Ross Center for Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was identified during the Kitchen Task. Specifically, during follow-up kitchen tours on 01/15/2026 and on 01/16/2026, the walk-in freezer temperatures were observed to be 26 degrees Fahrenheit (the food safety requirement should be at or below zero (0) degree Fahrenheit). Additionally, one (1) of the three (3) evaporator fans in the walk-in freezer were not operational. The finding is: The facility policy and procedure titled Food Storage dated 01/13 documented all perishable foods are stored in either refrigerators maintained at 41 degrees [Fahrenheit] or below, or freezers at zero (0) degree [Fahrenheit], or below respectively. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not immediately inform the resident's Physician when there was a significant change in the resident's physical, mental, or psychological status (that is, a deterioration in health, mental, or psychological status in either life threatening conditions or clinical complications). This was identified for one (1) (Resident #84) of two (2) residents reviewed for Nutrition. Specifically, on 12/15/2025 Resident #84 was identified with an undesired significant weight loss of 5% in one month, and on 1/16/2026 an undesired significant weight loss of 10.2% in 3 months. There was no documented evidence that the resident's Physician was notified of the resident's significant weight loss. The finding is: [...]

Inspectors wroteBased on interviews and record review (Incident # 2677700), the facility did not ensure each covered individual report immediately, but not later than two (2) hours, to the administration of the facility and to the New York State Department of Health after the allegation was made. This was identified for one (1) (Resident #116) of two (2) residents reviewed for Abuse. Specifically, on 11/23/2025 at 2:00 AM, Resident #116 reported a verbal abuse allegation to Licensed Practical Nurse #5. Registered Nurse #2 was made aware of the abuse allegation and did not report the incident to the facility administration until 11/24/2025, 24 hours after the allegation was made. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure that a comprehensive person-centered care plan was implemented to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #37) of two (2) residents reviewed for Position and Mobility. Specifically, Resident #37 required use of a pillow for the lower extremities to prevent direct contact of the boney prominences (knees) due to contractures as per the resident's plan of care. On multiple observations, the resident was observed without the use of the pillow in between the knees. The finding is:The facility policy titled Management and Treatment of Pressure Ulcers dated 12/2024 documented interventions to use devices, such as pillows and foam wedges to prevent direct contact between bony prominences and consult with the Physical Therapist for the positioning devices. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #84) of two (2) residents reviewed for Nutrition. Specifically, on 12/11/2025, Registered Dietitian #1 documented Resident #84 as having a weight loss of 5.4 pounds in one-month (a 4.5% decrease in the resident's usual body weight) and recommended weekly weights for four (4) weeks to further assess the accuracy of the resident's weight trends. On 12/15/2025, Registered Dietitian #1 documented Resident #84 triggered for an undesired significant weight loss (5% in one month). The weekly weights were not completed as per the recommendations, and no new dietary interventions were put in place. On 1/16/2026, Resident #84's weight reflected an additional loss of 4 pounds (3. [...]

Inspectors wroteBased on observations, record review, and interviews the facility did not ensure that parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (1) (Resident #117) of one (1) resident reviewed for Antibiotics. Specifically, Resident #117 had a physician's order to infuse Ceftriaxone (antibiotic) medication; however, the route of infusion was not specified in the order. During multiple occasions, Resident #117 was observed with a Peripheral Intravenous Catheter in their left hand. There was no physician's order for the assessment and care of the intravenous catheter. The finding is: [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that residents were assisted in obtaining routine Dental Care. This was identified for one (1) (Resident #5) of one (1) resident reviewed for dental care. Specifically, Resident #5 was not seen by a Dentist since their admission to the facility in June 2024. The finding is:The facility's policy titled, Dental Services, last reviewed 10/2025, documented residents will be seen and evaluated by the Dentist upon admission, annually, as requested by the resident and/or representative, and as needed with a significant change of condition. The policy did not state if a physician's order was required for a resident to be seen by a Dentist. [...]

Inspectors wroteBased on observation, record review, and interviews the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (1) (Resident #88) of six (6) residents reviewed for Medication Administration Task. Specifically, during the medication administration task, Licensed Practical Nurse #1 removed a calcium /vitamin D3 tablet (vitamin supplement) from a blister pack with their bare hands. Licensed Practical Nurse #1 broke the tablet in half and put the two halves of the tablet in the souffle cup and proceeded to offer the medication to Resident #88. The finding is:The facility policy titled Medication Administration last reviewed/revised 12/2025, documented pills should not be handled with fingers. Pour directly from blister packs into souffle cup. [...]

Inspectors wroteBased on observations, record review, and interviews the facility did not ensure call systems were accessible to each resident while residents were in their rooms. This was identified for one (1) (Resident #57) of one (1) resident reviewed for call systems. Specifically, during multiple observations, Resident #57 was observed in bed, and the call bell was out of their reach. The finding is:The facility policy titled Call Bells last revised on 12/2025, documented to have a call bell at the bedside within reach. The purpose of the call bell is to provide the resident with a method of communication to assist in meeting needs in a timely manner. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Abbreviated Survey case #NY00368340 and initiated on 1/15/2025, the facility did not ensure that residents have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely, including that the physical layout of the facility maximizes resident independence and does not create a safety risk. This was identified for 8 of 18 residents reviewed for Quality of Care. Specifically, a complaint was received reporting that the East unit of the facility was freezing cold affecting all the residents on that unit. The finding is: The facility's policy titled; 'Cold Weather Emergency' updated 1/16/2025 documented under Plan A Residents are to be checked and temperatures are to be taken immediately on all residents. [...]

Inspectors wrote§483.90 The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. (d) Space and equipment. The facility must (2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. (b) Equipment. The nursing home shall maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. (j) Housekeeping. (1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not ensure each resident was served food and drink that was palatable, attractive, and at a safe and appetizing temperature. This was identified for ten (Resident #9, Resident #10, Resident # 14, Resident # 39, Resident #50, Resident #72, Resident #77, Resident #91, Resident #94, and Resident #103) of eleven residents during the Resident Council meeting; one (Resident #102) of four residents reviewed for food, and one (Resident #48) of sixteen residents reviewed during the dining task. Specifically, during the resident council meeting held on 10/28/2024 ten of eleven residents in attendance complained the hot meals were served cold. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not distribute and serve food in accordance with professional standards for food service safety. This was identified during the kitchen facility task; for ten (Resident #9, Resident #10, Resident # 14, Resident # 39, Resident #50, Resident #72, Resident #77, Resident #91, Resident #94, and Resident #103) of eleven residents during the Resident Council meeting; for one (Resident #102) of four residents reviewed for food, and for one (Resident #48) of sixteen residents reviewed during the dining task. [...]

Inspectors wroteBased on record review and staff interviews, during the re-certification survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure food served to the residents was at acceptable temperature parameters for three of the three resident units. Cross Reference F 804 Food and Nutrition Services F 812 Food and Nutrition Services The finding is: The undated facility policy titled Food Temperatures documented temperatures of all food items will be taken and properly recorded prior to service each meal. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's cold food concern identified on three of three units observed during the dining task. Specifically, multiple complaints were brought up during Resident Council meetings that hot meals were being served cold; however, the Quality Assurance Performance Improvement Committee did not address, review, analyze, and act on available data on the identified issue to make improvements and to ensure improvements are sustained. Cross Reference: F 804 Food and Nutrition Services F 812 Food and Nutrition Services The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored and the written description of the facility policy to implement advance directives were followed. This was identified for one (Resident #18) of two residents reviewed for advance directives. Specifically, Specifically, the facility did not ensure that Resident #18's advance directives (their preferred code status in the event of cardiac or pulmonary arrest) were accurately identified per their wishes. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure that each resident was provided with a comfortable and homelike environment. This was identified on one (East Unit) of three resident units during the environmental tour. Specifically, the hot water temperatures were not maintained within an acceptable range and were noted below the required range of 90 degrees-110 degrees Fahrenheit in the resident areas. The finding is: 42 CFR 483.470 (d)(3) PART 483-REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES 483.470 Condition of Participation: Physical environment. (d) Standard: Client bathrooms. The facility must ensure: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/1/2024, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (Resident #27) of two residents reviewed for Advanced Directives. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect Resident #27 had an advanced directive of Do Not Hospitalize. The finding is: The facility's policy titled Comprehensive MDS Policy last revised on 9/2024 documented the Minimum Data Set provides an assessment that is comprehensive, accurate, standardized, and reproducible for each resident's functional capabilities. [...]

Inspectors wrote2) Resident #27 was admitted with diagnoses including Metabolic Encephalopathy (a type of brain disorder), Moderate Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] did not include a Brief Interview for Mental Status because the resident was rarely or never understood and had severely impaired skills for daily decision-making. The Minimum Data Set documented the resident had advanced directives including Do Not Resuscitate, Do Not Intubate, and feeding restrictions. A Comprehensive Care Plan titled Advanced Directives, effective [DATE] and last revised on [DATE] documented advanced directives including to send the resident to the hospital. A physician's order effective [DATE] and renewed on [DATE] documented an advanced directive of Do Not Hospitalize. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/28/2024 and completed on 11/01/2024, the facility did not ensure medications were properly stored in medication carts. This was identified for one (Unit North Medication Cart 1), of 2 units reviewed during the Medication Storage Task. Specifically, Unit North Medication Cart#1 was utilized for storing items other than the resident medications such as the hearing aids, dirty measuring tape, three rolls of surgical tape, seven hearing aid batteries, and a small box of loose rubber bands.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey initiated on 10/29/2024 and completed on 11/1/2024, the facility did not ensure all portions of the resident call system were functioning to allow each resident to call for staff assistance. This was identified for one (Unit East) of three resident units. Specifically on 10/22/2024, Resident # 102 was placed by staff on the toilet and was instructed to use the call bell to call for assistance when they were ready. The resident tried to use the call bell for staff assistance; however, the call bell was not functioning. Subsequently, the resident attempted to transfer from the toilet on their own, resulting in a fall with injury.

Inspectors wroteBased on record review and interviews during the Recertification Survey and the Abbreviated Survey ( Complaint # NY00324033) initiated on 10/2/2023 and completed on 10/6/2023, the facility did not ensure that the resident's Designated Representative was notified when the need to commence a new form of treatment was identified. This was identified for one (Resident #56) of one resident reviewed for Notification of Change. Specifically, Resident #56 was started on intravenous (IV) Ceftriaxone (An antibiotic used to treat infections) 1 gram (gm) daily for Bacterial Infection. There was no documented evidence that Resident #56's Designated Representative was notified of the Antibiotic therapy use. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interview during the Recertification Survey initiated on 10/2/23 and completed on 10/6/23, the facility did not ensure that each resident has the right to be free from abuse. This was identified for one (Resident #53) of four residents reviewed for abuse. Specifically, on 9/28/2023, Resident #53 who had a history of frequently wandering into other residents' rooms, wandered into Resident #69's room and took their (Resident #69) personal belongings (a large stuffed animal), in response, Resident #69 became verbally agitated and slapped Resident #53 on the left arm. There were no new interventions put in place for Resident #53 to prevent them from entering Resident #69's room again. On 10/6/2023, Resident #53 was observed entering Resident #69's room. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/2/2023 and completed on 10/6/2023, the facility did not ensure that an incident of a resident-to-resident altercation was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #53) of four residents reviewed for Abuse. Specifically, on 9/28/2023 Housekeeper (HK) #1 witnessed Resident #69 slapping Resident #53 on the left arm when Resident #53 wandered into Resident #69's room and took a large stuffed animal. Resident #69 verbalized that they (Resident #69) pushed Resident #53 because they (Resident #69) did not want Resident #53 taking their stuffed animal. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 10/2/2023 and completed on 10/6/2023, the facility did not ensure that services provided or arranged by the facility met professional standards of quality. This was identified for one (Resident #75) of five residents reviewed for Unnecessary Medications. Specifically, Resident #75, who had no prior history of Schizophrenia, was ordered Olanzapine (antipsychotic medication primarily used to treat Schizophrenia and Bipolar Disorder) 7.5 milligrams (mg) 1 tablet once daily since 8/18/2023 for a diagnosis of Schizophrenia. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/2/2023 and completed on 10/6/2023, the facility did not ensure medical care of each resident was adequately supervised by a physician. This was identified for one (Resident #75) of five residents reviewed for Unnecessary Medications. Specifically, Resident #75's Primary Care Physician did not know and therefore did not monitor that Resident #75, who had no history of Schizophrenia, was diagnosed with a new Schizophrenia diagnosis after the resident was admitted to the facility. Additionally, the resident was prescribed and administered Olanzapine (an antipsychotic medication) for the newly diagnosed Schizophrenia. The finding is: [...]