Affinity Skilled Living and Rehabilitation Center

Inspectors wroteBased on observations, record reviews and interviews during survey, the facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately following an allegation of staff-to-resident sexual abuse for one of 16 sampled residents (Resident #1) reviewed for abuse. Specifically, on 06/20/2026 Resident #1 alleged Certified Nursing Assistant #1 raped them while providing incontinence care, and the facility failed to implement interventions to address Resident #1's physical and psychosocial needs. Resident #1 remained in the facility for five and a half hours following the allegation without documentation of a medical or psychosocial assessment. This resulted in actual harm to Resident #1 that was Immediate Jeopardy and likely placed other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death. The Finding is: [...]

Inspectors wroteBased on record review and interviews during survey, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the Department of Health and local law enforcement no later than two hours after the allegations were made. This was identified for one resident (Resident#1) of 16 residents. Specifically, Resident#1 alleged that on 06/20/2026, Certified Nursing Assistant #1 sexually abused them while providing care. There is no documented evidence that the alleged sexual abuse was reported to local law enforcement or the New York State Department of Health as required. The facility's failure to report the incident to the New York State Department of Health posed the likelihood of harm to Resident #1 which was immediate Jeopardy and potential for harm to the other 16 residents.

Inspectors wroteBased on observations, interviews, and record review during the abbreviated survey (Intake # 3052049) the facility failed to conduct a thorough investigation of an allegation of staff to resident abuse for 1 of 1 sampled resident reviewed for abuse. Specifically, Resident #1 alleged a Certified Nursing Assistant raped them while providing incontinence care. The facility's investigative report revealed no written or recorded statement from the resident detailing the allegation, which limited the facility's ability to objectively investigate the allegation. The facility's reported that Resident #1 changed their description of the allegation and the facility reached a conclusion rather than completing a comprehensive investigation of all evidence. [...]

Inspectors wroteBased on observations, record review and interviews during the abbreviated Survey 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. This was identified for (1) (Resident #1), of sixteen residents. Specifically, the facility failed to ensure that alleged violations involving sexual abuse, neglect, exploitation or mistreating are reported immediately or not later than 2 hours to the Department of Health and Local Law Enforcement after the allegations are made. Additionally, the alleged incident Caused Resident #1 psychosocial harm. [...]

Inspectors wroteBased on observations, interviews and reviews, the facility failed to ensure that each resident received treatment and care based on their comprehensive assessment in accordance with professional standards of practice. This was identified for one (1) (Resident #180) of one (1) resident reviewed for physical restraints. Specifically, Resident #180 with severely impaired cognition had a diagnosis of down syndrome and a facility acquired stage III pressure ulcer (a deep, full-thickness wound extending through the skin into subcutaneous fat, but not exposing muscle, tendon, or bone) to their right buttock. Resident #180 was unable to verbalize their needs and required total assistance from two (2) staff members with all aspects of care except for eating. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (1) (Resident #180) of five (5) residents reviewed for Pressure Ulcers. Specifically, Resident #180 was admitted to the facility with no pressure ulcers and was assessed to be at risk for developing pressure ulcers, was incontinent of bowel and bladder, and used a Posey restraint (device to limit patient movements) in their wheelchair at night. On 01/01/2026: Developed a Stage 2 (a partial-thickness skin loss) ulcer on the coccyx (small triangular bone at the bottom of the spine). On 01/06/2026: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (1) of two (2) residents reviewed for skin conditions. Specifically, Resident #12 had a physician's order for contact precautions due to extended-spectrum -lactamase infection (antibiotic resistant bacteria) in the coccyx wound and enhanced barrier precautions for the wounds on both heels. There was no comprehensive care plan developed with interventions to address the resident's enhanced barrier precaution and contact precautions status. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #104) of two (2) residents reviewed for Dignity. Specifically, during multiple observations, Resident #104 was observed in their room with a urinary catheter drainage bag that was not covered. The urinary catheter drainage bag was half-filled with urine and was visible from the hallway. The finding is:The facility's policy titled, Dignity last revised on 02/02/2026 documented that residents shall be treated with Dignity and respect at all times. Treated with Dignity means the resident will be assisted in maintaining and enhancing their self-esteem and self-worth. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that each resident had secure and confidential medical records. This was identified for one (1) (Resident #27) of five (5) residents reviewed for the Medication Administration Task. Specifically, Licensed Practical Nurse #1 left Resident #27's electronic record open in the hallway with the personal and medical information visible to other staff, residents, and visitors. The finding is:Resident #27 was admitted with diagnoses that included fracture of the finger in the right hand, cerebral infarction (lack of blood supply to the brain tissue causing tissue death), chronic obstructive pulmonary disease (long-term lung disease that makes breathing difficult). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that each resident was free from physical restraints that was used for the purpose of discipline or convivence; and that the restraint was used to treat the residents' medical conditions with ongoing re-evaluation of the need for the physical restraint. This was identified for one (1) (Resident #180) of one (1) resident reviewed for restraints. Specifically, Resident #180 had diagnoses including down syndrome with severely impaired cognition and a facility acquired stage 3 pressure ulcer to their right buttock. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that each resident's environment remained free of accident hazards. This was identified for one (1) (Resident #28) of four (4) residents reviewed for Accidents. Specifically, an unsecured oxygen E-Cylinder tank (a portable, high-capacity metal cylinder used to store compressed medical grade oxygen) was observed on Resident 21's bed side. The E-Cylinder tank was not secured in a holder or a metal rack. The finding is: The facility's policy, titled Oxygen Cylinder Storage last revised on 02/02/2026, documented that the facility will store, handle, and maintain oxygen cylinders in a safe manner. Oxygen cylinders should be stored to prevent tipping, damage, contamination, or fire hazards and should be readily accessible for resident care needs while ensuring staff and resident safety. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents who have an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible. This was identified for one (1) (Resident # 40) of four (4) residents reviewed for Urinary Catheter. Specifically, Resident #40 was admitted to the facility with a chronic long-term Foley catheter. On 03/09/2026, Resident #40 was observed with the Foley catheter drainage bag stored above their waistline causing potential for urinary retention and the urine to flow back into the bladder. The finding is: The facility policy and procedure for Foley Catheter dated 2/2/2026 documented that the purpose of this procedure is to prevent infection of the resident's urinary tract. [...]

Inspectors wroteBased on record review and staff interviews during a recertification survey, the facility failed to ensure the provision of care and services necessary to maintain acceptable parameters of hydration status. This was identified for one (1) (Resident #277) of eight (8) residents reviewed for nutrition and for one (1) (Resident #14) of one (1) resident reviewed for Dialysis. Specifically. The facility did not monitor and document the fluid intake for Resident #277 and Resident #14 who had a physician ordered 1200 milliliter (mL) fluid restriction. As a result, the facility staff were unable to determine whether the residents' prescribed fluid restriction orders were followed, placing the residents at risk for fluid imbalance.

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure medications were properly stored in medication carts. This was identified for one (1) (Unit 3 southwest medication cart) of eight (8) medication carts reviewed during the medication storage task and Medication Administration task. Specifically, an unlocked and unsupervised medication cart was observed on unit 3 southwest in the hallway. There was no nursing staff present in the vicinity of the medication cart. The finding is:The facility policy titled Storage of Medications last reviewed 02/02/2026, documented the medication nurse on duty is responsible for the security of the carts contents. The cart must be locked and secure at all times when not in use. The facility policy titled Medication Administration, last reviewed 02/02/2026 documented to keep all mediations under lock and key. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was identified for one (1) (Resident #74) of four (4) residents reviewed for Tube Feeding. Specifically, Resident #74's tube feeding formula and the water bags were unlabeled and did not indicate the resident's name, the date, or the time the tube feeding was initiated. The finding is:The facility policy titled Gastronomy Feedings last reviewed 02/02/2026, had no documentation for labeling the feeding with the resident's name date and start time. The policy documented disposable equipment is to be changed every 24 hours or as necessary. The Feeding is to be disposed within 24 hours of feeding administration. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to establish and maintain 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. This was identified for one (1) (Resident #12) of two (2) residents reviewed for skin conditions. Specifically, Resident #12 had a physician's order for Enhanced Barrier Precautions and Contact Precautions. Certified Nurse Assistant #3 was wearing two pairs of gloves, did not have a protective gown on, and their surgical mask was observed under their mouth. The finding is:The facility's Infection Control policy last reviewed on 8/2025 documented that any resident suspected or diagnosed as having communicable diseases shall be placed in the appropriate type of isolation precautions. [...]

Inspectors wrote3) Resident #546 was admitted with diagnoses including Encephalopathy, Acute Kidney Failure, and Moderate Protein-Calorie Malnutrition. There were no Minimum Data Set assessments completed because Resident #546 was recently admitted . A Social Work Progress Note dated 8/29/2024 documented a Brief Interview for a Mental Status score of 6, indicating the resident had severe cognitive impairment. A Comprehensive Care Plan for Right and Left Lateral Heel (Trauma) dated 8/28/2024 and revised on 9/4/2024 documented interventions including but not limited to contact precautions, administering treatment as per physician's order, and following measures to prevent contamination of the wound such as hand hygiene. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00346145) initiated on 9/4/2024 and completed on 9/11/2024 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #544) of two residents reviewed for hospitalizations, one (Resident #10) of four residents reviewed for skin conditions, and one (Resident #193) of five residents reviewed for tube feeding. Specifically, 1) Resident #544 was admitted to the facility with an abdominal surgical incision and treatment recommendations from the hospital and was also seen by the facility's wound care consultant with recommendations to treat the abdominal surgical site. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #2) of three residents reviewed for Pressure Ulcers. Specifically, Resident #2 had a Stage 4 pressure ulcer and an unstageable pressure ulcer to their back. Resident #2 had a care plan intervention and recommendations for an air mattress. During several observations, the adjustable weight setting for the air mattress was not set accurately. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure the resident environment remained as free of accident hazards as possible. This was identified for one (Resident #208) of four residents reviewed for Accidents. Specifically, on 9/4/2024, Resident #208 had an aerosol container of Lysol spray on their bedside table. Facility staff were aware of the aerosol spray container but did not remove it. The finding is: The facility's policy titled Environmental Hazard, dated 8/2023, documented aerosols (air fresheners, deodorants, hair sprays, disinfectants) are prohibited for use inside of the facility. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure intravenous (IV) fluids (fluids that were administered directly into a vein) were administered consistent with professional standards of practice and in accordance with physician orders. This was identified for one (Resident #58) of one resident reviewed for Hydration. Specifically, Resident #58 had a physician's order to receive Dextrose fluids at 70 cubic centimeters (cc)/hour via intravenous route. On two separate occasions on 9/6/2024, the resident was observed receiving the Dextrose fluid at 50 cubic centimeters (cc) /hour intravenously instead of the Physician's ordered 70 cubic centimeters (cc)/hour intravenously. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for one (Unit 3 South medication cart) of six medication carts reviewed during the Medication Storage Task. Specifically, the Unit 3 South medication cart was observed with one opened Basaglar 100 units per milliliter insulin pen for Resident #21 and one opened Lantus 100 milliliters per unit insulin pen for Resident #97. Both insulin pens did not have a date indicating when the pens were first opened for use. The finding is: Resident #21 was admitted with a diagnosis of Type 2 Diabetes Mellitus with Unspecified Complications. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure each resident received food that accommodated the resident's allergies, intolerances, and preferences. This was identified for one (Resident #27) of three residents reviewed for Nutrition. Specifically, Resident #27 had a Physician's Order that documented allergies to artificial sweeteners; however, Resident #27 was served sugar-free snack puddings and reduced-calorie syrup with artificial sweeteners. The finding is: The facility's policy and procedure titled Allergies, last revised on 8/2023 documented that upon admission, the admitting nurse shall review if the resident has any known drug and food allergies/sensitivities to prevent anaphylaxis and allergic reaction. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for one (Resident #18) of seven residents reviewed for the Resident Assessment Task. Specifically, Resident #18's Annual Minimum Data Set assessment was not completed until 31 days from the Assessment Reference Date of 8/6/2024. The finding is: The facility's policy and procedure for Minimum Data Set, last revised on 8/2023 documented that a Registered Nurse shall be designated for conducting and coordinating each resident's assessment. The Assessment Coordinator must date and sign each assessment to certify that the assessment has been completed. [...]

Inspectors wroteBased on record review and interviews during the Recertification survey initiated on 9/4/2024 and completed on 9/11/2024, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for seven (Residents #99, #18, #95, #31, #211, #130, #105) of seven residents reviewed for the Resident Assessment Facility Task. Specifically, the Minimum Data Set assessments for Resident #99, #18, #95, #31, #211, #130, and #105 were not transmitted within 14 days of the assessment completion date. The finding is: The facility policy for Minimum Data Set, last revised on 8/2023, documented the Registered Nurse shall be responsible for conducting and coordinating the development and completion of the resident's assessment. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Abbreviated Survey (Complaint # NY00287059) initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #310) of three residents reviewed for Accidents. Specifically, Resident #310 had a history of multiple falls and was identified at risk for falls. Resident #310 was to be placed in a high visibility observational area when out of bed as per the resident's plan of care. On 11/24/2021 Resident #310 was left unsupervised when Certified Nursing Assistant (CNA) #5 did not follow their assignment to monitor the Northeast TV lounge that was designated by the facility as a high visibility area. [...]

Inspectors wroteBased on record reviews and interviews conducted during a Recertification Survey and an Abbreviated Survey (NY00303538), initiated on 1/5/2023 and completed on 1/13/2023 the facility did not report alleged violations involving Narcotic Diversion to the New York State Department of Health (NYSDOH). Specifically, Licensed Practical Nurse (LPN) # 6 was terminated due to Narcotic Diversion and this was not reported to the NYSDOH.

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that a comprehensive person-centered care plan (CCP) for each resident was implemented. This was identified for one (Resident # 30) of four residents reviewed for Activities of Daily Living (ADL). Specifically, Resident #30 had a Physician's order dated 5/13/2022 for heel booties when out of bed (OOB) due to Lymphedema. On 1/12/2023 Resident #30 was observed sitting in a wheelchair not wearing the heel booties on multiple occasions. The finding is: Resident #30 was admitted with diagnoses that include Lymphedema (swelling due to the build-up of lymph fluid in the body), Morbid Obesity, and Gout. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident's comprehensive person-centered care plan (CCP) included the resident's current plan of care or was revised when there was a change in the plan of care. This was identified for one (Resident #30) of four residents reviewed for Activities of Daily Living (ADL), and for one (Resident #42) of five residents reviewed for Accidents. Specifically, 1) Resident #30 had a Physician's order to wear heel booties when out of bed due to Lymphedema (swelling due to the build-up of lymph fluid in the body). There was no documented evidence that the resident's care plan and the Resident Profile (directions provided to Certified Nursing Assistant for resident care needs) were updated to include the use of heel booties. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #65) of two residents reviewed for positioning. Specifically, Resident # 65, who was ventilator dependent, was observed sitting in a Geri recliner improperly positioned with their head resting on a Ventilator. The finding is: Resident#65 was admitted with diagnosis of Epilepsy, Ventilator Dependent, and Anoxic Brain Damage. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident has severely impaired daily decision-making skills. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident who needs respiratory care is provided such care consistent in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #42) of six residents reviewed for Respiratory care. Specifically, Resident #42, with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a Physician's Order to administer oxygen at 2 liters per minute via a nasal cannula (tubing used to deliver supplemental oxygen). The resident was observed with an empty oxygen tank and complained of feeling short of breath. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure a system of records of receipt and disposition of all controlled drugs was maintained and periodically reconciled. This was identified for one of six medication storage rooms observed during the medication storage task. Specifically, Resident #41 was prescribed Morphine Sulfate (Roxanol) five milligrams (ml) every four hours for pain by mouth. During the medication storage task, the Narcotic sheet documented there was 13.25 ml of Roxanol; however, the medication bottle contained only 12 ml of the medication. The finding is: The facility's Policy titled, Controlled Substances, last reviewed on 12/2022 documented that control substances must be counted upon delivery. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey and Abbreviated Survey (NY00268500) initiated on 1/5/2023 and completed on 1/13/2023, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections. This was identified for one (Resident #113) of two residents observed for wound care. Specifically, the wound care nurse, Registered Nurse (RN) #3, did not follow proper hand hygiene during the wound care treatment observation to prevent cross-contamination for Resident #113. The finding is: The Facility Wound Care Policy last updated 06/22/2022 documented to use a disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. [...]