Hope Center for Hiv and Nursing Care

Inspectors wroteBased on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident #1 had a Physician's Order dated 03/10/2026 and 03/18/2026 for laboratory tests to be done for Prothrombin Time and International Normalized Ration (used to monitor patients taking blood-thinning medications) and several other tests. Record review revealed that the laboratory tests were not performed, and a Nursing Supervisor and Medical Doctor were not notified. Cross Reference:

Inspectors wroteBased on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident #1 had a Physician's Order dated 03/10/2026 and 03/18/2026 for laboratory tests to be done for Prothrombin Time (measures how long your blood takes to clot) and International Normalized Ratio level (used to monitor patients taking blood-thinning medications) and several other laboratory tests. Record review revealed that laboratory tests were not performed, and a Nursing Supervisor and Medical Doctor were not notified.

Inspectors wroteBased on record review, and interviews during survey, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident in one out of four residents sampled. Specifically, Resident #1 was on Warfarin (blood thinner), and Medical Doctor #1 ordered laboratory tests on 03/10/2026 and 03/18/2026 for Prothrombin Time (measures how long your blood takes to clot) and International Normalized Ratio level (used to monitor patients taking blood-thinning medications) and several other laboratory tests. Medical Doctor #1 failed to follow up on several laboratory tests they ordered. Cross Reference: F658 Services Meet Professional Standards and F684 Quality of CareThe

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility failed to maintain each resident's right to a safe, clean, comfortable, and homelike environment. This was evident in 1 (Units 2) of 3 units observed. Specifically, floors in residents' rooms were sticky and not waxed, there was a leak in the bathroom shower, the bedside tables had dirt and dust, and there was a missing window treatment.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical nursing, mental and psychosocial needs. This was evident in 2 (Residents #1 and #213) of 19 total sampled residents. Specifically, 1.) Resident #1 who had an active diagnosis of Chronic Obstructive Pulmonary Disease had no care plan developed to address their respiratory status. 2.) Resident #213 who had diagnoses of Pulmonary Mycobacterial Infection and Pneumocytosis had no car eplan developed to address their respiratory status.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/19/2025, the facility did not ensure that each resident received treatment and care in accordance with goals for care and professional standards of practice. This was evident in 2 (Resident #213 and Resident #41) of 3 residents reviewed for respiratory care. Specifically, Resident #213 and Resident #41 had a physician's order for incentive spirometry that was not implemented because there was no available incentive spirometer in the facility. Cross Reference: F-tag 695 Respiratory/Tracheostomy care and Suctioning

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/19/2025, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident in 3 (Residents #6 and #213) of 7 residents reviewed for respiratory care out of 19 total sampled residents. Specifically, 1.) Resident #6 received oxygen at a flow rate inconsistent with the physician's order. 2.) Residents #41 and 213's physician's order for the use of incentive spirometer 3 times daily was not implemented.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident. This was evident during the Sufficient and Competent Nurse Staffing Task. Specifically, interviews with residents, members of the Resident Council, and staff members; as well as review of minutes of the Resident Council meeting reflected ongoing concern about staffing levels at the facility.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was evident in 1 (4th Floor) of 3 units observed during the medication storage task. Specifically, the facility failed to keep an accurate count and record of disposition for Dronabinol, a controlled medication. In addition, there were missing licensed nurses' signature in the Dronabinol narcotic sheet to verify accurate count.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 05/12/2025 to 05/16/2025, the facility did not ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident in 3 (Resident #2, #41, and #55) of 5 residents reviewed for Unnecessary Medications out of 19 total sampled residents. Specifically, there was no documented evidence that the attending physician addressed the consultant pharmacist's recommendations for Residents #2, #41, and #55 in a timely manner.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that food were stored and prepared in accordance with professional standards for food service safety. This was evident during the kitchen task. Specifically, 1.) Outdated food items were stored in the refrigerator. 2.) Pureed food were not maintained at safe temperature.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that the interdisciplinary team reviewed and revised a resident's comprehensive care plan after each assessment. This was evident in 1 (Resident #2) out of 19 sampled residents reviewed for unnecessary medication and advance directives. Specifically, Resident #2's Comprehensive Care Plan for Advance Directives, Diabetes Mellitus, Skin Integrity, Anticoagulant medication use, and Psychoactive medication use was not reviewed or revised after each assessment.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/15/2025, the facility did not ensure that a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident in 1 (Resident #29) of 1 resident reviewed for Limited Range of Motion out of 19 total sampled residents. Specifically, Resident #29 was not provided with a left resting hand splint and a left elbow extension splint per the physician's order.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that drugs and biologicals were stored in accordance with professional standards. This was evident in 2 (3rd and 4th Floor) of 3 units observed for medication storage. Specifically, 1.) The 4th floor medication storage room refrigerator was unlocked and contained controlled medications that were not stored in the affixed lock box. 2.) The 3rd Floor medication storage room contained food, and multiple prescribed medications were stored in unlocked cabinets. 3.) A previously administered 50 milliliter bag of intravenous solution was stored inside the 3rd Floor medication cart.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that the Infection Preventionist participated on quality assessment and assurance committee. Specifically, the Infection Preventionist had not participated in any of the Quality Assurance and Performance Improvement meetings held from June 2024 through April 2025.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from [DATE] to [DATE], the facility did not ensure that infection control practices and procedures were maintained. This was evident in 1 (3rd Floor) of 3 units observed for medication storage. Specifically, a bag of previously administered antibiotic intravenous solution was observed inside the medication cart.

Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00332540), the facility did not ensure that a resident was able to exercise their rights as a resident in the facility and as a citizen or resident of the United States. This was evident in one out of four residents sampled (Resident #1). Specially, on 01/25/2024 at 11:00 AM, Recreational Aide #1 reported to Recreational Supervisor #1 that Resident #1 refused to have their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair.

Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00332540), the facility failed to ensure a resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was evident for one out of four residents sampled (Resident #1). Specifically, on 01/25/2024, Recreational Aide #1 reported to their Recreation Supervisor that Resident #1 was refusing their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was evident during observation of the kitchen. Specifically, 1) the dish washing machine did not maintain appropriate temperatures for washing and rinsing dishes, and 2) Dietary Worker #1 did not follow proper sanitation procedure during the pot washing process.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure garbage and refuse were disposed of properly. This was evident during observation of the kitchen. Specifically, garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests.

Inspectors wroteF584 The resident has a right to a safe, clean, comfortable and homelike environment. Based on observations and interviews conducted during a standard recertification survey, the facility did not ensure that residents had a homelike environment due to multiple issues with paint chips and scratches, broken bathroom equipment and shabby furnishings in communal areas.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated (NY00327468 and NY00321011) survey from 12/18/2023 to 12/22/2023, the facility did not ensure adequate supervision to prevent accidents or hazards. This was evident for 2 of 16 total sampled residents. Specifically, 1) Resident #264 was at high risk for elopement and was able to climb the fence bordering the facility's back patio and elope, and 2) Resident #33 had incidents of being verbally abusive towards others and was unsupervised while in the Main Dining Room with other residents, placing them at risk for an altercation with Resident #214.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 12/18/2023 to 12/22/2023, the facility did not ensure a discharge planning process was in place which addressed each resident's discharge goals and needs. This was evident for 1 (Resident #33) of 16 total sampled residents. Specifically, Resident #33's discharge care plan was not reviewed and revised to reflect the resident's desires and goals for discharge from the facility.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure that foods were served at a safe and appetizing temperature. This was evident for 2 (Unit 3 and 4) of 3 resident units during dining observation. Specifically, hot and cold food items were not held at safe and appetizing temperatures during meal service on Unit 3 and Unit 4.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure a resident was provided with required rehabilitative services. This was evident for 1 (Resident #55) of 16 total sampled residents. Specifically, Resident #55 was not evaluated for Physical Therapy (PT) services after a referral to PT was ordered by the Attending Physician.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure a safe and comfortable environment for residents, staff, and public. This was evident for 1 (Unit 2) of 3 units. Specifically, the Unit 2 nursing station had mismatched paint and a damaged desk.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure handrails were firmly secured to the wall. This was evident for 1 (Unit #2) of 3 resident units during environmental observation. Specifically, 2 sections of handrail were not fully connected in the Unit 2 hallway.

Inspectors wroteBased on observation, record review and interviews conducted during an Abbreviated Survey (NY00324241), the facility did not ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to New York State Department of Health (NYSDOH). This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 09/12/23 at approximately 12:00 PM, Recreational Aide (RA) #1 reported that they observed Certified Nurse Assistant (CNA) #1 hitting Resident #1 in the face with a towel and cursed at Resident #1while providing personal care. The facility did not report the alleged violation of abuse to NYSDOH.

Inspectors wroteF 842 Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00324241). In accordance with accepted professional standards and practices, the facility did not maintain clinical records that were completed and accurately documented. This was evident in one of three residents (Resident #1) reviewed for Abuse. Specifically, on 09/12/2023, Recreation Aide (RA)#1 reported to the Administrator that they observed Certified Nurse Assistant (CNA) #1 hit Resident #1 with a towel and cursed Resident #1 while providing care. Registered Nurse Supervisor (RNS) #1 assessed Resident #1 and did not document the assessment in Resident #1's medical record.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 3 resident units. (Unit #2) The Findings Include: The policy titled Physical Plan last revised date 11/2017- documented that environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood Borne Pathogens Standard. The housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. [...]

Inspectors wroteBased on observation, staff interview and record review conducted during the Recertification/Complaint Survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no CCP developed and implemented for resident's Self-Care Administration of Tube Feeding and Self-Performance of respiratory care. This was evident for 1 of 1 resident reviewed for Tube Feeding and for 1 of 2 residents reviewed for respiratory care respectively, out of 18 sampled residents (Resident #48).

Inspectors wroteBased on observation, record review and staff interviews during the Recertification/Complaint survey, the facility did not ensure that care and services are provided according to accepted standards of clinical practice to meet professional standards of quality. Specifically, the facility did not ensure that a resident with Intravenous Peripherally Inserted Central Catheter (IV PICC) line for an antibiotic is provided with care and services to prevent further infection. This was evident for 1 of 5 residents observed for Medication Administrations out of a sample of 18 residents. (Resident #110).

Inspectors wroteBased on observation, staff interview and record review conducted during the Recertification/Complaint Survey, the facility did not ensure that needed care and services that are resident centered, in accordance with the professional standards of practice that will meet resident's physical, mental, and psychosocial needs are provided to a resident. Specifically, a resident that required Self-Administration of Tube Feeding and Self-Performance of respiratory care were not properly monitored and supervised. This was evident for 1 of 1 resident reviewed for Tube Feeding and for 1 of 2 residents reviewed for respiratory care respectively, out of 18 sampled residents (Resident #48).

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, two residents (Resident #15 and #42) did not receive doses of intravenous antibiotics ordered for the overnight hours on 10/04-08/2021.

Inspectors wroteBased on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, the meat slicer was observed uncovered and electric wire coiled (wrap around) the meat slicer for three days. This was evident during the kitchen inspection. The Findings Include: The policy titled Sanitization policy last revised 02/2021 documented that equipment near preparation areas shall remain covered once cleaned and air dried to prevent cross contamination. The instruction manual for the Globe G12 slicer documented to prevent illness caused by the spread of food borne pathogens, it is important to properly clean and sanitized the entire slicer as any surface of the slicer can become contaminated. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification/Complaint survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, The residents on oxygen/nebulizer/suction treatment were observed with the tubing not properly labelled and dated to indicate the time the tubing was replaced. This was evident in 2 of 2 residents reviewed for respiratory care area (Residents #6 and #48).