Every finding on record at White Plains Center For Nursing Care, L L C

Based on observation and interview conducted during a Recertification Survey the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, undated and unlabeled food items were observed in multiple freezers and refrigerator/s. The findings are;The facility policy Food Dating and Labeling dated 01/01/2023 documented all dining services employees shall enforce food safety by properly dating and labeling of all food items. Upon delivery all food items must be labeled with date received. In addition to food products being dated upon delivery, items will be dated when container is opened if not used in entirety.During an initial tour/observation of the kitchen on 09/09/2025 at 8:28 AM the refrigerator in the main kitchen contained a package of sliced cheese and a large container of applesauce that were not dated or labeled. The meat freezer contained unlabeled and undated chicken (two packages), rib meats, two sleeves of hamburger meat, a pork loin and pork chops. An adjacent freezer had undated and unlabeled packages of waffles, potatoes and buttered bread slices. A storage shelf next to the freezers had ten bags of cookies without labels. During an interview on 09/09/25 at 08:28 AM Food Service Worker # 22 stated they had no idea why the foods did not have proper labels and dates. They stated all foods in the kitchen refrigerators and freezers needed to have labels and dates in order to determine how long the foods had been there. Thet stated the bags of cookies needed to include the date they were prepared and a label with the type of cookie for allergy reasons.During an interview on 09/09/25 at 2:34 PM the Food Service Director stated they were responsible for everything in the kitchen. They stated foods needed to be labeled to prevent the potential for illness. They stated they conducted frequent staff in service about food label/dates. They stated foods should be dated when delivered and put in the refrigerators and freezers. They stated staff needed constant reminders. 10 NYCRR 415.14(h)

Based on observation and interview during the recertification survey indicated that the facility did not provide residents with a clean, comfortable, and homelike environment. Specifically, multiple resident rooms showed signs of maintenance issues, including spackle and chipped paint, stained and sticky floors, an unpleasant odor, missing blinds, cabinets with chipped paint, black streaks on doors, and a white tint on a window. Furthermore, there was damage to the left armrest of Resident #74's wheelchair, and the wheelchair/seat cushion were soiled with white particles. The findings include:The Maintenance Policy last revised 10/2024 documented the purpose was to establish procedures for reporting, prioritizing, and resolving maintenance and repair needs in the facility, ensuring a safe and well-maintained environment for residents, staff, and visitors.The Wheelchair and Geri-Chair Cleaning Policy last revised 9/2025 documented the purpose is to remove dirt and dust for the purpose of infection control, to ensure proper operation of the equipment and to provide the resident with a sanitary and pleasant environment. A monthly calendar will be created by the Director of Environmental Services for routine and scheduled cleaning of all wheelchairs, also including any immediate cleaning needs.During an observation on 09/09/2025 at 09:02 AM, Resident #7's room had spackle and chipped paint behind the beds and dry brownish stains on the floor between both beds. The floors were sticky.During an observation on 09/09/2025 at 09:02 AM, 09/10/2025 at 10:03 AM, 09/11/2025 at 9:43 AM and 09/11/2025 at 12:25 PM, the second-floor unit had a strong stale pungent odor.During an interview on 09/9/2025 at 09:30 AM, Resident #27 stated they would like a blind for the small thin window in their room because the sun often shined in on their face. They stated in March of 2025 when they were admitted , they told maintenance about the window, and the facility tried to fix it with the plastic covering. Resident #27 stated the white plastic did not help shade the sun and that they told maintenance they still needed a blind for the window. During an observation on 09/10/2025 at 9:17 AM, Resident #3's room radiator was dirty and had chipped paint. On the right side of the window the wall was peeling and bubbling. The small center piece of the window was hanging and loose. The paint on the room door was chipped with black streaks, and the cabinets had chipped paint on the drawers.During an observation on 09/11/2025 at 08:45 AM and 09/11/2025 at 12:25 PM, the left armrest on Resident #74's wheelchair was peeling and ripped. The wheelchair and seat cushion were soiled with white particles.During an observation on 09/11/2025 at 12:43 PM, Resident #27 had a white tinted plastic over the window.The Wheelchair Cleaning schedule for August 2025 documented Resident #74 wheelchair was last cleaned on 8/16/25.The work order logs from January 2025 to September 2025 were reviewed for the [NAME] Unit, the Post Road Unit and the Second Floor Unit. There was no documented evidence of the following observed items in the logs. There was no documented evidence of a need for repair or that repairs had been done. During an interview on 09/12/2025 at 10:45 AM, Certified Nurse Aide #4 observed Resident #74 sitting in the dining room at an arts and crafts activity, the wheelchair was dirty with white particles on it and the wheelchair cushion was soiled with white particles and stains. Certified Nurse Aid #4 stated they did not see the wheelchair earlier that day and did not notice the wheelchair was dirty. During an interview on 09/12/2025 at 10:53 AM, Registered Nurse # 3 stated wheelchairs were cleaned overnight, and housekeeping had a rotating schedule for cleaning wheelchairs. They further stated if a wheelchair was noticeably dirty and needed to be cleaned outside the cleaning schedule, the certified nurse aides were to report it to nursing. During an interview on 09/12/2025 at 11:15 AM, the Maintenance Worker stated they were aware of Resident #27's request to have a thin blind put on the window in their room. They stated when they replaced the window a few months ago they removed all the blinds and Resident #27 asked for a blind, so they put up white tinted plastic to help shade the window and the resident did not like that. The Maintenance Worker stated they did not replace the blind because they worked alone, and other projects were a priority. The Maintenance Worker stated they were down a Maintenance Worker for the department. The Maintenance Worker stated Resident #74 and Resident #7 rooms had areas that needed to be addressed and further stated other projects took priority.During an interview on 09/15/2025 at 09:50 AM, the Director of Environmental Services stated they had only been working at the facility for 3 months and were short staffed, as they were missing 1-2 staff members for the department. The Director of Environmental Services stated they had multiple things they were responsible for central supply, housekeeping, laundry and maintenance. The Director of Environmental Services stated they never hired a floor buffer so housekeeping staff that knew how to use the buffer would take on the extra task. The Director of Environmental Services stated Resident #74's wheelchair was cleaned last month on 8/16/25 and they were not aware the wheelchair was dirty and needed to be cleaned. The Director of Environmental Services stated they had staff that came in from 8-11 PM to clean wheelchairs based on the monthly wheelchair schedule and they also cleaned wheelchairs on request. They stated wheelchairs/cushions were cleaned at the same time. They stated they never smelled odors on the second floor and did not see that the floors needed to be cleaned.During an interview on 09/15/2025 at 2:19 PM, the Administrator stated they had not changed the number of staff working in the housekeeping and maintenance department. The Administrator stated for the most part they felt the facility was clean and things were being repaired. The Administrator stated the second floor needed a total renovation.During an interview on 09/15/2025 at 4:00 PM Certified Nurse Aide #12 stated Resident $74's wheelchair looked good and there was nothing wrong with it. They further stated they never saw Resident #74 wheelchair soiled and never noticed the wheelchair armrest ripped and peeling. During an interview on 09/15/2025 at 4:06 PM Licensed Practical Nurse #3 stated Resident #74's wheelchair was sent down to the basement on 09/12/2025. Licensed Practical Nurse # 3 stated they only noticed the chair was dirty and the armrest was ripped the day they sent it downstairs. 10 NYCRR 483.10(i)(2)

Based on observation, record review and interviews during the recertification survey the facility did not ensure care was provided in a manner to maintain dignity and privacy for one (1) of (2) two residents (Resident #4) reviewed for dignity. Specifically, Resident #4 was observed undressed in bed with their body fully exposed and visible from the hallway. The findings include:The policy and procedure titled Resident Dignity and Privacy Policy last revised 03/17/2025, documented assist residents in grooming with full respect for their privacy and dignity. Visual privacy during activities of daily living care should be maintained at all times.Resident #4 was admitted to the facility with diagnoses including hemiplegia, aphasia and non-Alzheimer's dementia. The 07/13/2025 Minimum Data Set (resident assessment) documented Resident #4 had severely impaired cognition received substantial staff assistance with toileting hygiene, rolling left to right and showers/baths and was dependent on staff with chair to bed transfers. The 10/06/2019 comprehensive care plan titled Preferences documented Resident #4 would be clean/dry and dressed appropriately.The 06/22/2020 comprehensive care plan titled Communication documented meet and anticipate all resident needs.During observation on 09/10/2025 at 09:06 AM and 09:47 AM Resident #4 was awake in bed with their room door open. Resident #4 was undressed, and their body was fully exposed and visible from the hallway. Resident #4's privacy curtain was not drawn around the bed. Staff members and other residents were observed passing by the resident's room. During an interview on 09/11/2025 at 10:38 AM Certified Nurse Aide #17 stated they usually checked on Resident #4 several times during their shift, specifically at the beginning of the shift and after breakfast. Certified Nurse Aide#17 stated Resident #4 often removed their gown. Certified Nurse Aide #17 stated on the morning of 09/10/25, they did not observe whether Resident #17's privacy curtain was drawn, whether Resident #17 was without a gown, or whether the room door was open. Certified Nurse Aide #17 stated they received resident dignity education but could not recall when.During an interview on 09/11/2025 at 11:08 AM Registered Nurse #3 stated in order to maintain resident privacy and dignity during the provision of care, staff must ensure the privacy curtain was drawn around the resident's bed and the door remained closed. Registered Nurse #3 stated when care was not being provided, the privacy curtain should still be drawn around the resident's bed. 10 NYCRR 415.5 (a)

Based on observation and interview during the recertification survey the facility did not ensure the residents right to personal privacy, including the right to promptly receive a package delivered to the facility for the resident, including those delivered through a means other than a postal service for one (1) of three (3) residents (Resident #33) reviewed for choices. Specifically, 1) the facility did not promptly deliver a package within 24 hours to Resident #33 after it had been shipped to and received by the facility.The findings include:The undated policy and procedure titled Mail Delivery documented the facility will ensure that all mail and packages are delivered to the appropriate recipient in a timely, correct and efficient manner. Resident #33 was admitted to the facility with diagnoses including peripheral vascular disease, heart failure and diabetes mellitus.The 06/11/2025 Minimum Data Set (resident assessment) documented Resident # 33 had intact cognition.During observation and interview on 09/09/2025 at 10:50 AM Resident #33 stated they ordered a device, as recommended by their physician, to help manage leg swelling. Resident #33 stated they had been waiting for the package to be delivered for a long time. Resident #33 stated when they contacted the shipping company, they learned their package had been delivered to the facility on [DATE]. Resident #33 stated they asked staff whether the package had been received, but no one responded to their inquiry. Resident #33 stated they called the facility front desk twice during the previous week and were told their package had not arrived. During an interview on 09/10/2025 at 11:47 AM the Recreation Director stated their department distributed all resident packages when they were delivered to the facility, with the exception of medical supplies. The Recreation Director stated medical supplies were received and distributed to units by the Administrative Assistant. The Recreation Director stated they checked downstairs 09/10/2025 and located Resident #33's package in the business office. During an interview on 09/10/2025 at 03:00 PM Resident #33 stated on 09/10/2025 recreation staff brought the package to them.During an interview on 09/10/2025 at 03:49 PM the Receptionist stated all packages were delivered either through the front entrance or if the packages were big, through the back entrance. They stated packages delivered to the back entrance were to be placed across the hall from the housekeeping office, after which either housekeeping or a social worker may bring them to the front desk. The Receptionist stated a package for Resident #33 arrived on Monday, 09/08/2025 but they did not see it at that time. They stated Resident #33 reached out to them twice on 09/09/2025, to check on the arrival of their package. They stated no one answered the phone in the recreation department and because they were busy, they had not followed up with anyone regarding the package.During an interview on 09/11/2025 at 10:17 AM the Administrative Assistant stated all packages entered the facility through the back door, where they were signed for by dietary, housekeeping, or administration staff and stored in the hallway. The Administrative Assistant stated they received a package for Resident #33 last week and placed it in the business office. They stated they planned to follow up.10 NYCRR 415.3

Based on observation, record review and interviews during the recertification survey the facility did not ensure that needed equipment was provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for one (1) of (4) residents (Resident # 50) reviewed for position and mobility. Specifically, Resident #50 was observed on three occasions without the use of a physician prescribed left elbow extension splint and left-hand roll. The findings include:The policy and procedure titled Use of Positioning Devices for Residents last revised 01/2025, documented proper use of positioning devices is essential to support resident independence and mobility. Nursing staff are responsible to implement care plans, perform skin assessment, apply and monitor devices, document care provided. Resident #50 was admitted to the facility with diagnoses including cerebrovascular accident, hemiplegia and non-Alzheimer's dementia.The comprehensive care plan titled Contractures/Actual last updated on 11/15/2023 documented use a left elbow extension splint and hand roll, as per physician order. The 10/29/2025 physician order documented apply a left elbow splint during the day shift and remove for activities of daily living, passive range of motion and skin checks.The 10/29/2025 physician order documented apply a left-hand roll at all times and remove for activities of daily living, passive range of motions and skin checks.There was no documented evidence in the comprehensive care plan to address refusal of the left elbow extension splint and hand roll. The 06/27/2025 Minimum Data Set (resident assessment) documented Resident # 50 had moderately impaired cognition. During observations and interview on 09/09/2025 at 09:19 AM, 09/10/2025 at 09:37AM and 09/11/2025 at 01:26 PM Resident #50 was in bed. Resident #50 did not have a left-hand roll and left elbow splint in place. Resident #50 stated staff needed to put a hand roll and elbow splint on for them to wear, but they had not done that. During an interview on 09/11/2025 at 01:28 PM Certified Nurse Aide #16 stated they were aware Resident #50 was to wear a left-hand roll and left elbow splint during the day. Certified Nurse Aide #16 stated at times Resident #50 refused to wear the elbow splint and left hand-roll and they reported that to the nurse. During an interview on 09/11/2025 at 01:46 PM Registered Nurse #3 stated Resident #50 was supposed to wear a left elbow splint and left-hand roll during the day. Registered Nurse #3 stated at times Resident #50 refused to wear devices and the staff tried to encourage the resident to wear them. Registered Nurse #3 stated they did not document Resident #50's refusal to wear devices. Registered Nurse #3 stated they were aware of the need to report Resident #50's refusal to wear the splint and hand roll to the physician and rehabilitation therapy, but they had not reported.During an interview on 09/15/2025 at 03:46 PM the Rehabilitation Director stated Resident #50 was admitted with left-sided hemiplegia and contractures in the left elbow and hand. They stated the use of splints helped slow the progression of contractures, whereas not wearing splints may accelerate the progression of the existing contractures. They stated according to staff Resident #50 had a limited tolerance for wearing splints for extended periods during the day. 10 NYCRR 415.12(e)(2)

Based on record review and staff interview during the Recertification Survey the facility did not ensure that they adequately maintained an infection control program designed to provide a safe and sanitary environment for one (1) of two (2) residents (Resident #3) reviewed for pressure ulcers and that a Legionella sampling and water management plan for its potable water system was adopted and implemented. Specifically, (1) Registered Nurse #3 touched surfaces and then without performing hand hygiene handled guaze that was used to clean Resident #3's wound and (2) the facility did not provide a water management and sampling plan at the time of survey. The findings include: The infection and prevention control program policy dated 02/20/2025 documented the facility will establish and maintain an infection prevention and control program under which it prevents, identifies, reports, investigates, and controls the spread of infections and communicable diseases in the facility. (1) Resident # 3 was admitted with diagnoses including but not limited to hypertension, hyperlipidemia, and traumatic subdural hemorrhage. The 06/02/2025 Significant Change Minimum Data Set (an assessment tool) documented Resident #3 had severely impaired cognition, was dependent for bed mobility, and had one unhealed pressure ulcer that was not present on admission. The 08/13/2025 physician order documented pressure ulcer of the buttocks/sacral area. Cleanse with normal saline, pat dry, apply a duoderm hydrocolloid dressing and Medi-honey every shift and as needed. During an observation on 09/10/2025 at 9:45 AM Registered Nurse # 3 opened the medication cart, removed Medi-honey from the medication cart, and placed Medi-honey into a calibrated cup. Registered Nurse # 3 placed the Medi-honey back into the medication cart and closed the drawer. Without performing hand hygiene and without the use of gloves Registered Nurse #3 removed guaze from its packaging, placed one guaze into the calibrated cup and used a finger to push the guaze down into the calibrated cup. Registered Nurse #3 repeated this process two additional times. Registered Nurse # 14 poured normal saline into the calibrated cup which contained the guaze that had been placed by Registered Nurse #3 and proceeded to cleanse Resident #3's sacral wound. During an interview on 09/15/2025 at 1:41 PM, Registered Nurse # 3 stated they could not remember using hand sanitizer before they prepared the gauze and placed each into the calibrated cup. They stated if they did not use hand sanitizer, it was their error. Registered Nurse # 3 additionally stated they were in-serviced on proper set up for treatments. They stated hand hygiene should have been performed after they touched surfaces and before they touched and placed the guaze into the calibrated cup. During an interview on 09/15/2025 at 1:56 PM, Registered Nurse # 14 stated they did not observe Registered Nurse # 3 touch the guaze with their hand/s, without performing hand hygiene. They stated they would have discarded the gauze and started over. (2) There was no documented evidence of the facility's required annual Legionella assessment for the year 2024 and 2025 and the Water Management plan for the potable water system was missing and not provided at time of survey. The facility submitted legionella lab test results dated 01/13/2025 and the water sampling lab reports for the year 2024 were missing and not provided at time of survey. During the exit conference on 09/10/2025 at 1:30 PM, the Administrator stated the annual facility assessment and the water management plan were conducted, however the documents could not be located. 10 NYCRR 415.19(a) (1-3)

Based on observation, record review and interview conducted during the recertification survey the facility did not ensure infection control prevention practices were maintained to prevent development and transmission of communicable diseases and infection for all residents. Specifically, there was no documented evidence of COVID-19 education, COVID-19 vaccination administration and/or COVID-19 declination for two (2) of ten (10) staff (Certified Nurse Aide #20 and Licensed Practical Nurse #21) reviewed for COVID-19 vaccination. The findings are:Review of staff immunization records revealed there was no documented evidence that Certified Nurse Aide #20 and Licensed Practical Nurse #21 were offered the COVID-19 vaccination, COVID-19 vaccination education, and that COVID-19 vaccination consent or declination had been signed. During an interview on 09/10/2025 at 12:07 PM the Director of Nursing stated they started obtaining consent/s for the COVID-19 vaccination last fall. They stated they also provided COVID-19 vaccination education and had staff sign declinations. They stated they were unable to provide documented evidence for Licensed Practical Nurse #21 and Certified Nurse Aide #20. During an interview on 09/10/2025 at 3:40 PM Registered Nurse #14 stated they were being trained and were new to the role of Infection Preventionist. They stated the records left behind by the previous Infection Preventionist were not orderly and needed to be set up better. 10NYCRR 415.19 (a)(1-3)

Based on observations, interview, and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. Two heavily soiled circulation fans were in use, one in a food production area and one at the clean side of the dishwasher, 2. a. kitchen staff used their bare hand to retrieve a piece of aluminum foil that had fallen into a pan of chicken and gravy, and b. a soiled and peeling food cart was in use for holding cooked foods, 3. 1 of 3 nourishment refrigerators contained multiple unlabeled and expired food items, 4. a. For 2 of 2 microwaves for use on the resident units ([NAME] and Maple Avenue), there were no thermometers available to check food temperatures and b. for 1 of 2 microwaves (Maple Avenue) there were no procedures/guidance posted and no thermometer available to ensure monitoring for safe food temperatures, and 5. Dietary staff did not follow safe food handling procedures while recording food temperatures. The findings are: During the initial tour of the kitchen on [DATE] at 10:24 AM and follow up kitchen and pantry observations, the following were observed: 1) On [DATE] at 11:04 AM a food preparation (prep) table was observed in a storage room containing dry goods, frozen foods/freezer, and refrigerated food/refrigerators. A large fan was observed on the wall directly above the prep table, the fan was in use, and the fan grill and blades were observed to be heavily soiled with an accumulation of dust. During a follow up observation conducted on [DATE] at 12:14 PM, Dietary Aide #1 was observed working on the storage room prep table portioning a fruit dessert for the residents. The large black fan was in use and remained heavily soiled with an accumulation of dust on the fan grill, and the fan blades were soiled a black-ish colored grime. In an interview at that time, Dietary Aide #1 stated they did not check the cleanliness of the fan. In an interview on [DATE] at 12:20 PM, the Food Service Director stated the fan was dusty, they should not prepare food under the dusty fan, and the dust could get in the food and contaminate the residents' food. The Food Service Director stated that maintenance was responsible for cleaning the fan. During an observation and interview on [DATE] at 12:38 PM, maintenance worker #1 (MW #1) and surveyor observed the soiled storeroom fan. MW #1 stated their procedure was to check the fan monthly and clean if dirty. At that time, surveyor and MW #1 walked the kitchen and observed an additional large circulation fan in use which was blowing air on the cleaned and sanitized equipment side of the dishwasher. The dishwasher fan's grill was heavily soiled with an accumulation of dust, and the fan blades were soiled with black-ish colored grime. MW #1 stated they were responsible to check the fan monthly and clean if dirty. MW #1 offered no explanation as to why the fans had not been cleaned timely. In an interview on [DATE] at 12:48 PM, The Director of Environmental Services stated that the fans were last cleaned on [DATE]. The Director of Environmental Services produced a weekly log titled Kitchen/Dining Room - Exhaust Fan, Vents, and Fans dated November. The weekly log documented that the dishwashing area and back storage room fans had been cleaned and were working properly for the first two weekly audits of November dated [DATE] and [DATE]. The third week audit was completed and undated, and the fourth week audit was not completed. An undated policy titled Kitchen/Dining Room Exhaust Fans which documented that the dietary department must inspect and document daily that the fan is cleaned, and that the Director of Environmental Services and/or designee would document and monitor the exhaust fan monthly and/or as needed. 2. (a) On [DATE] at 11:21 AM a food prep cart was observed in the cook's area holding pan #6 was covered with aluminum foil and contained chicken and gravy pan. Cook #1 opened the foil on pan #6 and a small piece of aluminum foil fell into the pan. Cook #1 reached their bare hand into pan #6 to remove the piece of aluminum foil. In an interview at that time, Cook #1 stated that they should have put on a glove before removing the foil to prevent the risk of food contamination. (b) The food prep cart was observed with peeling, plastic surfaces. In an interview at that time Cook #1 stated they did not know if the peeling plastic surfaces were safe to hold/serve food from. In an interview on [DATE] at 11:33 AM, the Food Service Director stated that once the cart surfaces start losing their glaze and stuff starts coming up, it was not good. The Food Service Director stated that anything that was peeling or loose could get into the food. 3. During observations of the nourishment pantries and refrigerators on [DATE] between 11:15 AM - 12:01 PM the following were identified: The 1st floor Post Road unit nourishment refrigerator contained multiple expired items including: - An opened, undated, and unlabeled 8.5 oz. bottle of Deli dressing with a use by date of [DATE]. - An opened 12 oz. bottle of Honey Mustard with a use by date of [DATE]. - An opened, undated, and unlabeled 15 oz. bottle of Mayonnaise with a best by date of [DATE]. - An unopened, undated, and unlabeled 5.5 oz. bottle of Mayonnaise with a best used by date of [DATE]. - An opened, undated, and unlabeled 24 oz. bottle Pancake syrup with no manufacturers expiration date or use by date on the label. In an interview on [DATE] at 11:31 AM, the Licensed Practical Nurse (LPN #3) stated they did not know who the items belonged to. In an interview on [DATE] at 11:33 AM, the Food Service Director stated that the dietary department is responsible for discarding expired food items, and they would discard the items. 4. (a) During an observation of the 2nd floor (Maple Avenue) pantry on [DATE] at 11:40 AM a microwave was observed. A policy dated ,d+[DATE] and titled Microwave Reheating was posted in the pantry and documented that foods reheated in a microwave were to be reheated to 165 degrees, stirred, covered, and allowed to stand for 2 minutes as a safeguard against foodborne illness, and a thermometer should be used to verify final reheated temperatures. No thermometer was found in the pantry. In an interview on [DATE] at 11:47 AM, LPN #4 stated there was no thermometer for checking the microwaved foods, and they knew the warmed food was a safe temperature for the resident by touching the top of the plate cover. (b) During an observation of the first floor [NAME] unit nourishment pantry on [DATE] at 11:53 AM a microwave was observed. There was no written guidance found for use of the microwave. No thermometer was found in the pantry. In an interview on [DATE] at 11:55 AM, LPN #3 stated that they did not see a thermometer to use after microwaving food. When asked how they determine a safe food temperature for the residents' reheated food, LPN #3 stated they would heat the food on a low time, about 15 seconds. 5. On [DATE] at 12:08 PM during an observation of food temperature monitoring the Food Service Director wiped a thermometer probe with a pink cloth, then placed the thermometer probe into a pan of chopped broccoli. The Food Service Director then proceeded to wipe the thermometer probe with the pink cloth and place the thermometer probe into a pan of yellow rice. The Food Service Director continued to repeat this procedure for chicken, mashed potato, pureed broccoli, and chopped fish. In an interview at that time, the Food Service Director stated they knew they should have used alcohol wipes to sanitize the thermometer probe. 10NYCRR 415.14 (h)

Based on observation, record review and interview during the recertification survey from 11/28/23 to 12/4/23, the facility did not ensure residents had the right to a dignified existence in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 5 residents (Resident #46) reviewed for dignity. Specifically, Resident #46 had a sign next to their bed stating walk me every day. Findings include: Resident #46 was admitted with diagnoses including but not limited to malignant neoplasm of the lung and acquired absences of the larynx. The annual Minimum Data Set (MDS) dated [DATE] documented Resident #46 had moderately impaired cognition and required limited assistance of one staff for ambulation. During observations on 11/28/23 at 3:09 PM, 11/30/23 at 1:00 PM and 12/1/2023 at 10:56 AM, the wall next to near the bed of Resident #46 had a sign which documented walk me every day and included a picture of staff assisting with ambulation. During an interview on 12/1/2023 at 3:28 PM the resident's family stated they did not put signup or give permission for staff to hang signs in Resident #46's room. During an interview on 12/1/2023 at 3:00 PM, Certified Nurse Aide (CNA) #1 stated the signs were there to alert staff to walk Resident #46. CNA #1 stated directions for resident care were also in the care card. During an interview on 12/1/2023 at 3:15 PM Licensed Practical Nurse (LPN) #1 stated the sign was placed in the resident room to remind the rehabilitation staff and the nursing staff to ambulate Resident #46. During an interview on 12/1/2023 at 3:39 PM, the Rehabilitation Director stated the signs were placed to remind Resident #46 that they should walk with staff. 10NYCRR 415.5 (a)

Based on observations, interviews, and record review conducted during the recertification survey from 11/28/23 to 12/4/23, it was determined the facility did not ensure maintenance services necessary to maintain a safe, clean, comfortable and homelike environment were provided for 1 of 1 resident (Resident #40) reviewed for environment. Specifically, Resident #40's room had an accordion style bathroom door that was falling off the track. The findings are: The policy titled Maintenance effective 10/2017, documented to ensure that necessary work was completed on a timely basis and that appropriate records of all work were maintained. The maintenance logbook dated 7/10/2022, documented room [ROOM NUMBER]/216 toilet door was still broken. The maintenance logbook dated 3/17/2023, documented room [ROOM NUMBER]-bathroom door was broken and falling down. During observations on 11/28/2023 at 12:55 PM and 11/30/2023 at 12:51 PM, the bathroom door on the side of room [ROOM NUMBER] was broken and hanging off the track. During an interview on 11/28/2023 at 12:58 PM, Resident #40 stated the accordion style bathroom door had been broken for at least a year. During an interview on 12/04/2023 at 10:57 AM, Licensed Practical Nurse (LPN) #2 stated they never noticed the bathroom door in room [ROOM NUMBER] was broken. During an interview on 12/04/2023 at 11:33 AM, Registered Nurse (RN) #1 stated they knew the bathroom door in room [ROOM NUMBER] was broken. RN #1 stated information regarding the broken accordion style bathroom door was entered in the maintenance logbook. During an interview on 12/01/2023 at 12:34 PM, the Environmental Services Director stated they were unsure why the bathroom door in room [ROOM NUMBER] was not fixed. 10NYCRR415.11(c)(1)

Based on observations, interviews, and record review during the recertification survey from 11/28/23 to 12/4/23, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their mobility for 1 of 1 resident (Resident #65) reviewed for Activities of Daily Living (ADLs). Specifically, nursing staff did not ensure Resident #65's progressive mobility was maintained in accordance with the providers orders and professional standards. The findings are: Resident #65 was admitted to the facility with diagnoses including but not limited to intracerebral hemorrhage, epilepsy, and chronic obstructive pulmonary disease. A review of the quarterly Minimum Data Set (MDS- a resident assessment tool), dated 10/1/23, documented Resident #65 was severely cognitively impaired, had impairment of both upper and both lower extremities, and required assistance for mobility and transferring. A current provider order initiated 3/1/23 document Resident #65 was to be out of bed to their geri-chair, and out of bed with the assistance of two persons and a mechanical lift. A physical therapy assessment dated [DATE], documented Resident #65 was to be out of bed to their geri chair with the assistance of two staff and a mechanical lift. During observations on 11/28/23 at 10:09 AM and 12:16 PM, 11/29/23 at 11:51 AM, 11/30/23 at 2:59 PM, and 12/01/23 at 9:16 AM, Resident #65 was in their bed in a hospital gown. During an interview on 11/30/23 at 3:08 PM, Certified Nurse Aide (CNA) #2 stated Resident #65 had not been out of bed this week. CNA #2 stated the facility did not have a schedule to get residents out of bed and the last time they remembered Resident #65 being out of bed was a week ago. During an interview on 12/1/23 at 12:28 PM, the Director of Nursing (DON) stated Resident #65 should be out of bed daily and stated there was no formal system in place to ensure staff were getting residents out of bed. 10NYCRR 415.12(a)(2)

Based on observations, interviews and record review conducted during a recertification survey, it cannot be ensured that the facility stored food in resident refrigerators according to professional standards for food safety to prevent foodborne illness. Specifically, foods stored in 2 of 3 unit refrigerators (First and Second Floors) were not labeled with the resident's name or the date the item was brought to the facility. The findings are: Review of the facility policy titled, Use and Storage of Food Brought to Residents by Visitors, dated 8/2019 showed that food brought in for a resident is to be labeled by nursing staff with the resident's name, room number, and date the item was brought to the facility. Furthermore, cooked or prepared food brought to the facility is to be discarded after 72 hours by the nursing staff. 1. The first-floor resident pantry refrigerator on the Quimby Unit was observed with RN #1 on 10/8/2020 at 12:05PM and contained several items brought in from outside the facility. Three leftover meal containers had no date that indicated when the food was first placed in the refrigerator. RN#1 stated that all food brought in by family members needs to be dated and labeled with the resident name and room number by the nursing staff. When asked how long the food was kept in the refrigerator, he stated there was no way to tell. 2. The second-floor resident pantry refrigerator was observed with the Unit Manager LPN #1 on 10/13/2020 at 9:58AM. The refrigerator contained food items in containers placed in plastic bags. Two of the bags had no date as to when the food was brought in from outside the facility. Of note, one plastic bag with food in containers was labeled with the date 10/5/2020 indicating the food should have been discarded five days prior to the observation date. LPN #1 stated that nursing is supposed to examine the food items in the refrigerator each shift and discard food items after 72 hours. The Food Service Director was interviewed on 10/8/2020 at 2:26PM regarding the policy for food stored in residents' refrigerators. He stated that the nursing department is responsible for labeling and dating foods prior to placing them into the refrigerator. He added that items brought in from outside must be held no more than 3 days. 415.14(h)

Based on observation, interview and record review conducted during the most recent recertification survey, the facility did not ensure that written menus were followed as planned. Specifically, the dietary staff did not ensure that adequate amounts of fresh fruits were available for service for 2 of 2 residents (#57 and #16) when indicated on the menu. The findings are: 1) On 3/5/19 at 4:04 PM during an interview, Resident #57 stated that fresh fruit was not being served. According to the menu fresh fruit was to be served at the breakfast meal on 3/8/19. Observation of this meal revealed that canned pears were served as a substitute. A review of the three-week cycle menu revealed that fresh fruits were planned to be served at least two times weekly. On 3/8/19 at 11:40 AM the Food Service Director (FSD) was interviewed. He stated that the fresh fruits served during the winter months were apples, bananas, cantaloupe and grapes. When a purchase order is submitted, if the cost of the the fresh fruits were too high the item(s) would not be purchased. Another fresh fruit was not substituted for an item that was not purchased. Observation of the fruit and vegetable reach-in refrigerator on 3/8/19 at 3:30 PM revealed no fresh fruits. Immediately following this observation the FSD was interviewed. He stated that fresh fruits were not available for the week of 3/3/19. Deliveries are made once weekly to the facility, which had an impact on the availability of certain fresh fruits such as bananas. 2) An interview was conducted on 03/05/19 at 03:21 PM with Resident #16 and she stated she did not receive fresh fruits (especially grapes and bananas) on her meal tray and that she had spoken with dietary multiple times, but nothing changed. According to the menu fresh fruit was to be served at the breakfast meal on 3/8/19. Observation of the breakfast meal revealed that canned pears were served as a substitute. An interview was conducted on 3/8/19 at 11:44 AM with the FSD. He stated the facility provided the residents with fresh fruit two times weekly. He further stated the facility received a fruit delivery weekly but had been out of bananas for a few days. 415.14(c)(1-3)

Based on observation and interview conducted during the most recent recertification survey, the facility did not ensure that refrigerated food items were safe for consumption and that food service equipment was maintained free of debris to prevent contamination. Specifically, 1) deli meat (salami) over 6 weeks past the sell by date was being stored in the refrigerator for later use; 2) refrigerated perishable food items were not dated; and 3) food service equipment was not being maintained free of dust, debris and built-up grease. The findings are: During the initial tour of the kitchen on 3/5/19 at 9:50 AM the following was observed: 1. A roll of salami sealed in plastic and weighing 7.5 pounds was stored in one of the reach-in refrigerators. A follow-up visit to the kitchen on 3/5/19 at 2:30 PM revealed that the sell by date on this item was 1/19/19. There was no date on the salami to indicate when it was delivered to the facility. At that time the Food Service Director (FSD) discarded the salami. On 3/8/19 at 3:15 PM the FSD was interviewed to determine if the facility had a system in place to ensure that foods are rotated in accordance with professional standards for food service safety. He stated that he was new to the facility and that they do follow the first in first out method of rotating food items. 2. A plastic container with what appeared to be tuna fish was opened and undated in another reach-in refrigerator. Additionally, three wrapped sandwiches containing deli meat (possibly bologna) and processed cheese not labeled and dated were being stored in this reach-in refrigerator. The FSD discarded these items. 3. A fan containing dust was noted near the rack on which pots and pans were stored. The top shelf of this rack was covered with a layer of dust. Another dusty fan was noted next to the clean receiving end of the dishwasher. The fan was blowing on items as they came out of the dishwasher. 4. The interior and exterior surfaces of the oven, the top of the stove and a table on which the steamer was placed exhibited dust, grime and/or debris. The FSD and one of the cooks stated that they did not have sufficient staff to clean the equipment in the kitchen because they were short three dietary workers. 415.14(h)

483.70 (b) Compliance with Federal, State, and Local laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Based on observation and interview during the recertification survey, the facility was not in compliance with Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. Carbon monoxide detectors were not installed in mechanical rooms in the basement containing fuel fired equipment (laundry room, boiler room, generator room, etc). The findings are: On 3/8/19 at approximately 9:30 AM during a tour of the 2nd floor nursing unit conducted during the recertification survey, a maintenance department staff member was asked whether carbon monoxide (CO) detectors had been installed in the facility. He said that battery powered combination smoke/carbon monoxide detectors were installed at each nurse's station and that they cover a large area. A detector was observed on the ceiling in front of the 2nd floor nurse's station. Both modes (smoke and CO) were tested and functioned. Two additional detectors were observed installed on the first floor units (Quimby and Post Road) during a tour conducted between 10:20 AM - 11:00 AM that same day. According to the maintenance staff member, these detectors sound a local alarm only, and are supplemental to the facility's hard-wired smoke detectors that are tied into the fire alarm panel. On 3/08/19 at 8:00 AM, a tour of the basement was conducted and carbon monoxide detectors were observed to be lacking in the following areas housing natural gas-powered equipment: -boiler room (2 boilers) -generator room (1 generator) -laundry room (2 dryers) -kitchen (stove) In an interview at that time, the Director of Environmental Services stated that he had contacted a vendor to install additional hard-wired carbon monoxide detectors in the required mechanical areas and on the nursing units if needed. 483.70 (b)

Based on observation and interview during the recertification survey, the facility did not maintain all mechanical equipment in safe operating condition. This was evidenced by: 1. The roof was not maintained in a manner necessary to prevent leaks in exit corridors and stairs. Specifically, water was observed dripping from a ceiling mounted air conditioning unit near the 2D stairwell exit and collecting in a trash trash can, and a bucket had been placed above the ceiling tiles to capture water in the same stairwell. These conditions would not ensure that the exit corridor and stairwell would be safe and readily available at all times in the event of an emergency. 2. Sufficient air circulation was not provided for the employee dining room, and an exhaust fan in the adjacent main kitchen was broken, resulting in excessive moisture and condensation in the employee dining room. The findings are: During the recertification survey conducted on 3/7/19, 3/8/19 and 3/11/19 between 8:00 AM - 3:00 PM, the following issues with ventilation in the staff dining room and the condition of the roof were noted: 1. At 11:30 AM on 3/7/19, during a tour of the basement, the employee dining room was visited and it was noted that one wall of the room is almost completely glass. The glass was covered in condensation and the small windows located along the bottom of the glass panel were closed. There was no mechanical exhaust provided in this room. A steam table was located across the space between the employee dining room and the adjacent main kitchen. A fan in the exterior wall of the kitchen nearest the employee dining room was off and its baffles were coated with dirt and dust. In an interview at that time, the Director of Environmental Services confirmed that a heat detector in the employee dining room had gone off due to the steam from the steam table. He added that the door to the employee dining room is usually kept open, but it had been closed the previous day due to the cold weather. (This room is located adjacent to a parking lot exit). A technician was scheduled to come on site on 3/7/19 or 3/8/19 to replace the smoke detector if necessary and reset the fire alarm panel. In a concurrent interview at 9:50 AM the same day, a Maintenance Department staff member stated that a new fan had been ordered approximately 2 weeks ago. At 12:00 PM on 3/8/19, a technician stated that he had adjusted the existing heat detector and reset the fire alarm panel. According to the technician, the employee dining room is not provided with enough ventilation. The dining room was re-visited at that time and the glass panel was free of condensation. In a separate interview at 12:10 PM on 3/8/19, the Maintenance Department staff member stated that the existing fan will be cleaned and that he will try to repair the exhaust fan while waiting for the new fan to be delivered. 2. At 8:25 AM on 3/8/19, a tour of the 2nd floor unit was conducted and water was noted to be dripping from a large ceiling mounted air conditioning unit directly in front of stairwell exit D2 into two small trash cans. The stairwell was examined and two ceiling tiles were noted to be missing. A plastic bucket on a plywood base was visible above the ceiling. In an interview at 8:30 AM on 3/8/19, the Director of Environmental Services stated that when it rains heavily or there is melting snow on the roof, water enters in the areas noted. The roof was visited at approximately 8:35 AM on 3/8/19. There were areas noted to be covered with snow, but the 4 drains were free of leaves and snow. In an interview at that time, the Director of Environmental Services stated water and snow are regularly swept off the roof by a member of the Maintenance Department. He further stated that he will ensure that the emergency exit Stair D2 is accessible at all times is maintained in a safe manner. In an interview conducted at 9:35 AM on 3/8/19, the Administrator stated that ownership is aware of the issues with the roof, and that 4 or 5 proposals to replace the roof have been received and are being reviewed. The Administrator was instructed to submit a construction notice application with a safety plan for this anticipated project. 483.90(d)(2)

Based on record review and interview the facility did not ensure that care plans were developed to address issues related to pain and depression. This was evident for 1 resident reviewed for pain (Resident #65) and 1 of 5 residents reviewed for unnecessary medications (Resident #60). The findings are: 1) Resident #65 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) 60 day assessment dated [DATE] indicated the resident had occasional pain at a level 2, that does not interfere with sleep or activities. During the resident interview on 3/7/19 at 3:55 PM the resident complained of pain. The following pain medications were included in the physician's orders [REDACTED].>Tylenol 650 mg every 6 hours as needed, [MEDICATION NAME] (a medication for nerve pain) 100mg three times per day for [MEDICAL CONDITION] and Diabetic [MEDICAL CONDITION]. There was an additional order to monitor and record pain every shift. The MAR (Medication Administration Record) was reviewed and the pain scale was documented as 0 (having no pain) on all shifts during (MONTH) 2019 and (MONTH) 2019. The assigned CNA (certified nursing assistant) was interviewed on 3/08/19 at 9:15 AM. When asked if the resident complains of pain she stated sometimes he complains of pain in his knee. In an interview with the resident on 3/08/19 at 10:09 AM regarding pain he stated he has a lot of burning pain in his right leg. He stated he can't really feel his foot. When asked if he told anyone he stated he tells everyone. In an interview with the RN (registered nurse) supervisor at that time he stated he just moved the resident to a new room and spent a lot of time with him and he did not complain of any pain. In an interview with the Nurse Practitioner at that time she stated she saw the resident on the previous day and he stated he has some pain in his throat but did not express pain in his leg. She stated she would increase his [MEDICATION NAME] dose as he is on a very low dose. Review of the comprehensive care plan indicated the resident did not have a care plan to address pain. The RN supervisor was interviewed on 3/08/19 at 11:16 AM. When asked about a care plan to address the resident's complaints of pain he stated he was not present when the resident was admitted . He stated with a new admission he would review the medications the resident is prescibed and create care plans related to that. He stated he would also look at [DIAGNOSES REDACTED]. 2) Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident was receiving antidepressant medication during all 7 days of the assessment period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. daily for depression until 1/4/19. The order was changed to Trazadone 25mg. three times daily at that time. Review of the (MONTH) 2019 physician's orders [REDACTED]. at bed time for depression. The comprehensive care plan was reviewed and there was no documented evidence that a care plan had been developed to address the resident's depression. The RN supervisor was interviewed on 3/08/19 at 11:16AM. He stated he was not present when the resident was admitted and for a new admission he would review the medications the resident is prescribed and create care plans related to them. 415.11(c)(1)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that 1 of 2 residents (Resident #74) was given the opportunity to participate in the development, review and revision of his care plan. Specifically, Resident #74 was not invited or included in his latest quarterly or annual care plan meetings. The finding is: Resident #74 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident assessment and screening tool) dated 8/3/18 indicated that the resident scored 15 out of 15 on the BIMS (Brief Interview for Mental Status; used to measure memory, recall and orientation) and suggested the resident was cognitively intact and able to participate in his assessment. Resident #74 was interviewed on 3/5/19 at 2:30 PM and stated that he did not recall being invited or attending a care plan meeting within the past year. There was no documented evidence in resident's clinical record that a quarterly or annual care plan meeting was held, or that the resident and his representative had been invited to attend. The Director of Social Work (DSW) was interviewed on 3/7/19 at 12:35 PM. The DSW stated that he was employed at the facility for a month and could not take responsibility. The MDS Coordinator was interviewed on 3/8/19 at 12:30 PM and stated that the social worker was responsible for care planning. She also stated that the DSW was new to the facility, he was not trained, and she had assumed the role of care planning. When requested, the MDS Coordinator was unable to locate any progress notes or signature attendance sheets for the resident's latest quarterly or annual care plan meetings. The Director of Nursing (DON) was interviewed on 3/8/19 at 1:30 PM. The DON was unable to provide any documented evidence that the resident or his representative was invited to or attended his latest quarterly or annual care plan meetings. 415.11(c)(2)(i-iii)

Based on observation, record review and interview conducted during the re-certification survey, it was determined that treatment and care was not provided in accordance with professional standards in order to meet the resident's physical needs. Specifically, 1 of 2 residents (Resident #8) reviewed for positioning and mobility was observed on multiple occasions without a positioning device as ordered by the physician. The findings are: Resident #8 had [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set; an assessment tool) indicated the resident had severe cognitive impairment and functional limitation to both upper and lower extremities. Review of the physician's orders [REDACTED]. Review of the comprehensive care plan dated 2/7/18 revealed the following; actual contracture to both upper and lower extremities; functional versus non-functional with interventions to apply the right elbow and wrist/ hand splint as per the physician's orders [REDACTED].>An observation on 03/06/19 at 11:43 AM revealed the resident sitting in a geri chair without the use of the right elbow or wrist splint as per the physician's orders [REDACTED].>Multiple observations on 3/7/19 at 10:30 AM, 11:45 AM and 1:54 PM revealed the resident lying in bed without the right elbow or wrist splints in place as per the physician's orders [REDACTED].>An interview was conducted on 3/7/19 at 1:56 PM with Licensed Practical Nurse (LPN #2) and she stated she was not sure who was responsible for applying the resident's splints. An interview was conducted on 3/7/19 at 2:03 PM with LPN #1 and she stated the CNAs ( certified nursing assistants) were responsible for applying the splints. An interview was conducted on 3/7/19 at 2:15 PM with CNA #1 and she stated the resident did not use positioning splints and she did not apply them. She then checked the CNA care guide which contained directives for the use of the splints and stated the resident was supposed to wear splints but she did not know what they were. 415.12

Based on observation, record review and interview conducted during the re-certification survey, it was determined for 1 of 1 residents (Resident #76) reviewed for communication/sensory status that treatment and care was not provided in order to meet the resident's physical, mental, and psychological needs. Specifically, the resident was not provided optometry services per physician's orders [REDACTED].>The findings are: Resident #76 had [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set; an assessment tool) dated 2/3/19 indicated the resident was cognitively intact and had adequate vision with the use of glasses. Review of the physician's orders [REDACTED].>Review of the comprehensive care plan revealed the following; 7/21/18- visual deficit as evidenced by use of glasses, interventions; eye drops as needed, maintain eye glasses, ophthalmology and optometry consults as appropriate. Review of the nurses' progress notes dated 11/4/18 indicated the resident requested to see the eye doctor as she had difficulty reading with her current eyeglasses. The resident was placed on a list for the optometrist to follow up. An interview was conducted with Resident #76 on 3/5/19 at 1:58 PM and she stated she had glasses but she had been having difficulty reading with her eye glasses. She further stated she had been asking for a long time to be seen by the eye doctor. An interview was conducted on 3/7/19 at 11:47 AM with the Registered Nurse (RN #1) and she stated she checked the electronic medical record and was unable to find documentation that the resident had been seen by the optometrist. She stated the optometrist was scheduled for (MONTH) 20, 2019 and added she did not know why the resident had not seen earlier 415.12(3)(b)