Franklin Center for Rehabilitation and Nursing

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. This was evident for one (1) of six (6) residents reviewed for Activities of Daily Living out of a total of 38 sampled residents. Specifically, Resident #238 was observed to have their call bell out of reach on multiple occasions.

Inspectors wroteBased on record review, observations, and interviews, the facility to ensure it promoted and facilitated resident self-determination through support of resident choice. This was evident for two (2) residents (Resident #13 and #188) of six (6) residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #13's and Resident #188's bathing preferences were not honored.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that a resident is free from physical restraints imposed for discipline or staff convenience and not required to treat the resident's medical symptoms. This was evident for two (2) residents (Resident #109 and Resident #184) of two (2) residents reviewed for Physical Restraints out of 38 sampled residents. Specifically, 1). Resident #184 was observed on several occasions, lying on a perimeter mattress and, 2). Resident #109 was observed on two occasions, lying on a perimeter mattress with an armchair and pillow wedged on the left side of the bed, in between the upper part of resident's bed and the window area.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents comprehensive care plans were reviewed and revised to reflect the resident's status after each assessment. This was evident for one (1) resident (Resident #68) of two (2) residents reviewed for Activities, and one (1) resident (Resident #4) of two (2) residents reviewed for Urinary Catheter, out of 38 sampled residents. Specifically, 1). the comprehensive care plan for Activities for Resident #68, and 2). the comprehensive care plan for bladder care for Resident #4 were not revised after each assessment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that services provided meet professional standards of quality. This was evident for two (2) residents (Residents #7 and #28) observed during Medication Administration. Specifically, 1) Registered Nurse #8 was observed administering intravenous medications without flushing the access line, and 2) Registered Nurse #7 was observed administering multiple medications via gastrostomy tube without flushing the tube with water before and after each medication.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that services provided meet professional standards of quality. This was evident for two (2) residents (Resident #7 and Resident #28) observed during Medication Administration. Specifically, 1). Registered Nurse #8 did not check for patency and placement of the Resident #7's gastrostomy tube (a surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach) prior to administering medications, and 2). Registered Nurse #9 checked for patency and placement of Resident #28's gastrostomy tube by auscultation (listening to sounds with a stethoscope) instead of using a recommended method for checking placement.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that drugs and biologicals were stored in locked compartments. This was evident for one (1) unit (Unit 6) of eight (8) units observed for Medication Storage. Specifically, seven (7) blister packs of medications and a bag containing several vials of unmixed antibiotics for several residents were observed in an open box in an unlocked nursing supervisor's office which was located across from the nurse's station on Unit 6.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain medical records that are accurately documented. This was evident for one (1) out of three (3) residents (Resident #28) reviewed for Tube Feeding out of a total of 38 sampled residents. Specifically, Resident #28's medication orders inaccurately documented to be given by oral route when medications were being given by gastrostomy tube (a flexible tube placed in the stomach for feeding, hydration and medication administration).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to 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 evident for one (1) resident observed during Medication Administration. Specifically, Registered Nurse #8 was observed changing gloves multiple times during medication administration without performing hand hygiene between glove changes.

Inspectors wroteBased on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in Resident #1's mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. Certified Nursing Assistant #1 who was present stated Resident #1 was refusing their medication.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that allegations of abuse were investigated thoroughly and that residents were protected from further abuse during the investigation. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026 at approximately 11:25 PM, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in their mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one (1) out of two (2) residents (Resident #1) sampled for fall. Specifically, Resident #1 who has acquired bilateral below knees amputation was observed on the floor in their room on 05/01/2026. Certified Nursing Assistant #1 went into the room picked up Resident #1 and placed them back into the bed before Resident #1 was assessed by Registered Nurse Supervisor #1. On assessment Resident #1 was observed with a small scratch on their lower lip.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 02/21/2024 to 02/28/2024, the facility did not ensure that a resident and/or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. This was evident for 3 residents (Resident #31, #142, and #165) reviewed for Care Planning out of 38 total sampled residents. Specifically, 1) Resident #31 and/or their designated representative were not invited to their care plan meeting, 2) Resident #142 and/or their designated representative were not invited to their care plan meeting, and 3) Resident # 165 was not invited to their care plan meeting.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility did not ensure that residents were provided a safe and homelike environment and that residents received care and services safely and does not pose a safety risk. This was evident for 1 (Resident #5) of 3 residents investigated for Respiratory care out of an investigative sample of 38 residents. Specifically, on 02/22/2024, a Maintenance staff was observed cleaning the air conditioning unit while Resident #5 was in bed sleeping in their room.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00330116) Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that all alleged violations involving abuse and injuries of unknown source were reported immediately but not later than 2 hours after the allegation was made to the New York State Department of Health. This was evident for 3 (Resident #655, #203, and #97) of 38 total sampled residents. Specifically, 1) On 02/12/2024, Resident #655 sustained a laceration to their right eyebrow. The injury was not witnessed, and the source of injury could not be explained by the Resident. The injury was not reported to the New York State Department of Health, and 2) On 12/18/2023 at approximately 5:45 AM, Residents #203 and #97 were involved in a resident-to-resident altercation. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that the Minimum Data Set assessments accurately reflected the residents' status. This was evident for 2 (Resident #181 and Resident#25) of 2 residents sampled for catheter care, out of 38 sampled residents. Specifically, Resident #181's Foley catheter was not documented, and Resident #25 's use of suprapubic catheter was documented as an ostomy, instead of indwelling catheter.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure a person-centered comprehensive care plan was developed and implemented to meet residents' preferences. This was evident for 1 (Resident #116) of 38 total sampled residents. Specifically, a Comprehensive Care Plan was not developed to address Resident #116's preference not to use a urinary catheter privacy bag.

Inspectors wroteBased on interviews and record review conducted during a Recertification and Complaint survey (NY00295349) from 02/21/2024 to 02/28/2024, the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for 1 (Resident #163) of 5 residents investigated for Accidents out of an investigative sample of 38 residents. Specifically, on 05/02/2022 at 7:45 PM, Resident #163 identified as at high risk for elopement, was able to exit the facility undetected through the fire exit gate on the main floor. Resident #163 was located by the New York City Police Department on 05/04/2022 at an apartment building that Resident claimed they previously lived.

Inspectors wroteBased on observation, record review, and staff interviews conducted during Recertification survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, the most recent MDS did not accurately indicate tube feeding. This was evident for 1 out of 35 sampled residents reviewed (Resident # 34). The finding is: The facility's policy and procedure titled MDS Assessment and Completion dated 12/01/2020 states that the assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff in identifying health problems and care plan development. [...]

Inspectors wroteBased on record review, observations, and staff interviews during the recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, (1) a resident was not provided with assistive device - right ankle orthosis and not ambulated as per discharge instructions from the rehabilitation department (2) a resident was not provided with the hand roll device as per plan of care to improve resident's contractures. This was evident for 2 out of 2 residents reviewed for Rehab and Limited ROM, (residents #41 and #106) out of total sample of 35 residents sampled.