Campbell Hall Rehabilitation Center Inc

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility failed to ensure that one (1) of five (5) residents (Resident # 106) reviewed for pressure ulcers received the necessary care and services to promote healing. Specifically, Resident #106 who was dependent for bed mobility was identified as having a Stage 2 pressure on the sacrum during an assessment by Registered Nurse Supervisor #1 on 10/16/2025. A wound consult was ordered which was not initiated until 11/05/2025. There was no documented evidence of wound assessments from 10/16/2025 to 11/05/2025. The first wound consult identified two (2) Stage 3 pressure ulcers on the right and left buttock. Additionally, there was no documented evidence of the wound progression from 11/12/2025 to 11/19/2025. [...]

Inspectors wroteBased on observation, record review and interviews, conducted during the Recertification and Abbreviated surveys (2622355, 2622747) the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, actual staffing levels were below facility assessment desired levels on eleven of ninety shifts as documented on the daily staffing sheets. Residents remained in bed and did not receive showers as planned (See F677) and were not available for activities (See F679). Interviews with staff, residents and family members reported low staffing and care not being completed.

Inspectors wroteBased on observations, interviews, and record reviews during the recertification and abbreviated (2670229) surveys from 12/03/2025-12/10/2025, the facility did not ensure the resident's right to a safe, clean, and homelike environment. Specifically, Unit 2 had a strong urine smell, room [ROOM NUMBER] had a very strong urine smell that emanated into the hallway and surrounding areas, Unit 2 floors were visibly soiled or stained (both the hallways and the dining room), the Unit 2 shower room had used linens left on the shower chairs and bagged linens out of receptacles, and there was garbage that was observed on the floor in the shower room, dining room, and unit hallways. The Unit 1 dining room cabinet drawer had garbage in it. room [ROOM NUMBER] was cluttered with an unused oxygen concentrator. room [ROOM NUMBER] had boxes of supplies stored on the floor.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated surveys( 2622747) from 12/3/2025 to 12/10/2025, the facility did not ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for three (3) of six (6) (Residents #6 #76, #105) residents reviewed for Activities of Daily Living. Specifically, 1) Resident #6 was not provided showers as scheduled. 2) Resident #105 was observed on multiple days in bed into the afternoon and missed social activities and was not provided showers as scheduled. 3) Resident #76 was observed on multiple soiled in urine while in wheelchair in hallway.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 12/03/2025 to 12/10/2025, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, unlabeled and undated food items were observed in the kitchen and unit pantry, and expired food was observed in kitchen storage pantry and unit pantry.

Inspectors wroteBased on observation, interview and record review during recertification and abbreviated survey (2637641) from 12/3/25 to 12/10/25, the facility did not ensure the residents rights to be free from physical abuse one (1) of four (4) residents reviewed for abuse (Resident #110). Specifically, Resident #110 was lying in bed when Resident #7, who had a history of wandering into other residents' rooms, wandered into Resident #110's room, and proceeded to hit Resident #110 with a Reacher (an assistive device), scratched their upper right arm causing their Dexcom sensor (a glucose monitoring system) to come off, leaving red scratch marks on their arm, and also threatened them with scissors.

Inspectors wroteBased on observations, record reviews and interviews during a recertification and abbreviated survey (2637641) from 12/03/25 to 12/10/25 the facility did not ensure that each resident received adequate supervision to prevent accidents for one (1)( Resident#7) of six (6) residents reviewed for accidents. Specifically, Resident#7 who had a history of wandering by self-propelling in their wheelchair, accessed an alarmed stairwell door and fell down the stairwell in their wheelchair. The resident sustained two fractured vertebrae and a hematoma on their scalp.

Inspectors wroteBased on observation, record review and interviews during a recertification survey conducted from 12/03/2025 to 12/10/2025, the facility did not ensure adequate nutrition care and services for two (2) of eight (8) residents reviewed for Nutrition (Resident #1 and Resident #3). Specifically, 1) Resident #1 had a 12% weight loss over five (5) months; a sacral wound with no supplemental protein to promote wound healing, and their meal intake was not consistently monitored. 2) Resident #3 had a 9.8% weight loss in six (6) weeks; they consumed less than 50% of over half of all meals served during the survey, and there was a delay in providing a dietary supplement for weight loss.

Inspectors wroteBased on observations record review and interviews on recertification and abbreviated surveys (2670229) from 12/3/25 to 12/11/25 the facility did not ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, 37 nurse signatures of 624 opportunities over 104 days were missing from the change of shift narcotic count log from 8/5/25 to 11/17/25. The facility policy for Narcotic Counting and Control dated 3/8/24 documented a complete count of all narcotics present on a nursing assignment, shall take place at any change of personnel which results in exchange of keys and change of responsibility for narcotic supply. This may occur at traditional shift change, or a mid-shift personnel change. The narcotic sheets are to be counted and logged with every count as part of the correct and accurate narcotic count procedure. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Abbreviated Surveys (2610401) from 12/3/2025 to 12/10/2025, the facility did not ensure that residents were free from significant medication errors one (1) of three (3) residents (Resident #98) reviewed for medications. Specifically, Resident #98 had a physician order for Lamictal (anti-seizure medication), five (5) doses were missed, the physician was not notified, and Resident #98 experienced a breakthrough seizure.

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00377106), the facility did not ensure (Residents #1) of 3 residents reviewed for abuse, had the right to be free from abuse, neglect, or mistreatment. Specifically, Resident #1 was observed by Certified Nurse Aide #2 being hit on the arm by Certified Nurse Aide #1 while they were both providing care to the Resident. Additionally, upon review of Certified Nurse Aide #1's trainings/education, they did not have any abuse trainings while employed by the facility.

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00377106) the facility did not ensure for 1 (Residents #1) of 3 residents reviewed for abuse, that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, 1) the facility investigation did not include a review of the facility camera footage, 2)The facility did not provide documented evidence that a report was made to law enforcement regarding the incident of alleged abuse by staff that occurred on 4/6/25, 3)The Medical Director was not notified of the alleged abuse of Resident #1 that occurred on 4/6/25 until 4/17/25. Physician #1 was notified of the incident on 4/16/25 and the investigative report was missing signatures from the Administrator, the Physician, and the Nurse Manager.

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00377106 and NY00370944) the facility did not ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status at the time of the assessments for 1(Resident #1) of 3 residents reviewed. Specifically, the Minimum Data Set assessment inaccurately documented that Resident #1 was assessed to have no behaviors. The Certified Nurse Aide Documentation dated 2/27/25, 3/2/25, and 3/3/35 and the Nursing Progress notes dated 3/2/25 documented Resident #1 had multiple physically aggressive behaviors.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00377106, NY00370944), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Resident # 1 and # 2) reviewed. Specifically, 1) Resident # 1 had a diagnosis of dementia with behavior disturbances and no care plan in place to address these behaviors; 2) Resident # 2 had diagnoses of Schizoaffective disorder and Alzheimer's disease with no care plan in place to address the resident's verbal and physically aggressive behaviors.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00377106, NY00370944), the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 2 (Residents # 1, and # 2) of 3 residents reviewed. Specifically, 1) Resident # 1 had a diagnosis of Dementia with behavioral disturbances and did not have an individualized care plan with interventions in place to address the resident's verbal and physically aggressive behaviors to enhance their well-being and guide staff in managing the resident's care; 2) Resident # 2 had a diagnosis of Alzheimer's Disease with no behavioral care plan to address Resident # 2's verbal and physically aggressive behaviors.

Inspectors wroteBased on record review, and interviews conducted during the Abbreviated Survey (NY00377106) the facility did not ensure that the Certified Nurse Aide training included dementia management and resident abuse prevention training for 1(Certified Nurse Aide#1) of 2 to ensure delivery of safe care. Specifically, the facility was unable to provide documented evidence that Certified Nurse Aide #1 was provided with abuse and/or dementia training.

Inspectors wroteBased on observation, record review, and interview during the recertification, abbreviated (NY00359302), and extended surveys from 12/15/2024 to 12/22/2024, the facility failed to provide adequate supervision to prevent accidents related to smoking for 6 of 6 residents (#2, #6, #9, #29, #41 and #54) identified as smokers. Specifically, Resident #41 was a known smoker in a non-smoking facility and the facility failed to complete safety assessments or develop and implement a plan of care to ensure their safety, when it was known that the resident continued to smoke outside of the facility. On 11/1/2024 a fire was started on the outside patio when Resident #41 threw a cigarette butt into dry leaves. There were no facility staff supervising the resident during this smoking activity. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and extended survey conducted 12/15/2024-12/22/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical, nursing mental and psychosocial needs for 4 of 8 residents (Resident #15, #84, #29, and #75) reviewed. Specifically, Resident #15's comprehensive care plans did not include Dementia Care, Psychotropic Drug Use, or a Diabetic care plan; 2) Resident #84's comprehensive care plans did not include an at risk for pressure ulcer care plan; 3) Resident #29's comprehensive care plans did not include a smoking care plan; 4) Resident #75's comprehensive care plans did not include respiratory/oxygen use care plan.

Inspectors wroteFACILITY Extended Survey Based on observation, record review and interview conducted during a recertification, abbreviated, and extended survey from 12/15/24-12/22/24 (complaint # NY00359302), the facility did not ensure that operative oversight for an effective system was in place to maintain health, safety, and the highest practicable well-being of residents. reviewed for accidents. Specifically, 1) the facility failed to provide adequate supervision to prevent accidents from smoking for 1 out of 3 residents reviewed for accidents. The facility Administrator did not ensure that smoking was not allowed in the facility grounds. 2) The facility Administrator did not ensure that employees were periodically instructed and followed the general fire procedures in accordance with the facility's Fire Emergency Plan, or that it conducted the required number of fire drills per quarter. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification, abbreviated (NY00359302), and extended survey from 12/15/24 to 12/22/24 it was determined the facility did not ensure a process or frequency for the reporting by the Administrator to the governing body. The method of communication was not documented, and the governing body failed to establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Specifically, the facility failed to provide adequate supervision to prevent accidents from smoking for six residents who were known smokers. Several observations documented residents smoking on the patio and gazebo, despite the facility being a nonsmoking facility. A fire occurred on 11/1/24, on the patio due to a discarded cigarette butt.

Inspectors wroteBased on interview and record review during the recertification survey conducted 12/15/24-12/22/24, the facility did not ensure each staff member was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence of immunization records for COVID-19 vaccine for Registered Nurse Supervisor #2, Receptionist #3, Licensed Practical Nurse # 21 Certified Nurse Aid #9#22, #23,#24, Physical Therapist #25, [NAME] #26 and Maintenance staff #27.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification, Abbreviated (NY00359302) and Extended Survey from 12/15/24 - 12/22/24, the facility did not ensure residents had a right to make choices regarding aspects of their life for 5 of 6 residents reviewed for smoking. Specifically, the facility did not offer a designated smoking area and did not offer a smoking cessation program prior to and after the facility changed its policy to prohibit smoking for Resident # 6, #9, #29, #41, and #54 who were known smokers at the time of admission.

Inspectors wroteBased on observation, record review and interview during the Recertification Survey from 12/15/24-12/22/24, the facility did not ensure that the building was maintained in good repair to provide a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel, and the public.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification and Abbreviated (NY00361230) Surveys conducted from 12/15-12/22/24, the facility did not ensure that the Comprehensive Care Plans were revised for 4 of 14 residents (#41, #89, #48, and #34) reviewed for Care Planning. Specifically, 1) The Smoking Care Plan for Resident #41 was not revised to include interventions for safe smoking after resident caused a fire when they extinguished a cigarette in the leaves behind the gazebo on the facility patio; 2. The Respiratory Care Plan for Resident # 89 was not revised to reflect the intervention of the physician order for oxygen as needed. Furthermore, the Psychotropic Medication Care Plan for Resident #89 was not revised to include interventions or goals. 3. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during a Recertification Survey from 12/15/24-12/22/24, the facility did not ensure sufficient nursing staff to provide nursing and related services to attain or maintain the well-being of each resident in accordance with the facility assessment. This was evident for 17 of 90 shifts from 11/20/2024-12/20/2024 during the staffing review. Specifically, the facility triggered a 1-star rating in the payroll-based journal report. A review of the Facility Assessment documented minimal staffing levels required to provide residents quality of care and services. The facility's actual staffing reports revealed that they did not meet those staffing levels the facility did not provide actual staffing as documented in their Facility Assessment.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey from 12/15/24-12/20/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. [...]

Inspectors wroteBased on record review and interview during the recertification survey from 12/15/24-12/22/24, the facility did not ensure residents or resident's representatives were notified in writing of the facility policy for bed hold for 2 of 2 residents reviewed (Resident #49 and Resident #93) for hospitalization. Specifically, Residents #49 and #93 were transferred to the hospital, and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the resident or the resident's representative.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification Survey from 12/15/24 to 12/22/24, the facility did not ensure a Preadmission Screen was completed for 1 of 22 residents reviewed. Specifically, for Resident #55, the facility did not ensure the Screen form (DOH-695) was completed.

Inspectors wroteBased on observations, interviews, and record review conducted during the standard survey from 12/15/24-12/22/24, the facility did not ensure that residents who had an indwelling/ suprapubic (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #86) of three residents reviewed for bowel and bladder. Specifically, Resident #86 had a size 16 French suprapubic catheter surgically inserted, the facility did not develop a care plan, obtain a doctor's order with diagnosis to include the catheter size or directions on care of the suprapubic tube or when the catheter should be changed. The finding is: Resident #86 had diagnoses of Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Hypertension. [...]

Inspectors wroteBased on observations, interviews and record review during the recertification survey conducted from 12/15/24-12/22/24, the facility did not ensure that acceptable parameters of nutritional status for 1 of 2 residents (Residents #93) reviewed for Nutrition were maintained. Specifically, Resident #93 had a significant weight loss of 28.12% in four months (8/28/24-12/18/24) and that weight loss was not communicated to the physician effectively resulting in no assessment by the physician for weight loss.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 12/15-12/22/24, the facility did not ensure residents who need respiratory care are provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2/2 residents reviewed for Respiratory Care (Resident #75 and Resident #89). Specifically, 1) Resident #75 was provided oxygen 2.5 liters via nasal cannula without a physician order and 2) Resident #89 with a physician order for oxygen 2 liters as needed via nasal cannula for saturation below 90% was observed with oxygen being administered at 3 liters via nasal cannula.

Inspectors wroteBased on observations, interviews and record review during the recertification survey conducted 12/15/24-12/22/24, the facility did not ensure that the Physician provided supervision of medical care for 1 of 1 resident (Resident #93) reviewed for Physician Services. Specifically, Resident #93 had a significant weight loss of 41 pounds, 145.8 pounds to 104.8 pounds or a 28.12% weight loss, in sixteen weeks (8/28/24-12/18/24), and there was no assessment specific to the recorded weight loss by the Physician.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 12/15/24-12/22/24, the facility did not ensure that drugs and biological's in 1 of 2 medication storage areas were labeled and stored in accordance with professional standards. Specifically, antibiotics and intravenous fluids were found expired in the medication storage room.

Inspectors wroteBased on record review and interview during the recertification survey conducted 12/16/24 to 12/22/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #79) reviewed. Specifically, there was no documented evidence Resident #79 was offered, declined, or educated about the pneumococcal immunization.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey completed on [DATE]-[DATE], the facility did not develop and maintain policies and procedures for the monthly drug regimen review. The facility did not ensure that the attending physician, the facility's medical director and the Director of Nursing received and acted upon the Pharmacy Consultant's recommendations within a timely manner and documented in the medical record that the identified irregularities had been reviewed and what action should be taken for 3 of 5 residents reviewed for unnecessary medications (#9, #79, and #89 ). Specifically, 1) Resident # 9 had no documented follow up for drug regimen reviews from [DATE]. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00340632, NY00340457) the facility did not ensure the resident environment was free of accident hazards and that each resident received adequate supervision to prevent accidents for 1(Resident #1) out of 3 residents reviewed for accidents. Specifically, on 4/28/2024 at 5:45 AM Resident #1 is seen on video surveillance walking with their cane and pushed open the locked inner lobby door with their body. Licensed Practical Nurse #1 was seen coming from outside the facility, passed through the outer lobby door and pushed the inner lobby door against Resident #1, which caused Resident #1 to fall to the floor. Subsequently, Resident #1 sustained a bloody nose, black right eye, and a bruised left ankle. [...]

Inspectors wroteBased on record review and interviews during the abbreviated and partial extended survey (NY00340632, NY00340457), the facility did not ensure all violations were thoroughly investigated and that results of all investigations were reported to the administrator and other designated representative and to other officials in accordance with State law, including the State Agency, within 5 working days of the incident and appropriate corrective action taken for 4 (Resident #1, #2, #3, #4) of 5 residents reviewed. Specifically, (1) Review of video surveillance dated 4/28/2024 revealed, Resident #1 was trying to exit the facility through the front door and a facility staff member was rushing from outside the facility through the outermost door and pushed the inside door against Resident #1, causing the resident to fall to the floor. [...]

Inspectors wroteBased on record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457) the facility did not complete a performance review once every 12months for Certified Nurse Assistant reviewed. Of every nurse aide at least once every 12 months. Specifically, Certified Nurse Assistant #1's performance evaluation was last completed 2018. Certified Nurse Assistant #2's performance evaluation was last completed 2019.

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00340632, NY00340457), the facility did not to ensure that the resident was provided with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 (Residents #1 & #2) of 3 Residents reviewed for behavioral health. Specifically, (1) on 4/28/2024 at 5:45 AM, Resident #1 was seen on surveillance walking with unsteady gait and trying to exit the facility through the front door unsupervised; Resident # 1 was identified as an elopement risk, and a wanderer. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey and extended survey (NY00340632, NY00340457), the facility did not ensure that all staff were in serviced in the behavioral health needs of the residents. Specifically, the facility was unable to provide documented evidence that they provided staff education on behavioral health between 1/1/2024 and 7/2024.

Inspectors wroteBased on record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457), the facility was not 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, (1) Specifically, there was no documented evidence that the facility Assessment was reviewed and/or updated from 7/31/2021 to 7/18/2024; (2) The Facility experienced an Electronic System Outage during the extended survey on 7/19/2024, and the Administrator was not aware of the emergency plan or process for mitigating the occurrence; [...]

Inspectors wroteBased on record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457), the facility did not ensure a facility-wide assessment was conducted and documented to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, there was no Facility Assessment readily available for review upon request during the survey on 7/17/2024. There was no documented evidence that the Facility Assessment was reviewed/or updated from 7/31/2021 to 7/18/2024.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00335594), the facility did not ensure the Minimum Data Set (an assessment tool) accurately reflected the resident's status for 1 (Resident#1) out of 3 residents reviewed. Specifically, Resident #1's Quarterly Minimum Data Set, dated [DATE] had no documented evidence of the resident's rejection of care, having a pressure ulcer, and complaints of occasional mild pain.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY0035594), the facility did not ensure comprehensive care plans were reviewed/updated quarterly and as needed in a timely manner. This was evident for 1 (Resident #1) out of 3 residents reviewed for care planning. Specifically, Resident # 1's Care Plans for Pain, Osteomyelitis, Lymphedema, Pressure Ulcer, and Behavior were not updated quarterly and after a comprehensive assessment.

Inspectors wroteF689 Based on record review and interviews conducted during an abbreviated survey (NY00316488), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible. This was evident for 1 out of 6 residents (Resident #6) reviewed for accidents. Specifically, Resident #6 who required supervision with locomotion on and off the unit was able to disarm the 15 second hold on the unit exit door and fell down a flight of stairs in their wheelchair on 5/13/2023. Resident #6 was found with wheelchair lying on top of them. The facility did not ensure adequate supervision and monitoring for 1 of 6 residents reviewed for adequate supervision and accidents.

Inspectors wroteBased on observation and interview conducted during a recertification survey from 4/18/2022 to 4/29/2022, the facility did not ensure that food was stored and prepared in a manner to prevent contamination. Specifically, undated rice and pastrami and a platter of cooked turkey were observed in the kitchen walk- in refrigerator and uncooked shrimp was observed being thawed in the sink in an unapproved manner.

Inspectors wroteBased on observation and staff interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, two (2) Certified Nursing Assistants (CNAs #1 and #10) were observed, not performing hand hygiene during the resident's lunch. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not maintain an Infection Prevention and Control Program (IPCP) to ensure residents' health and safety and to prevent the transmission of COVID-19 infection. Specifically, the facility did not obtain and maintain vaccination medical records of a newly hired staff prior to starting on 4/13/22. In addition, this staff was present in the facility on 4/14/22, 4/15/22, and 4/16/22 and worked in areas where residents were at high risk for exposure to COVID-19.

Inspectors wroteBased on observations and staff interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure that each resident was provided with a dignified dining experience, specifically, staff did not provide lunch meal trays in a timely manner for five residents (Residents # 32, #59, #44, #31, and #91). Specifically, the residents were not provided their lunch meal trays at the same time as their tablemates.

Inspectors wroteBased on record review, observation, and interviews conducted during Recertification Survey and Abbreviated Survey (NY00288478) and (NY00292194) from 4/18/2022-4/29/2022, it cannot be ensured that the facility thoroughly conducted and completed an investigation to rule out abuse, neglect, and mistreatment for 1 of 5 residents (#275) reviewed for abuse and 1 of 5 residents (#112) reviewed for accidents Specifically, 1.a thorough Accident/Incident Investigation was not conducted for Resident #275 with a reported allegation of abuse and 2. a thorough Accident/Incident Investigation was not conducted for Resident # 112 with a Left Femur Fracture.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services/ equipment for 1 of 6 residents (Resident #90) reviewed for ADLs. Specifically, for Resident #90, who was dependent on staff for Activities of Living (ADL) care (transfer) the facility did not ensure the resident was transferred out of bed in a timely manner with the use of a Hoyer lift in accordance with the resident's preference. The Findings Are: The Policy and Procedure titled AM and PM Care dated 6/2021, documented unless restricted by doctor's orders, all residents must be up and out of bed each day as much as allowed by medical condition. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey and abbreviated survey (NY00289709), conducted 4/18/2022-4/29/2022, the facility did not ensure that the necessary care and services were provided to promote the highest practicable well-being for 1 of 6 residents (resident #109) reviewed for non pressure related skin ulcer/wound and 1 of 5 residents (Resident #112) reviewed for accidents. Specifically, 1. heel booties were not applied as per physician order for a resident at high risk for skin breakdown (#109) 2. the facility did not ensure ongoing monitoring was provided for ( R#112) to ensure timely medical intervention and or hospitalization following a fall.

Inspectors wroteBased on record review and interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. Specifically, the facility did not provide residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS-10055) at the termination of their Medicare Part A benefits. The residents remained in the facility. This was evident for 2 of 4 residents reviewed for Beneficiary Protection Notification Rights specifically, (Residents #21 and # 82).

Inspectors wroteBased on observation, interview and record review conducted during a Recertification Survey and Abbreviated Survey (NY00268466) completed on 6/24/21, the facility did not make information on how to file a grievance available to the residents. This was evident for 11 of the 11 residents who attended the Resident Council Meeting. Additionally, the facility did not ensure that a grievance was resolved in a timely manner for one (Resident #90) of three residents reviewed for personal property. Specifically, the lack of a thorough investigation and resolution into a resident's report of missing property.

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP) to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not ensure a person-centered care plan was developed (1) for 2 of 5 residents (#56, #83) reviewed for Activities; (2) for 1 of 8 residents (#76) reviewed for Activities of Daily Living (ADL); (3) for 2 of 6 residents (#14, #76) reviewed for Dementia Care; and (4) 1 of 5 residents (#14) reviewed for Unnecessary Medications Review.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that the Comprehensive Care Plan (CCP) were reviewed and revised in a timely manner. Specifically, (1) the CCP was not reviewed and revised for 2 of 7 (#36, #44) residents investigated for Accidents; (2) The CCP was not reviewed and revised for 2 of 5 (#4, #28) residents investigated for Activities; (3) the CCP was not reviewed and revised for 4 of 8 (#4, #28, #56, #83) residents investigated for Activities of Daily Living (ADL) Functional / Rehabilitation Potential; (4) the CCP was not reviewed and revised for 3 of 6 (#28, #69 #83) residents investigated for Dementia Care; and (5) the CCP was not reviewed and revised for 1 of 3 (#4) residents investigated for Urinary Catheter or UTI.

Inspectors wroteBased on observation, interviews and record review conducted during a Recertification Survey and Abbreviated Survey (NY00274235), the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, the Certified Nursing Assistant (CNA) actual staffing levels were below the facility assessed minimum levels 24.3% of shifts for the months of April 2021, May 2021 and June 2021.

Inspectors wroteBased on observation and staff interview, the facility did not ensure that carbon monoxide detectors in buildings with fuel-fired appliances were installed in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State. Specifically, a carbon monoxide detector was not installed in the generator room. The generator is located in the basement of the building and is fuel operated.

Inspectors wroteBased on observations, interviews and record review on a recent recertification survey, the facility did not ensure residents have a right to a dignified existence for two of three residents screened for dignity. Specifically, several observations were made of Resident #85 and #5 with his/her Foley bag uncovered so that passing by staff and residents can see his/her urine in the tubing and bag and for Resident #85, staff were observed performing a dressing change exposing him/her to passing by staff.

Inspectors wroteFACILITY Based on observations, interviews and record reviews on a recent recertification survey, the facility did not ensure that the Office of the Long Term Ombudsman was made aware of transfers and discharges for the months of April, May and June 2021. Specifically there were 68 discharges/transfers made from 4/1/2021-6/22/2021 without notification to the Ombudsman.

Inspectors wroteBased on observation, record review and staff interview during the recertification survey the facility did not ensure that each resident received an accurate assessment reflective of the resident's current status. This was evident for one (Resident #62) resident reviewed for Minimum Data Set (MDS) accuracy. Specifically, Annual Assessment of the MDS dated [DATE] and Quarterly assessment 05/05/21 did not document the Resident's Brief Interview for Mental Status (BIMS) score. The finding is: Resident #62 was admitted to the facility on [DATE] and had diagnoses including Psychotic Disorder, Schizophrenia and Major Depressive Disorder. An admission MDS assessment dated [DATE] documented the resident was cognitively intact with some mood and behavior issues. The Quarterly MDS assessment dated [DATE] did not have a BIMS score documented. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for 2 (Resident #85, and #42) of 3 residents reviewed for ADL's staff provided incomplete AM (morning) care. Specifically, staff did not give Resident #85 a shower for more than ten days, shave and provide oral and nail care and Resident # 42 did not receive showers.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated surveys the facility did not ensure that 2 of 5 residents (Resident #66 and Resident # 53) reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, 1. 2.

Inspectors wroteBased on record reviews and interviews during a recertification survey, for 2 of three residents reviewed for medication administration (#85) (#64), the facility did not ensure residents were free from significant medication errors. Specifically, Resident #85 had three omissions of Intravenous antibiotics and Resident (64) Insulin amounts were not documented on the Medication Administration Record (MAR) for a resident receiving sliding scale insulin.

Inspectors wroteBased on observation, record review and staff interview conducted during a recertification survey, the facility did not ensure that juice thickeners in the nourishment refrigerators located on the nursing units (2 of 2 resident floors), on the refreshment cart and in the kitchen storage room, were stored in accordance with acceptable standards of food safety practice. The finding is: On 6/16/21 at 8:50 AM an examination of the first floor unit refrigerator was conducted and it was noted that there were two containers of Ready Care thickener cranberry cocktail in the refrigerators and the containers had a use by date of 12/24/20 and 6/8/21. In an interview with the Licensed Practical Nurse (LPN) # 1 at the time of the findings, LPN #1 stated that dietary staff is responsible for removing the outdated foods in the refrigerator. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Recertification Survey completed on 6/24/21, the facility with a licensed bed capacity of 134 was operating without a Social Worker (SW) from 4/30/21 to present.

Inspectors wroteBased on observation, record review and staff interview, the facility did not ensure that a Legionella Risk Assessment and Water Management Plan was provided in accordance with Section 483.80. Specifically, the facility policy and procedures did not contain the required elements; a risk assessment, control measures to maintain the physical, chemical, and temporal conditions of the system, and a system description analysis of hazardous conditions or corrective actions.