Orchard Rehabilitation & Nursing Center

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

waited up to three (3) hours for assistance to the bathroom and at times have used the bathroom unassisted to avoid having an accident.During an interview on 09/02/2025 at 8:20 AM, Resident #7 stated staffing is absurd, we are lucky if the call light gets answered on the weekends. During a telephone

interview on 09/02/2025 at 9:06 AM, the Director of Human Resources/Scheduler stated they were responsible to create the nursing schedule, and the minimum number of licensed nurses was four (4) on day shift and three (3) on night shift and the minimum number of Certified Nurse Aides was six (6) on day, evening and night shift.During an interview on 09/02/2025 at 5:42 AM, Certified Nurse Aide #1 stated there were 56 beds on the unit and when they were responsible 14 residents, they were unable to complete showers, turn and position, or toilet residents per the plans of care. They stated they had to rush to complete basic care, and it was not fair to the residents.During an interview on 09/02/2025 at 5:50 AM, Licensed Practical Nurse #1 stated they are responsible for 40 residents on the day shift and medications are often administered late.During an interview on 09/02/2025 at 9:40 AM, Licensed Practical Nurse (Unit Manager) #2 stated staffing looks good on paper, but then there are call ins. Medications were not always administered on time when one (1) nurse was responsible for 40 residents.During an interview on 09/02/2025 at 9:50 AM, Licensed Practical Nurse #3 stated that it was impossible to be the nurse they were taught to be when responsible for 40 residents. Medications are not always administered on time in the morning because they have to assist in the main dining room during breakfast service and assist the aides with hands on care. Additionally, they stated it was not safe and we can't take care of the residents, we miss things.During an interview on 09/02/2025 at 10:07 AM, the Director of Nursing stated the facility has been recruiting to hire additional nursing staff at the facility but have not been successful. Additionally, they were aware of the state minimum staffing requirements and were aware the facility was not meeting the minimum required nursing staff.During an interview on 09/02/2025 at 10:18 AM, the Administrator stated they were aware of the state minimum staffing requirement and were aware the facility was not meeting the minimum required nursing staff. The Administrator stated staffing has been an ongoing focus of the facility and the facility has been recruiting for additional staff. 10 NYCRR 415.13 (b)(1) (i-ii) (2)(ii)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Rehabilitation & Nursing Center

600 Bates Road Medina, NY 14103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review conducted during a Complaint investigation (NY00358687- 745392) the facility did not ensure food and drink were provided/served at a safe and appetizing temperatures. Specifically, food and beverages during the lunch meal were served at suboptimal temperatures and were not palatable.Residents #1, #4, #5, #6, and #7 involved. The finding is: The policy Safe Food Temperature and Danger Zone Compliance dated 04/2025 documented the facility will maintain strict control of food temperatures to prevent the growth of harmful bacteria. All food will be stored, cooked, held, and served at temperatures that comply with New York State Department of Health requirements, CMS (Centers for Medicare & Medicaid Services), and ServSafe guidelines (guidelines that focus on essential food safety practices, including personal hygiene, cross-contamination prevention, time and temperature control, and cleaning and sanitation). The temperature danger zone is defined as 41 degrees Fahrenheit to 135 degrees Fahrenheit. During observation 08/28/2025 at 11:40 AM, the lunch meal tray line was started in the main dining room servery. Temperatures were taken at the start of tray line service and all hot food items were above 140 degrees Fahrenheit. Cold food and drink items were held pre-portioned and pre-poured on metal trays. During an observation/interview on 08/28/2025 at 11:57 AM, Resident #5 was eating their lunch meal in the main dining room. Resident #5 stated the food was never served hot, and

the lunch meal was lukewarm at best and the drinks were not served cold. During an observation/interview

on 08/28/2025 at 11:59 AM, Resident #6 was eating their lunch meal in the main dining room. Resident #6 stated the lunch meal was served lukewarm. During an observation on 08/28/2025 at 12:19 PM, tray line service for the hall trays began. The Side two (2) Cart two (2) left the servery for the unit at 12:50 PM in a metal cart with doors and all the residents were served lunch meal at 12:56 PM. A test tray was completed with the Food Service Director at 12:56 PM for temperatures and palatability. The temperatures were taken by the Food Service Director using the Food Service Directors digital thermometer. The results were as follows: - carrot vegetable blend was 118 degrees Fahrenheit, tasted lukewarm and bland.- chicken with biscuit and gravy 115 degrees Fahrenheit, tasted lukewarm and salty.- cranberry juice 64.2 degrees Fahrenheit, tasted warm.- milk 56.5 degrees Fahrenheit, tasted warm.- coffee 119.5 degrees Fahrenheit, tasted lukewarm. During an interview on 08/28/2025 at 1:01 PM, Resident #1 stated their lunch meal was served barely warm and the water for the tea the temperature of tap water. During an interview on 08/28/2025 at 1:12 PM, Resident #4 stated the lunch meal was barely edible, barely even warm they stated

the juice was not cold and the water for hot cocoa was not warm. During an interview on 09/02/2025 at 8:20 AM, Resident #7 stated the food is served cold, at room temperature, most of the time and the quality of the food served is suboptimal. During an interview on 09/02/2025 at 8:48 AM, the Food Service Director stated

the food on the plate in front of a resident should be 140 degrees Fahrenheit or higher and milk and juices should be served less than 41 degrees Fahrenheit. Foods outside these temperatures were considered in

the danger zone where bacteria can grow within 20 minutes and potentially cause illness. Additionally, the test tray temperatures on 08/28/2025 were not good, food should have been hotter and the drinks colder.

During an interview on 09/02/2025 at 10:21 AM, the Administrator stated milk, and juices should be served under 41 degrees Fahrenheit, coffee should be served above 160 degrees Fahrenheit, and hot foods should be served above 140 degrees Fahrenheit to keep the foods out of the temperature danger zone where food can spoil and pathogens can grow, 10 NYCRR 415.14(d)(1)(2)

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet