Every finding on record at Upstate University Hosp at Community General T C U

Entrance conference worksheet documents required for survey were not received timely.Based on record review and interviews during the recertification survey conducted 7/23/2025-7/25/2025, the facility did not make available clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for all 15 residents of the facility. Specifically, upon survey entrance, resident-identifiable information including form CMS-802 Matrix for Providers, and an alphabetical listing of all residents was not provided to the Department of Health in a timely manner. Additional information needed from the facility within one hour and four hours of entrance was not provided in a timely manner. Findings include:The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet documents:The complete matrix for new admissions in the last 30 days who were still residing in the facility and an alphabetical list of all residents was to be provided to the surveyors immediately upon survey entrance. The schedule of mealtimes, schedule of medication administration, number and location of medication cart and storage rooms, actual working schedules for all staff, and a list of key personnel were to be provided within one hour of survey entrance.The complete matrix for all other residents, admission packet, dialysis contract, infection prevention and control program standards policies and procedures, influenza and pneumonia immunization policy, Quality Assurance committee information and Quality Assurance and Performance Improvement Plan, and facility assessment were to be provided within four hours of survey entrance. The Department of Health survey team entered the facility on 7/23/2025 at 9:30 AM. The Team Coordinator met with the Deputy Director of Nursing at 9:45 AM for the entrance conference meeting and reviewed the documents required for survey as outlined on the entrance conference worksheet. The Deputy Director of Nursing was also provided a copy of the worksheet. This included the time frame for providing CMS-802 Matrix for Providers and the alphabetical list of all residents (immediately upon entrance). The Deputy Director of Nursing was unable to provide the completed matrix for new admissions in the last 30 days and the alphabetical list of all residents. The Team Coordinator sent a follow up email with electronic copies of the required documents at 10:07 AM including a blank matrix form and the instructions for completion. Required documents were received via secure file transfer:On 7/23/2025 at 12:25 PM, (over two and a half hours after survey entrance) the Administrator sent an alphabetical list of residents (due immediately upon entrance), and a document labeled CMS-802. The document labeled CMS-802 was not the correct form. At 12:31 PM, the Team Coordinator informed the Administrator that document was not correct and again requested the correct CMS-802 form that was provided in both a hard and electronic copy and due upon entrance.On 7/23/2025 at 2:12 PM, (four and a half hours after survey entrance) the Administrator sent form CMS-802. The new admission matrix (due immediately upon entrance) and the complete matrix (due four hours after entrance) were the same as there were no residents at the facility longer than 30 days. On 7/23/2025 at 2:54 PM, the Team Coordinator sent an email via secure file transfer to the Administrator and the Associate Administrator for Accreditation and Regulatory informing them the entrance conference items were past due. A follow up email was sent at 4:15 PM documenting entrance conference items were not received and was impeding the survey process. On 7/23/2025 at 4:17 PM, (six and a half hours after survey entrance) the information required from the facility within one hour of entrance was received.On 7/24/2025 at 9:00 AM, the Team Coordinator sent another follow up email to the Administrator, the Deputy Director of Nursing, and the Director of Quality regarding the missing documents from the entrance conference worksheet that were due within four hours of entrance.On 7/24/2025 at 11:05 AM, (over 25 hours after survey entrance) the remaining required information was received. During an interview on 7/25/2025 at 9:32 AM, the Administrator stated the unit should always be ready for survey entrance. The delay in providing the documents in the required timeframe was because the unit was recognized as part of the hospital. It should be recognized as a stand-alone unit despite being located in the hospital. They did not have a process to identify staff that was responsible for providing the surveyors requested documents timely. 10NYCRR 483.70(i)

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

Based on interview and record review during the recertification survey conducted 3/11/2024-3/13/2024 the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 11 residents residing on the unit. Specifically, administration did not ensure the facility appropriately outlined the roles of the required administrative staff and that they had developed specific policies and procedures for resident care that were reviewed annually. Additionally, deficiencies related to Administration were identified in the area of infection control (F 880). Findings include: The 3/13/2024 Transitional Care Unit Administrative Organizational Chart documented registered nurse/Unit Manager #2 reported to Director of Nursing #21. The 8/2023 Facility Assessment documented professional Transitional Care Unit support services shared with the hospital included the Transitional Care Unit Administrator and Infection Prevention. The staffing plan for the Transitional Care Unit as of 6/16/2022 included one full time Unit Manager and did not designate a Director of Nursing. During an interview on 3/11/2024 at 5:52 AM, registered nurse #10 stated Director of Nursing #12 covered the two hospital campuses. They stated the Unit Manager for the Transitional Care Unit would be in at 9:00 AM and the Administrator did not come to this hospital campus, as they worked at the other hospital campus. During an interview on 3/13/2024 at 9:10 AM, registered nurse #6 stated the recipients of care on the Transitional Care Unit should be referred to as residents. The Transitional Care Unit functioned with long term care regulations and the unit was supposed to present a home like unit for the resident as they prepared for discharge. During an interview on 3/13/2024 at 9:20 AM, registered nurse/ Unit Manager #2 stated they were aware they worked in the role of Director of Nursing for long term care, but the hospital title on this unit was Unit Manager. During an additional interview at 11:35 AM, they stated the standard for policy review as every 2 years. The hospital standard was biannually and if a policy needed to be changed or reviewed this was done as needed. During an interview on 3/13/2024 at 1:59 PM, the Administrator stated Director of Nursing #21 was the Transitional Care Unit Director of Nursing and was the responsible Director of Nursing for the hospital. They stated according to the hospital staffing registered nurse/Unit Manager #2 was a Unit Manager but was technically the Director of Nursing for the Transitional Care Unit without the official title. They were aware that registered nurse/Unit Manager #2 should have a badge and title of Director of Nursing per long-term care regulations. Registered nurse/Unit Manager #2 was listed as the Director of Nursing in the Health Commerce System and was responsible for leading the quality assurance meetings. They stated the Transitional Care Unit policies were on the policy network and coded TCU. It was important to have specific policies for the Transitional Care Unit because the unit was required to follow the long-term care regulations which were very different from the hospital acute care regulations and guidelines. It was important to have specific long term care Transitional Care Unit policies for infection control because the regulations for acute care did not match the long-term care regulations. The staff responded to infection control issues differently in long term care than they would in acute inpatient care settings. They were not aware there were no specific infection control policies, and all their policies should be reviewed annually. 10 NYCRR 483.70(i) 48895

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

Based on interview and record review during the recertification survey, the facility did not ensure each resident was screened for a mental disorder or intellectual disability prior to admission for 3 of 8 (Residents #2, 55 and 64) residents reviewed for DOH-695 (Department of Health) Pre-Admission Screening and Record Review (PASRR, a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, there was no documentation the facility reviewed and maintained DOH-695 PASRR screens prior to admission to the Transitional Care Unit (TCU) for Residents #2, 55 and 64. Findings include: The 7/19/18 revised Admission Criteria to the Transitional Care Unit policy documented: - the TCU is a short-term sub-acute skilled nursing unit that accepts admissions directly from the hospital acute care units; and -A patient review instrument (PRI) and Screen will be completed prior to admission to the TCU. 1) Resident #2 was admitted to the unit on 10/4/19 and had [DIAGNOSES REDACTED]. The 10/9/19 admission Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required limited assistance with most activities of daily living (ADLs). On 10/17/19 at 9:30 AM, Resident #2's PASRR was not observed in the TCU electronic or paper medical records. 2) Resident #55 was admitted to the unit on 10/10/19 and had [DIAGNOSES REDACTED]. The 10/17/19 admission Minimum Data Set (MDS) assessment documented the resident had functional cognition. On 10/17/19 at 9:30 AM, Resident #55's PASRR was not observed in the media section of her electronic chart or in the resident's chart at the nursing station. On 10/17/19 at 11:15 AM, the surveyor requested from RN Case Manager #1 the PASRR screen for Resident #55. At 11:27 AM, RN Case Manager #1 stated she just found the PASRR for Resident #55 in a nationwide e-chart system as they were not in the facility's e-chart system. 3) Resident #64 was admitted to the unit on 10/9/19 and had [DIAGNOSES REDACTED]. On 10/17/19 at 9:30 AM, Resident #64's PASRR was not observed in the media section of his electronic chart or in the resident's chart at the nursing station. On 10/17/19 at 11:15 AM, the surveyor requested from RN Case Manager #1 the PASRR screens for Resident #64. When interviewed on 10/17/19 at 10:28 AM, registered nurse (RN) Case Manager #1 stated the PASRR screens were done by the sending hospital unit case manager prior to the resident coming to the transitional care unit (TCU). The PASRR was faxed to the unit or hand carried to the TCU and placed in the resident's hard copy chart by the screener. Every resident was required to have a PASRR screen. She stated that sometimes there was a delay of a couple days in the e-chart system if the PASRR was being scanned, and RN Admission Liaison #3 was responsible to ensure each resident had one in their chart. When interviewed on 10/17/19 at 10:34 AM, RN Manager #2 stated residents were screened by the case manager on the hospital sending unit and they were to complete a PASRR prior to the resident coming to the TCU. She stated it was done in the e-chart (electronic) system. The sending case manager was responsible to ensure it was in the system, and RN Case Manager #1 and RN Admission Liaison #3 were to verify the PASRR was there prior to or upon arrival of the resident to the TCU. When interviewed on 10/17/19 at 12:02 PM, RN Admission Liaison #3 stated she and RN Case Manager #1 were responsible to ensure the PASRR's were in the chart. She stated she placed Resident #55, 64 and 2 's PASRR in the front of the hard copy chart and was not sure why they were not there. She stated she did not go back in the charts to ensure they were there, and it may have been removed accidentally. She stated both she and RN Case Manager #1 could access PASRR's via the nationwide data base. She stated the process was for her to obtain the hard copy from the case manager of the hospital sending unit and ensure it went in the front pocket of the hard copy chart. She stated there was no official audit done routinely to ensure the PASRR was in the chart. 10NYCRR 415.11(3)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 1 of 1 washer and 1 of 1 dryer. Specifically, the washer and dryer were not maintained according to manufacturer recommendations. Findings include: The 6/15/13 Proper Handling of Patients' Personal Laundry policy and procedure documented staff were to inspect and clean the lint trap. Clothing will be dried according to the manufacturer's instructions. Washer: The undated washer programming manual documented the door seal inspection/cleaning was required monthly. The washer was observed on 10/17/19 at 11:39 AM and the door seal section was not maintained/stained. During an interview with the Plant Operations Supervisor on 10/17/19 at 11:39 AM, he stated monthly inspections were not documented for the washer. Dryer: The undated heat pump dryer manual documented the inside cabinet lint removal was to be documented every 2 years. During an interview with the Assistant Director of Plant Operations on 10/17/19 at 11:45 AM, he stated the laundry room (per work order) construction was completed in 4/2017. There was no documentation the every two-year requirement for inside cabinet lint removal was completed for 2019. 10NYCRR 415.29(k)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure food was stored under sanitary conditions in 1 of 2 food service areas observed (Transitional Care Unit). Specifically, there were inaccurate thermometers in the dining room; potentially hazardous foods were out of temperature range and food items were inappropriately stored in the Transitional Care Unit. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 2/25/2015. Findings include: 1) On 3/30/2016 at 11:45 AM, a surveyor observed the thermometer in the dining room refrigerator was not accurate. The facility thermometer in the refrigerator read 60 degrees Fahrenheit (F), and the reading on the state surveyor's thermometer was 50 degrees F. There were approximately 20 small milk cartons in the refrigerator. On 3/30/2016 at 11:53 AM, a surveyor observed the thermometer in the dining room freezer was not accurate. The facility thermometer in the freezer read 30 degrees F, and the reading on the state surveyor's thermometer was 36 degrees F. There were approximately 10 four ounce ice cream container, 50 popsicles, and an Italian ice in the freezer. The Italian ice container was soft/melted when opened by the surveyor. An unpackaged popsicle in the freezer was also soft/melted. On 3/30/2016 at 1:00 PM, the Assistant Food Service Director stated in an interview he went to the Transitional Care Unit at 12:30 PM and took the temperature of one of the milk cartons in the refrigerator and it was 51 degrees F. He stated he discarded all the milks from the refrigerator at that time. The Assistant Food Service Director also stated all of the ice cream and the top layer of popsicles were soft/melted in the freezer, and he discarded them. The Assistant Food Service Director also stated the person responsible for doing the morning checks of the refrigerators and freezers for the Transitional Care Unit did not come in that day and the temperatures were never checked that morning. He was not aware the refrigerator and freezer temperatures were out of range. 2) On 3/30/2016 between 11:00 AM and 11:15 AM, a surveyor in the Transitional Care Unit dining room observed an unlocked activity recreation cabinet that had a expired container of oatmeal raisin cookies and two expired containers of cupcakes being stored next to five acrylic paint bottles and two bags of dog treats. The cookies had an expiration date of 3/26/2016, and the cupcakes had an expiration date of 3/18/2016. On 3/31/2016 at 11:56 AM, recreational therapist #1 stated in an interview the cookies and cupcakes were extra food probably from a birthday party, and were put back in the activity recreation cabinet for storage. 10NYCRR 415.14(h)

Based on observation and interview conducted during the standard survey, it was determined for half of the unit (the east end of the Transitional Care Unit) the facility did not ensure a functional and sanitary environment was maintained due to a lack of hot water. Specifically, an unapproved cross connection was created in a environmental services closet, resulting in a lack of hot water in handwashing sinks in the east end of the unit. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During observations on 2/24/2015 all hot water temperatures were determined in handwashing sinks with the hot water valve turned on, and the cold water valve left off. Two surveyors determined hot water temperatures in the east end of the Transitional Care Unit on 2/24/2015 between 12:25 and 12:35 PM as follows: - 59 degrees Fahrenheit (F) in resident room 5218 toilet room; - 52 degrees F in resident room 5219 toilet room; - 79 degrees F in resident room 531 toilet room; - 79 degrees F in corridor sink outside room 531; and - 73 degrees F in resident room 527 toilet room. During the observation there was an unapproved cross connection in the environmental services closet (room 5221), due to both the hot and cold water valves in the sink being left on, connected to a single hose, and a valve downstream being closed. When the hot water in the handwash sink in room 531 and in the handwash sink in the corridor outside room 531 was tested on [DATE] between 4:30 and 4:45 PM, the hot water temperature was: - 68 degrees F in room 531 after letting the water run for 30 seconds; and - 59 degrees F in the corridor sink outside 531 after letting the water run for 1 minute. During an interview with the Plant Operations Director on 2/24/2015 between 4:30 and 5 PM, he stated he was not aware the hot water was too cold on the eat end of the unit. During the interview, Maintenance staff #1 stated he understood what was causing the hot water to run cold. Maintenance staff #1 stated he found a cross connection in the environmental services closet due to both the hot and cold water faucets being left on. During an interview with registered nurse #2 on 2/24/2015 at 4:55 PM, he stated the hot water in the Transitional Care Unit had been cold for approximately the last 2 months; it was not consistently too cold, and sometimes the hot water did not warm up when staff let the water run for a while. During an interview with the Unit Clerk #3 on 2/24/2015 at 5 PM, she stated she was not aware of a work order being submitted related to hot water. Review of work orders between December 1, 2014 and February 24, 2015 revealed that there were no work orders for the hot water being cold during that time. 10NYCRR 415.29(f (5)

Based on observation, interview, and record review conducted during the standard survey, it was determined that the facility did not ensure the west side of the Transitional Care Unit was maintained free of accident hazards, specifically the hot water was too hot. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Two surveyors determined the hot water temperature at handwashing sinks in the Transitional Care Unit on 2/24/2015 between 1:40 PM and 2:10 PM, as follows: - room 5229 (shower room) was 124 degrees Fahrenheit (F); - the resident bathing room was 123 degrees F; - the resident room 535 toilet room was 122 degrees F; - the sink in the dining room was 122 degrees F.; - the corridor sink outside room 524 was 122 degrees F; and - resident room 527 toilet room was 122 degrees F. Per an interview with the Plant Operations Director on 2/24/2015 at 2:10 PM, he stated that he was not aware that the water temperature of these rooms was above acceptable high temperature allowed, and Maintenance Staff #1 stated he was aware the maximum allowable temperature for hot water in a resident area was 120 F. The Plant Operations Director stated maintenance staff checked the hot water temperature daily in the Transitional Care Unit. The Daily Midnight Readings (daily temperature log) dated 1/2015 and 2/2015 documented the hot water temperature in the Transitional Care Unit for was checked daily, and varied from 90 to 107 degrees F. 10NYCRR 415.12(h)

Based on observation, interview, and record review conducted during the standard survey, it was determined for the main kitchen the facility did not ensure food was prepared and stored under sanitary conditions. Specifically, outdated food was found in 2 refrigerators, multiple kitchen floor areas were unclean. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The kitchen and cafeteria was observed on 2/24/2015 between 10 AM and 11 AM with the Food Director. Outdated Food 1) A surveyor observed the following outdated food items: - a large plastic container of cooked great northern beans in a reach in refrigerator in the cold production area, with a production date of 2/16 and an expiration date of 2/18; and - a container of turkey, with an expiration date of 2/21 was found in cooler #4. The Food Service Director discarded the food items after the observation. Inadequate Cleaning of Food Preparation Equipment 2) A surveyor observed 3 blender containers in the kitchen, 2 of the 3, in the hot production area, were not washed by an approved method: - the large blender (stainless steel container) contained 2 large pieces of dried food; and - the smaller blender container (plastic) was covered, sitting on the blender base, and had approximately a tablespoon of water in the bottom, and was not air dried as required. Floor Cleaning 3) A surveyor observed soiled floor surfaces in multiple areas: - the floor was generally soiled with dirt and debris, including four plastic serving trays, one bowl, silverware, and plastic bowl lids on the floor under and adjacent to the dishwasher; - a package of sealed sausage, miscellaneous papers and plastic and other debris was found on the floor of freezer #3; - a box of potatoes was found on the floor of walk in cooler #1; and - multiple coffee creamers and extensive other debris was found on the floor of the cafeteria walk-in refrigerator. Interview with the Food Service Director on 2/24/2015 at 5:20 PM, he stated that: - the cold production staff were responsible for discarding outdated food in the cold production area; - he was aware of the required process for washing; and - he observed the floor areas that were not clean. The floor cleaning schedule, Master Cleaning Schedule, dated 7/2001 documented: - walk in coolers were to be swept and mopped daily; and - the dishroom floor was to be cleaned daily. 10NYCRR 415.14(h),14-1