East unit shower room was measured. The water temperature was 81 degrees Fahrenheit. The hot water in the shower room was running for at least four minutes before the temperature reading was obtained. During an interview on 10/31/2024 at 3:28 PM, Certified Nurse Assistants #1 and # 2 who were assigned to the East unit were interviewed and stated before showering a resident, they have to run the water for more than 1 hour for the water to get warm and still, the water temperature is not hot enough. Both Certified Nurse Assistants #1 and # 2 stated that the maintenance department was aware of the water temperature issues. Maintenance Personnel #1 was interviewed on 10/30/2024 at 03:11 PM and stated they monitor hot water temperatures daily on each unit by checking the water temperature of each shower room and two resident rooms. Maintenance Personnel #1 tested the hot water this morning and all temperatures were just barely above 90 degrees Fahrenheit in the East unit shower rooms. Maintenance Personnel #1 stated they were not made aware of any cold water temperature issues and there was no request to adjust the water temperatures. The Administrator was interviewed on 10/30/24 at 03:39 PM and stated they were aware of the problem with the mixing valve since 10/15/2024. We were sending residents who required showers to other units because of the problems with the hot water on the east unit showers. The Administrator further stated they were trying to get the mixing valve sooner; however, the supply company did not have the part available for the last 2-3 weeks. 10 NYCRR 415.5 (h)(2)

Based on record review and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (Resident #27) of two residents reviewed for Advanced Directives. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect Resident #27 had an advanced directive of Do Not Hospitalize. The finding is: The facility's policy titled Comprehensive MDS Policy last revised on 9/2024 documented the Minimum Data Set provides an assessment that is comprehensive, accurate, standardized, and reproducible for each resident's functional capabilities. Therapeutic Recreation, Social Services, Nutrition, and Minimum Data Set assessment staff are responsible for their specific area on the Minimum Data Set assessment. Each discipline that completes a section of the Minimum Data Set assessment signs, and dates the Minimum Data Set assessment for sections completed. Resident #27 was admitted with diagnoses including Metabolic Encephalopathy (a type of brain disorder), Moderate Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] did not include a Brief Interview for Mental Status because the resident was rarely or never understood and had severely impaired skills for daily decision-making. The Minimum Data Set assessment Section S documented the resident had advanced directives including Do Not Resuscitate, Do Not Intubate, and feeding restrictions. The Minimum Data Set did not document the resident had an advanced directive of Do Not Hospitalize. A Comprehensive Care Plan titled Advanced Directives effective 1/22/2019 and last revised on 4/24/2024 documented Resident #27's advanced directives included the following: Do Not Resuscitate, Do Not Intubate, and limited medical interventions. The comprehensive care plan documented an advanced directive to send the resident to the hospital. A Physician's Order effective 8/15/2024 and renewed 10/9/2024 documented an advanced directive of Do Not Hospitalize. A Medical Orders for Life-Sustaining Treatment (MOLST) form for Resident #27 dated 8/15/2024 documented do not send the resident to the hospital unless pain or symptoms cannot be otherwise controlled. During an interview on 10/31/2024 at 12:45 PM, the Minimum Data Set Coordinator stated the staff who completes and signs for sections in the Minimum Data Set assessment are responsible for assuring accuracy for the designated section. The Minimum Data Set Coordinator stated they sign the Minimum Data Set assessment once it is entirely completed. They stated the Quarterly Minimum Data Set for Resident #27 did not accurately reflect the resident's advanced directive status and should have indicated the resident had an advanced directive of Do Not Hospitalize. The Minimum Data Set Coordinator further stated the social workers were responsible for ensuring the accuracy of advanced directives on the Minimum Data Set assessment. During an interview on 10/31/2024 at 1:12 PM, Social Worker #1 stated they were responsible for completing and ensuring the accuracy of the advanced directives for Resident #27 on the Quarterly Minimum Data Set assessment dated [DATE]. Social Worker #1 stated the Minimum Data Set assessment should have reflected that Resident #27 had an advanced directive of Do Not Hospitalize and this was an oversight. During an interview on 11/1/2024 at 3:45 PM, the Director of Nursing Services stated the social workers were responsible for ensuring the accuracy of advanced directives on the Minimum Data Set assessment for each resident. The Quarterly Minimum Data Set assessment dated [DATE] should have accurately reflected Resident #27's advanced directives in accordance with Resident #27's Medical Orders for Life-Sustaining Treatment (MOLST) form and the Physician's Orders for advanced directives. 10 NYCRR 415.11(b)

Based on interviews and record review during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for each resident. This was identified for two (Resident #27 and Resident #18) of two residents reviewed for Advanced Directives. Specifically, 1) on [DATE], Resident#18 advanced directive wishes changed from Do Not Resuscitate to Cardiopulmonary Resuscitation. The comprehensive care plan was not updated to accurately reflect changes in the resident's advance directives until [DATE]. 2) Resident #27's comprehensive care plan was not updated to accurately reflect the resident's advance directives for Do Not Hospitalize as per the physician's orders and the resident's wishes. The findings are : The facility's policy titled Comprehensive Care Plan last revised on ,d+[DATE] documented the comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition, annual basis, on re-admission from an inpatient hospital stay, and as requested by the resident/representatives. The care plan shall be periodically reviewed and revised by a team of qualified persons after each assessment. The facility's policy titled Advanced Directives-MOLST, POLST last revised on ,d+[DATE] documented that residents will have their advanced directives honored and these will be reviewed during admission and throughout their stay. When a resident is initiating or revising a Medical Orders for Life-Sustaining Treatment (MOLST) form or Physician Orders for Life-Sustaining Treatment form while residing at the facility, the Medical Orders for Life-Sustaining Treatment (MOLST) form or Physician Orders for Life-Sustaining Treatment form will be executed as part of the care planning process and advanced care planning conversations. If the resident decides to revoke a Medical Orders for Life-Sustaining Treatment (MOLST) form or Physician Orders for Life-Sustaining Treatment form, the resident's clinician will be notified and changes to the medical orders will be obtained as soon as possible to ensure that the resident's wishes are accurately reflected in the plan of care. 1) Resident #18 was admitted to the facility with diagnoses including Lymphedema (swelling due to built-up of lymph fluid), Atrial Fibrillation, and Heart Failure. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status of 12, which indicated the resident had moderately impaired cognition. A Comprehensive Care Plan titled Advanced Directives dated [DATE] documented both the Do Not Resuscitate and the Cardiopulmonary Resuscitation (CPR) as Resident#18's advanced directives. The physician's order for advance directive dated [DATE] documented Full Code (Cardiopulmonary Resuscitation). A Medical Orders for Life-Sustaining Treatment (MOLST) form for Resident #18 dated [DATE] Full Code(Cardiopulmonary Resuscitation). During an interview on [DATE] at 1:00 PM, Registered Nurse Manager #2 stated the social workers were responsible for the advanced directive care plans. Registered Nurse Manager #2 stated they do not update the care plans for advanced directives. During an interview on [DATE] at 1:15 PM, Social Worker#1 stated the Social Work Department is responsible for the advanced directive care plans. Social Worker#1 stated Resident#18 changed their advance directive wishes on [DATE] from Do Not Resuscitate to a full code. Social Worker#1 stated they forgot to update the advanced directive care plan, and it was just a clerical error. During an interview on ,d+[DATE]//2024 at 3:45 PM, the Director of Nursing Services stated the comprehensive care plans should accurately reflect the resident's advance directive status and it is not acceptable that Resident#18's advanced directive care plan was not updated to accurately reflect the resident's wishes for a full code. 50423 2) Resident #27 was admitted with diagnoses including Metabolic Encephalopathy (a type of brain disorder), Moderate Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] did not include a Brief Interview for Mental Status because the resident was rarely or never understood and had severely impaired skills for daily decision-making. The Minimum Data Set documented the resident had advanced directives including Do Not Resuscitate, Do Not Intubate, and feeding restrictions. A Comprehensive Care Plan titled Advanced Directives, effective [DATE] and last revised on [DATE] documented advanced directives including to send the resident to the hospital. A physician's order effective [DATE] and renewed on [DATE] documented an advanced directive of Do Not Hospitalize. A Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE] included do not send the resident to the hospital unless pain or symptoms cannot be otherwise controlled. The comprehensive care plan for the Advance Directive was not updated to reflect the new advance directive order for Do Not Hospitalize. During an interview on [DATE] at 10:48 AM, Social Worker #1 stated they were responsible for initiating and updating the comprehensive care plan for advanced directives. Social Worker #1 stated they did not know why the advance directive comprehensive care plan did not reflect Resident #27's wish and the physician's order for Do Not Hospitalize. During an interview on [DATE] at 3:45 PM, the Director of Nursing Services stated the comprehensive care plan for advanced directives should be updated as soon as there are any changes in advanced directives for each resident. The Director of Nursing Services stated the comprehensive care plan for Resident #27 should have been updated to reflect the resident's wish and the physician's orders for advanced directives. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/01/2024, the facility did not ensure medications were properly stored in medication carts. This was identified for one (Unit North Medication Cart 1), of 2 units reviewed during the Medication Storage Task. Specifically, Unit North Medication Cart#1 was utilized for storing items other than the resident medications such as the hearing aids, dirty measuring tape, three rolls of surgical tape, seven hearing aid batteries, and a small box of loose rubber bands. The findings are: The Medication Storage policy dated 4/2019 documented that Medications will be stored in a manner that maintains product integrity; ensures residents' safety; and complies with the New York State Department of Health guidelines. The policy documented that with the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. The Medication Carts policy dated 12/2023 documented that items other than the medications that may be utilized and needed during medication administration will be stored separately in the cart away from the medications. North Unit Medication Cart #1 was observed on 10/30/2024 at 7:14 AM, in the presence of Unit Registered Nurse Manager#1. The top drawer of the medication cart had a tape measure with dried brown stains folded and secured with a rubber band, seven hearing aids batteries, three rolls of paper treatment tape, small boxes of used, loose rubber bands, and a scanning thermometer stored along with the eye drops and over the counter medications. During an interview on 10/30/2024 at 7:14 AM, Registered Nurse Manager #1 stated the items that were observed in the medication cart had to stay in the medication cart in the top drawer because these items are related to medical needs. Registered Nurse Manager #1 stated they use the thermometer to monitor the residents' temperatures, therefore the thermometer needed to stay in the first drawer of the medication cart. During an interview on 10/30/2024 at 7:19 AM, Licensed Practical Nurse #2 stated the observed items have to stay in the medication cart since they were all health-related items. During an interview on 11/1/2024 at 3:41 PM, the Director of Nursing Services stated that medical tape, hearing aids, rubber bands, and thermometers should not be stored in the medication cart. The medication carts should include only medications and items related to the medication administration. 10 NYCRR 415.18(e)(1-4)