Central Park Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made for one (1) of three (3) residents (Resident #1). Specifically, on 05/16/2026 during the 7:00 AM to 3:00 PM shift, Licensed Practical Nurse #3 alleged they witnessed Certified Nurse Aide #15 to have been verbally abusive and pushed Resident #1 toward a dining room chair. The incident was not reported as required and Certified Nurse Aide #15 continued to have access to residents. On 05/20/2026, the Director of Nursing discovered a written statement in their mailbox from Licensed Practical Nurse #3 that described the incident on 05/16/2026. Resident #1 was not assessed until 05/18/2026 at approximately 8:30 AM.

Inspectors wroteBased on observations, record review, and interviews during the recertification and partial extended surveys conducted 4/28/2025 - 5/5/2025, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler was not maintained in appropriate operating condition and had an air temperature of 50 degrees Fahrenheit. Milk stored in the walk-in cooler was measured at 47.8 degrees Fahrenheit. Potentially hazardous foods (food that requires time/temperature control for safety to limit the growth of pathogens) were in the stand-up unit refrigerators on four (4) of four (4) units (1st, 2nd, 3rd, and 4th floor) and originated from the main kitchen walk-in cooler. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/6/2025, the facility did not ensure a process was in place for residents to have their grievances addressed appropriately for 153 of 153 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, 14 of 14 anonymous residents present at the resident group meeting stated they did not know where to obtain grievances forms from or of their right to file anonymously; some residents present did not know who the grievance officer was.

Inspectors wroteBased on interviews and record review during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered or acted upon and responded to with a rationale for 14 of 14 anonymous residents present at the resident group meeting. Specifically, 14 of 14 anonymous residents present at the resident group meeting stated they did not receive responses to topics or concerns addressed in prior Resident Council meetings. Additionally, there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided to the residents.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for two (2) of four (4) resident units (First and Fourth Floors) and the main kitchen. Specifically, the first floor, the fourth floor, and the main kitchen had unclean surfaces including stained and sticky floors, unclean walls, and unclean shelving.

Inspectors wroteBased on observations, record review, and interview during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 4/30/2025 and 5/2/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 4/30/2025 and 5/2/2025. Additionally, Resident #5 complained the food was cold.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for four (4) of seven (7) residents (Residents #30, #97, #121, and #123) reviewed. Specifically, Residents #97, #121, and #123 were provided unplanned plastic silverware and plastic cups during meals; and Resident #30 wore soiled shorts because they did not get their personal laundry items returned to them timely.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00355209) survey conducted 4/28/2025-5/6/2025, the facility did not ensure all alleged violations were thoroughly investigated and a plan was implemented to prevent further potential abuse for one (1) of two (2) residents (Resident #121) reviewed. Specifically, Resident #121 sustained an injury of unknown origin, a human bite mark, and it was not reported to the New York State Department of Health within 24 hours as required.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00375619, NY00359259, and NY00351358) surveys conducted 4/28/2025-5/5/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (2) of eight (8) residents (Residents #60 and #158) reviewed. Specifically, Residents #60 was not provided showers as planned; and Resident #158 was not provided incontinence care as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not provide ongoing programs to support each resident in their choice of activities, for two (2) of three (3) Residents (Residents #74 and #156) reviewed. Specifically, Residents #74 and #156 were not offered meaningful activities that included their interests and preferences.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #56) reviewed. Specifically, Resident #56 had significant weight loss, weekly weights were not competed as ordered, reweighs were not obtained per policy, nutritional needs were not reassessed following the significant weight loss, and they did not receive assistance at meals as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for one (1) of one (1) resident (Resident #95) reviewed. Specifically, Resident #95 did not receive double portions per their preference. Additionally, during the facility's April 2025 Food Committee Meeting 20 residents voiced concerns regarding double portions.

Inspectors wroteBased on observation, record review and interview during the abbreviated survey (NY00341649), the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's bedroom had food debris on the floor, there were no linens on the bed, the mattress had large tears, and the privacy curtain was stained.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00318580, NY00315254, NY00312648, NY00302926, NY00315085, and NY00314497) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4). Specifically, floors were unclean, windows were damaged or had missing components, and linen items were not available in sufficient quantities for resident use on all units.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys(NY00302926, NY00311496, NY00314497, NY00315085, NY00315254, NY00317770, NY00318580, and NY00321728) conducted 9/5/2023-9/12/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain adequate nutrition, and personal care including grooming and oral hygiene for 7 of 9 residents (Residents #3, 27, 76, 95, 110, 133, and 417) reviewed. Specifically, Resident #3 was not dressed in clean clothes or shaved as they preferred; Resident #27 was not assisted with range of motion (ROM) as planned; Resident # 76 was not toileted every two hours as planned; Resident #95 was not turned and positioned, shaved, or provided with nail care as planned; [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00315085 and NY00318580) conducted 9/5/2023-9/12/2023, the facility did not ensure residents were treated with respect and dignity and cared for in a manner that promoted quality of life and protected the residents' rights for 2 of 5 residents (Residents #70 and 133) reviewed. Specifically, Resident #133 wore other residents' clothing that did not fit and attended an appointment wearing the clothing; Resident #70's urinary catheter collection bag was not covered and visible to other residents and visitors.

Inspectors wroteBased on observation and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Specifically, the survey results and plan of correction were in a black plastic file bin on the wall, approximately 4-foot off the ground behind a 5-foot sign.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00315085, NY00318580, NY00321728) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents were free from abuse for 1 of 2 residents (Resident #422) reviewed. Specifically, CNA #60 was witnessed verbally abusing Resident #422 and CNA #60 was not immediatley removed from the facility and returned to the unit after the abuse had occurred.

Inspectors wroteBased on record review and interview during the recertification survey conducted 9/5/2023-9/12/2023 the facility did not ensure that within 14 days after completion of a resident's assessment they electronically transmitted encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS (Centers for Medicare and Medicaid Services) System for 4 of 4 residents (Residents #24, 30, 81, and 100) reviewed. Specifically, the MDS assessments for Residents #24, 30, 81, and 100 were not transmitted within 14 days of completion.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not implement a person-centered care plan to meet the medical, mental, and psychosocial needs for 3 of 3 residents (Residents #119, 143, and 505) reviewed. Specifically, Resident #119 did not speak English and was not provided a communication board as planned; Resident #143 was addressed by a name not included in their care plan; and Resident #506 required glasses and was observed wearing broken glasses.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312648 and NY00315085) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure the resident environment remained free of accident hazards as is possible for 2 of 7 residents (Residents #65 and #95) reviewed. Specifically, Resident #65 had unidentified medications on the floor of their shared room, and following falls, Resident #95's care plan was not updated with recommended interventions for fall prevention (fall mats) and they were not implemented as recommended.

Inspectors wroteBased on observation, record review and interview during the recertification survey and abbreviated (NY00315254) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure that a resident being fed by enteral means (tube placed in the stomach for feedings) received the appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #17) reviewed. Specifically, Resident #17 did not receive the ordered amount of feeding formula in a 24 hour period and the resident's medication administration, tube flushes, tube placement checks, and feeding tube care were not performed according to acceptable professional standards. Additionally, the resident was on transmission based precautions and staff did not wear personal protective equipment (PPE) when providing care. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00312648) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #28 and #33) reviewed. Specifically, Resident #28's portable oxygen tank was not replaced when it was empty, Resident #28's care plan did not include directions for oxygen use, and Resident #33's care plan did not include the need for oxygen therapy.

Inspectors wroteBased on observation and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not post the following required information for resident and visitor viewing on a daily basis: the current resident census and the actual number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the last posted report during the survey period was 9/9/2023. During an observation on 9/12/2023 at 12:20 PM, the resident census and staff hours list was posted on the desk in the main lobby and was dated 9/9/2023. During an interview on 9/12/2023 at 12:20 PM, the Director of Nursing (DON) stated that the posted document that included the resident census and staff hours was for 9/9/2023, and the posted staffing was required to be updated every day. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 4 of 4 nursing units (1, 2, 3, and 4) and the main kitchen. Specifically, there was evidence of live fruit fly infestation on Units 1, 2, 3, 4 and the main kitchen.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00316269) conducted 9/5/2023-9/12/2023, the facility did not ensure access to medical records was provided to a resident's legal representative within 24 hours of an oral or written request (excluding weekends and holidays) for 1 of 1 resident (Resident #360) reviewed. Specifically, the facility did not provide Resident #360's requested medical records to the legal representative within 24 hours as required.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00280835) surveys conducted 2/9/22-2/17/22, the facility failed to properly maintain a clean comfortable and homelike environment for 4 of 4 units (Units 1, 2, 3 and 4) reviewed. Specifically, there were unclean floors, surfaces, privacy curtains, wheelchairs, and linens; and comfortable sound levels were not maintained during meal service on the 4th floor.

Inspectors wroteBased on interview and record review during the recertification survey conducted 2/9/22-2/17/22 the facility failed to ensure to the extent practicable, the participation of the resident and resident's representative(s) in the development of the comprehensive care plan (CCP) for 3 of 3 residents (Residents #30, 126, and 256) reviewed. Specifically, there was no documented evidence Residents #30, 126 or their representatives were invited to or attended comprehensive care plan meetings, and Resident #256 was not invited to attend a meeting regarding their care and discharge plan and was not updated timely following the meeting.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00288029, NY00276190, NY00278739, NY00280835, NY00289363, NY00261027, NY00264434, NY00269202, NY00269912, NY00271865, NY00272787, NY00274516, NY00276582, NY00275967, NY00277089, NY00280135, NY00281096, NY00281327, NY00283023, NY00289363, NY00261027) conducted 2/9/22-2/17/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 10 residents (Residents #9, 18, 88, 125, and 256) reviewed and 2 anonymous residents at the Resident Council Meeting. [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00267849 and NY00288029) conducted 2/9/22-2/17/22, 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 for 3 of 5 residents (Residents #43, 73, and 96) reviewed for isolation precautions, 2 of 31 residents (Residents #44 and 87) reviewed for COVID-19 vaccinations, and 1 of 4 (Unit 3 high side) medication cart storage areas. Specifically, Residents #43, 73, and 96 were COVID-19 positive and the facility did not ensure precautionary measures were in place to prevent transmission of COVID-19; there was no documented evidence Residents #44 and 87 were offered a COVID-19 vaccination; [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/9/22-2/17/22, the facility failed to ensure the right to reside and receive services in the facility with reasonable accomodation of resident needs and preferences for 2 of 9 Residents (#56 and 89) reviewed. Specifically, Residents #56 and 89 were not properly positioned during mealtime to maximize eating abilities and comfort.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00287571) conducted 2/9/21-2/17/22, the facility failed to ensure each resident had the right to be free from abuse for 3 of 5 residents (Residents #54, 109, and 141) reviewed. Specifically, Resident #109 had a history of sexually inappropriate behaviors and was care planned to be supervised when in common areas with other residents. Residents #54 and #109 were left unsupervised in a common area together and Resident #109 touched Resident #54 in a sexually inappropriate manner.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/9/22-2/17/22, the facility did not provide based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #15) reviewed. Specifically, Resident #15 was not offered meaningful activities and was not provided with activities of their choosing.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00280835) surveys conducted 2/9/22 -2/16/22, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #9) reviewed. Specifically, Resident #9 had a medical order for TEDS (thrombo-embolic deterrent stockings, compression stockings), the stockings were not applied and were documented as applied by licensed practical nurse (LPN) #19.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/9/21-2/17/21, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 (Resident #125) residents reviewed. Specifically, Resident #125 was at risk for pressure ulcers, did not have an air mattress in place as ordered, and nursing documented the air mattress was in place.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00276799, NY00284318, and NY00271865) conducted on 2/9/22-2/17/22, the facility failed to ensure 3 of 6 residents (Residents #38, 87, and 88) reviewed received adequate supervision and assistance devices to prevent accidents and/or their environments remained as free of accident hazards as possible. Specifically: - Resident #38 was on an altered consistency diet and had a history of attempting to consume other residents' meal items. Interventions were not implemented to prevent reoccurrence and the resident consumed food that was included with their ordered food consistency. - Resident #87 did not have interventions in place to prevent wandering and elopement and the resident exited the building. [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00280835) conducted on 2/9/22 through 2/17/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 6 residents (Resident #9 and 34) reviewed. Specifically, Resident #9 did not receive all their food items at 2 meals and weekly weights were not completed as ordered. Resident #34 had a significant weight loss and weekly weights were not completed as ordered.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/9/22-2/17/22, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 4 (first floor) nursing unit steam tables reviewed. Specifically, hot food items in the first floor steam table for the lunch meal on 2/9/22 were not held above 135 Fahrenheit (F).

Inspectors wroteBased on observation, record review and interview during the recertification and Focused Infection Control Surveys conducted 2/9/22-2/17/22, the facility failed to develop and implement policies and procedures to ensure proper precautions to prevent the spread of COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and the regulations for 3 of 6 employees (housekeepers #16 and #38, and certified nurse aide #39) reviewed. Specifically, housekeepers #16 and #38 and certified nurse aide (CNA) #39 were not fully vaccinated for COVID-19 and there was no process to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for staff who were not fully vaccinated.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/9/22-2/17/22, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 (Unit 1) nursing unit kitchenette steamtables. Specifically, the Unit 1 steam table did not maintain power and had a faulty AC (alternating current) plug and a faulty electrical wall outlet.