Hudson Valley Rehabilitation & Extended Care Ctr

Inspectors wroteBased on observation, interview, and record review conducted during a Recertification and Abbreviated Survey (NY00622225) from 2/19/26 to 2/27/26, it was determined that for one (1) of four (4) resident care units (2 East), the facility did not have sufficient nursing staff levels to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 02/08/2026 during 3:00 p.m. -11:00 p.m., there was no documented evidence that medications were administered to 35 residents when Registered Nurse Supervisor #17 was also assigned to work on unit 2 East and 2 West.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey and Abbreviated Survey (2677034) from 02/19/2026 to 02/27/2026 the facility did not provide sufficient support personnel to safely and effectively carry out the functions of food and nutrition services. Specifically, 1) observations of incomplete refrigerator temperature log documentation in the kitchen and on the units; expired food in unit 3W and 3E pantry refrigerators, and during the Resident Council Meeting held on 02/20/2026 residents stated they had missing food items on their meal trays, and 2) Resident #15's representative stated Resident #15 frequently did not receive 9:00 AM and / or 2:00 PM nutritional supplement snacks.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 02/19/2026 to 02/27/2026, the facility did not store, prepare and serve food in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen and unit pantry refrigerators, and 2) expired foods were stored in the kitchen, unit pantry refrigerators, and dry pantry.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment for three (3) of eight (8) residents (Resident #23, Resident #28, Resident #72) reviewed for the environment. Specifically, 1) Resident #23 was observed in their room with garbage and linens scattered on the floor and a disconnected catheter bag containing urine was hanging on the bed rail. 2)Resident #28 was observed sitting in a wheelchair with dust and dirt on the frame, the wheelchair cushion had brown stains on it, and the room bathroom had sticky floors and a smell of urine; 3) Resident #72's bathroom had an approximately 20-inch by 10-inch opening in the wall which allowed plumbing underneath the bathroom sink to be exposed.

Inspectors wroteBased on observation and interview conducted during the Recertification survey from 02/19/2026 to 02/27/2026, the facility did not ensure residents were provided food that was safe and/or at an appetizing temperature. Specifically, a test tray revealed lasagna that was being served to residents on the 3 W unit had a temperature of 120.5 degrees.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 02/19/2026 to 02/27/2026, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for 4 (four) residents observed during dining (Residents #63, #58, #39 and #30), one (1) of seven (7) residents reviewed for activities of daily living (Resident #84), and one (1) of one (1) resident (Resident #23) reviewed for bladder and bowel incontinence. Specifically, 1) During lunch tray delivery and tray set-up on 02/24/2026, Certified Nurse Aide #7 was observed touching the tops of straws and buttering a resident's roll with their bare hands 2) Resident #84 was lying in bed with their catheter collection bag hanging on the bed rail and touching the floor; [...]

Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 02/19/2026 to 02/27/2026, the facility did not ensure that each resident was treated in a manner and in an environment that maintains or enhances each resident's dignity and respect for three (3) residents (Resident #47, Resident #55, and Resident #90) observed during dining. Specifically, on 02/24/2026, Certified Nurse Aide #7 placed a clothing protector on Resident #47, Resident #55 and Resident #90 without asking the residents permission to do so.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure that the resident's right to formulate an advanced directive was documented in a manner to prevent those wishes from being followed for one (1) of 38 residents reviewed for advanced directives. Specifically, Resident #136 completed a Medical Orders for Life Sustaining Treatment form specifying their wishes as Do Not Resuscitate and Do Not Intubate, but the orders in the electronic medical record and the resident's wrist band did not all match the form.

Inspectors wroteBased on interviews and record review the facility did not ensure that a copy of the notice of transfer or discharge was sent to the State Long Term Care Ombudsman for four (4) of five (5) residents (Resident #15, Resident #2, Resident #84, and Resident #132) reviewed for Hospitalization. Specifically, there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman and a bed hold policy was provided to the resident representative when 1) Resident #15 was transferred to the hospital on [DATE], 2) Resident #2 was transferred to the hospital on [DATE] and, 3) Resident #84 was transferred to the hospital on [DATE]. Additionally, Resident #132 was hospitalized on [DATE] and a bed hold policy was not provided.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated survey (#2677034) from 02/19/2026 to 02/27/2026, the facility did not ensure Comprehensive Care Plans were reviewed and/or revised as needed to reflect changing needs for one (1) of six (6) residents (Resident #15) reviewed for accidents. Specifically, care plan interventions were not updated to reflect the hand-written note on the 03/28/2025 smoking evaluation that indicated Resident #15 must wear an apron at all times. The undated policy titled Resident Care Planning Procedure documented the care plan is updated according to resident needs, hospitalizations, illness, behavioral issues, nutritional needs, activity level, changes in activity of daily living status or any change in which the interdisciplinary team feels is a change in the resident's status. [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviate survey (#2677034) the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for three (3) of seven (7) residents (Resident #15, Resident #115, and Resident #18) reviewed for activities of daily living. Specifically, 1) Resident #15's resident representative stated they observed Resident #15 double briefed on 02/08/2026 2), Resident #115 was observed double briefed on 02/19/2026, and 3) Resident #18 was observed on multiple occasions with poor oral hygiene.

Inspectors wroteBased on observation, record review and staff interview conducted during recertification and abbreviated survey (NY00622225) from 2/19/26 to 2/27/26, it was determined the facility did not ensure that they provided an ongoing program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences of each resident, for one (1) of one (1) resident (#90) reviewed for activities. Specifically, Resident #90 was not provided with the opportunity to consistently attend activities of their choice or attend activities specified for residents with dementia.

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey conducted from 02/19/2026 to 02/27/2026, the facility did not ensure that necessary services, and/or equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one (1) of four (4) residents (Resident #44) reviewed for position and mobility. Specifically, Resident #44 was observed on three (3) occasions without the use of a right ankle-foot orthosis as per physician order. The policy and procedure titled Splinting/Bracing, reviewed on 05/01/2025, documented a valid physician order was required before the application of splints or braces. Therapy staff were responsible for evaluating fit, and position, and for establishing a schedule of wear. [...]

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure each resident receives adequate supervision and or assistance devices consistent with resident needs to prevent accidents for one (1) of two (2) residents (Resident #103) reviewed for accidents. Specifically, after Resident #103 had a documented 05/19/2025 intact blister on the left hand second digit related to smoking, care plan interventions were not updated to reflect Resident #103 smoking cigarettes down to the butt and/or the use of a cigarette extender as per a 05/21/2025 hand-written note. Subsequently, Resident #103 was observed on 02/25/2026 smoking without the use of a cigarette extender.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 2/19/2026 to 2/27/2026, the facility did not ensure care consistent with professional standards of practice, was provided for one (1) of one (Resident #5) reviewed for respiratory care. Specifically, Resident #5 was administered oxygen without a valid medical order from 01/29/2026 to 02/19/2026.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey conducted from 02/19/2026 to 02/27/2026, the facility did not ensure that medical supervision was provided for one (1) resident of five (5) residents reviewed for drug regimen review. Specifically, the pharmacy consultant recommended discontinuation of the drug Megace, an appetite stimulant, due to the resident's weight of 415 pounds. The physician agreed to discontinue the medication; however, the nurse practitioner reordered the medication, and the resident continued to receive the medication.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that residents with dementia were receiving the appropriate treatment and services to attain and maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of two (2) residents reviewed for dignity. Specifically, Resident #28 was observed soiled and in the same clothing on consecutive days. The resident had a history of refusals of care and poor hygiene. The activities of daily living and behavior care plans both contained interventions including a referral to social services as needed for evaluation and follow-up but that was never completed.

Inspectors wroteBased on observation, and interview during the recertification survey conducted 02/19/2026 through 02/27/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, 1) the recycle dumpster lid was broken, unable to be completely closed and left open which allowed cardboard boxes to spill over the top, 2) the compactor had food debris puddled in front of the compactor door, and litter on the ground between the compactor and the dumpster.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys on 02/19/2026 to 02/27/2026, the facility did not ensure that rehabilitative services were provided for two (2) of two (Resident #79 and Resident #10) reviewed for Rehabilitation. 1) Specifically, an occupational therapy screen was not completed for Resident #79 as per physician order and 2) an occupational screen was not completed to evaluate and treat leaning to the right side for Resident #10 as per physician order.

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00383624, NY00369540) the facility failed to ensure a resident's right to be free from involuntary seclusion for one (1) (Resident #2) out of six (6) residents reviewed for seclusion. Specifically, on 01/19/2025, Certified Nurse Aide #7 was observed on surveillance video following Resident #2 down the hallway to their room, closing the door and placing disposable washcloths in the corner of the door to prevent the resident from easily opening the door and exiting the room. This occurred at approximately 12:25 PM and was not discovered until 2:55 PM by the Housekeeper Lead and Housekeeper #2. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00369540, NY00369602), the facility did not ensure residents right to be free from abuse for 2 of 7 residents (Resident #2, Resident #5) reviewed for abuse. Specifically, (1) on 1/19/2025 Resident #2 was involuntarily secluded in their room by Certified Nurse Aide #7 for approximately three hours. Certified Nurse Aide #7 placed wash cloth wipes wedged in the corner of the resident's door preventing them from exiting the room. During a rounding of resident rooms Resident #2 was found by Housekeeper #2 and House Keeping Lead in their room with a puddle of urine on the floor and feces all over the room. Resident #2 was unclothed and had a pair of pants in their which they pulled up over their chest. Resident #2 was cleaned up by Certified Nurse Aide #6 and brought to the day room after the incident. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00369540, NY00369602), the facility did not ensure a reasonable suspicion of a crime against a resident was reported to law enforcement or an allegation involving abuse was reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse for 2 out of 6 residents (Resident #2, Resident #5) reviewed for abuse. Specifically, (1) on 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7 by placing wash cloth wipes in their door frame preventing the resident from exiting. Resident #2 was found by the Housekeeping Lead and Housekeeper #2 after getting the door opened. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00318055, NY00383624) the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 2 out of 3 residents (Resident #3, Resident #6) reviewed for quality of care. Specifically, (1) Resident #3 had a wound care treatment ordered for their left below the knee area to be completed daily. Review of Resident #3's treatment administration record for March 2025 revealed their treatment was not signed as completed by the Licensed Practical Nurse on 3/9/2025, 3/11/2025, 3/16/2025. (2) Resident #6 had a known history of constipation and a history of small bowel obstruction in 2020. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00369540, NY00369602), the facility did not ensure the Quality Assurance and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality of care deficiencies. Specifically, there was no documented evidence of the Quality Assurance and Performance Improvement committee convening to discuss, develop and prioritize actionable plans for the reportable incidents that occurred on 1/18/2025 and 1/19/2025. On 1/18/2025 Resident #5 was videorecorded by staff; the recording was posted on social media by Certified Nurse Aide #3. On 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7, the resident was found in their room by Housekeeper #2 and the Housekeeper lead approximately three hours later.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00369602), the facility did not ensure the residents right to a dignified existence or to be treated with respect and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 out of 7 residents (Resident #5) reviewed for dignity. Specifically, (1) Resident #5 was video recorded by Certified Nurse Aide #3 and Certified Nurse Aide #4 while cleaning their briefs in the sink. Certified Nurse Aide #3 then posted the video on social media (Tik Tok). Certified Nurse Aide #3 was terminated by the facility for violating abuse policy.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00369540) the facility did not ensure in response to allegations of abuse that all alleged violations are thoroughly investigated for 1 out of 7 residents (Resident #2) reviewed for abuse. Specifically, on 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7 by stuffing wash cloth wipes in the door of their room preventing the door from opening. There was no documented evidence of Resident #2 being assessed for injury after the incident and statements were not obtained from all staff on duty at the time of the incident. There was also no available video footage to review for the incident that occurred on 1/19/2025.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00383624) the facility did not ensure assessments accurately reflected the resident's status for 2 out of 3 residents (Resident #2, Resident #4) reviewed for assessments. Specifically, Resident #2 was a known wanderer and always has a wander guard in place. The quarterly Minimum Data Set assessment dated [DATE] (under section E) did not document the resident had wandering behavior. (2) Resident #4's was care planned as having a known behavior of rejecting medications and cares. Known to the facility staff as rejecting medication and cares. The Comprehensive Minimum Data Set, dated [DATE] did not accurately reflect the resident's behavior.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00383624), the facility did not ensure residents were free from medication errors and accepted professional standards and principles which apply to professionals providing services for 1 out of 3 residents (Resident #3) reviewed for medications. Specifically, Resident #3 was prescribed some narcotic pain medication (Morphine-medication used to help relieve severe pain) to be administered (while on comfort care) at the following scheduled times: 12 AM, 9 AM and 7 PM. Review of Resident #3's administration record for April 2025 and May 2025 revealed the standing doses were not administered within regulated times of one hour before or one hour after scheduled time. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00383624), the facility did not ensure enhanced barrier precautions were followed by staff for 2 out of 3 residents (Resident #4, Resident #15) reviewed for infection control. Specifically, (1) on 6/17/2025 Certified Nurse Aide #1 and Certified Nurse Aide #2 provided care to Resident #4, who was on enhanced barrier precautions and did not don gowns; (2) On 6/18/2025 Resident #15 was observed walking down the hallway from their room to the nurse's station with their Foley catheter drainage bag in their hand and used the telephone at the nurse's desk. Resident #15 was noted to be on enhanced barrier precautions.

Inspectors wroteBased on observations, interviews, and record reviews during an abbreviated survey (NY00349142), the facility did not ensure the services provided adhered to accepted standards of practice for medication administration (including right time) for 24 (Residents #26 and #18) of 40 residents reviewed. Specifically, 1) on 08/12/2024 at 12:30 PM Licensed Practical Nurse #1 was observed attempting to administer 13 medications to Resident #26, where the physician ordered these medications to be given at 9:00 AM. Licensed Practical Nurse #1 did not notify the physician prior to changing the medication administration time; 2) on 08/13/2024 from 10:05 AM to 10:12 AM Licensed Practical Nurse #4 was observed passing 10 medications for Resident #18 where the physician ordered them to be given at 9:00 AM. [...]

Inspectors wroteBased on observations, interviews, and record reviews during an abbreviated survey (NY00349142), it was determined that the facility did not ensure residents were free from significant medication errors for 23 (Residents #18, #4, #14, #19, #24) of 40 residents reviewed for late medication administration. Specifically, the Residents on the Second Floor Dementia Unit did not receive medications including but not limited to Antianxiety, Antidiabetic (Insulin), Anticoagulant, Antihypertensive, Antipsychotic, Anti-Parkinson's, and Antiseizure timely from 07/01/2024 to 08/13/2024 in accordance with prescriber's order and accepted health standards established by national boards and councils.

Inspectors wroteBased on record reviews, and interviews during an abbreviated survey (NY00349142), the facility did not ensure Resident Primary Care Physicians (Attending Physician) comprehensively reviewed the resident's total program of care, including the Residents' medications and treatments for 24 of 40 residents reviewed. Specifically, a review of the medication administration detailed report from 07/01/2024 to 08/13/2024 revealed residents received their medications late including 19 Residents with significant medications (Antianxiety, Antidiabetic (Insulin), Anticoagulant, Antihypertensive, Antipsychotic, Anti-Parkinson's, and Antiseizure). During an interview with the Medical Director, they stated they were unaware of the consistent late medication administration in the facility. [...]

Inspectors wroteF725 - Sufficient Nursing Staff Based on observation, interviews and record review conducted during an abbreviated survey (NY00349142), the facility did not provide sufficient numbers of personnel to meet the care needs of all residents on the Second Floor Dementia Unit. Specifically, an observation conducted on 08/13/2024 at 9:35 AM revealed that there was no additional medication nurse to pass medications on the north side of the unit. Consequently, 23 residents received their physician ordered 9 AM medications (see associated tag F760) late. Further review of the Medication Administration History Detailed Report from 07/01/2024 to 08/13/2024 revealed consistent pattern of late medication administration on the second floor. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00349142), the facility did not ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly review, analyzed, and act on available data to make improvements and to ensure improvements are sustained. Specifically, 1) On 06/28/2024 the facility received feedback from Bureau of Narcotics representative regarding facility staff not administering medications according to prescriber's order; 2) a complaint from the facility's Resident Council indicated residents received their medications late on 07/20/2024 and 07/21/2024, the facility did not conduct a thorough investigation, and/or audit the medication administration practice in the facility; [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 1/19/23 to 1/26/23, it was determined for 1 of 3 resident (Resident #30) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation of the completion of a thorough investigation and timely resolution of the resident's report of a missing shoe.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey and Abbreviated Survey #NY00263725 from 1/19/23 to 1/26/23, it was determined for 2 of 4 residents (Residents #6 and #15) reviewed for accidents, the facility did not ensure adequate supervision to maintain resident safety. Specifically, Resident #15 was not provided the planned assistance and rolled out of the bed and when Resident # 6 was assessed as unsafe to smoke, the facility did not implement consistent communication to ensure the resident's safety

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 1/19/23 to 1/26/23, the facility did not ensure the monthly medication review by the pharmacist was followed up by the attending physician/medical director for 1 of 5 residents (Resident #9) reviewed for Unnecessary Medications The finding is: During a review of facility policy titled The Pharmacy Drug Regimen Review revised 10/2/2018 documented the Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician when appropriate. The attending physician or licensed designee shall respond to the drug regimen review within 7 days of receipt. Resident #9 was admitted with diagnoses including Heart Failure, Osteoporosis, and Asthma. The 8/10/22 admission MDS (Minimum Data Set; [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 1/19/23-1/26/23, the facility did not ensure that food was stored in accordance with professional standards for food safety. Specifically, food was stored on the floor of the refrigerator, freezer, and non-perishable food storage area, and the unit refrigerator temperature logs were not completed.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 1/19/23 to 1/26/22, the facility did not ensure infection prevention and control standards were maintained. This was evident for the facility's Legionella Sampling and Management Policy and Procedure and Environmental Assessment of Water Systems reviewed during the Infection Prevention and Control Program (IPCP) review. Specifically, the facility did not complete the Legionella Risk Assessment and lacked a diagram of the facility water system to determine possible areas where Legionella could grow and spread in the water system. In addition, only one controlled location (water heater) for legionella was tested on [DATE] and 6/30/22. The Findings Are: Review of the facility Legionella Sampling Plan documented the sampling sites shall include, but not limited to the following locations: [...]

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure that housekeeping and maintenance services provided a comfortable home-like environment. Specifically, there were numerous instances of disrepair observed in multiple rooms. This was evident for 4 resident rooms including, but not limited to rooms #101, #113, #120, and #302.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that 4 out of 12 residents reviewed for Resident Assessment had the required Comprehensive Minimum Data Set (MDS; a resident assessment and screening tool) conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process.

Inspectors wroteF 638 Based on record review and interview conducted during the recertification survey, the facility did not ensure that the required Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) was conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. This was evident for 7 of 12 residents reviewed for Resident Assessment.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not electronically transmit encoded and completed MDS (Minimum Data Set; a federally-mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) to the CMS (Centers for Medicare and Medicaid Services) system within 14 days of the final MDS completion date as indicated in section Z0500 ( date the Registered Nurse (RN) assessment coordinator signed assessment as complete). This was evident for 11 of 12 residents reviewed for resident assessment.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not implement interventions for 1 of 5 residents reviewed for pressure ulcers. Specifically, a pressure relieving device was not implemented according to the physician's order. (Resident #71).

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that residents or their representatives and the Office of the State Long Term Care Ombudsman were given written notification of the resident's transfer to the hospital. This was evident for 1 of 4 residents reviewed for hospitalization. (Resident #152).

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not implement interventions to prevent the development of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. Specifically, pressure relieving interventions were not implemented per the physician's order. ( Resident #71).

Inspectors wroteBased on observation, record review and interview conducted during the re-certification survey, it was determined that treatment and care was not provided to meet a resident's physical needs. Specifically, the facility did not ensure that a resident was provided proper leg rests for positioning. This was evident for 1 of 6 residents reviewed for positioning and mobility. (Resident #178).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that the call bell was in reach for one of two residents (Resident #81) reviewed for accidents. Resident #81 had diagnoses including dementia. The Minimum Data Set (MDS, an assessment tool), dated 12/28/18 indicated the resident had severely impaired cognitive status, required extenisive assistance for transferring and toilet use, was occasionally incontinent of urine and had no history of falls. A Fall assessment dated [DATE] and noted to be signed on 1/24/19 identified the following interventions: bilateral side rails, call bell within reach and bed at proper height. Environmental rounds were conducted on 2 [NAME] on 2/21/19 at 9:30 AM. [...]

Inspectors wrote483.70 (b) Compliance with Federal, State, and Local laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Based on observation and interview, the facility was not in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. A carbon monoxide monitor was not installed in the room housing the facility's diesel-powered emergency generator.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that the completion date as indicated in section Z0500 ( date Registered Nurse (RN) assessment coordinator electronically signed the assessment as complete) reflected the actual completion date. Specifically, section Z0400 (signature and date for persons completing the assessment) was later than the completion date indicated by the RN coordinator in section Z0500. This was evident for 11 of 12 residents reviewed for resident assessment.