Northeast Ctr for Rehabilitation and Brain Injury

Inspectors wroteBased on observations, interviews and record review during survey, the facility failed to ensure that the environment remained free of accident hazards and that residents received adequate supervision to prevent accidents for three of eight residents (Resident #8, Resident #33, and Resident #35) reviewed for accidents. Specifically, 1) Resident #8 sustained a fall in the shower on 10/31/2025 when Certified Nurse Aide #44 failed to maintain one-to-one supervision. 2) Resident #33 sustained a fall from bed on 06/06/2025 resulting in abrasions to their back and right elbow after Certified Nurse Aide #39 failed to lower the bed to its lowest position and place floor mats at bedside upon completion of care per the resident's care plan. Additionally, neurological checks were not completed as ordered status post fall. [...]

Inspectors wroteBased on interview and review of facility records during the abbreviated survey, the facility did not ensure consistent sufficient nursing staff was provided to meet the needs of residents on all shifts. Specifically, 1) See F677 for deficient practice in activities of daily living. 2) multiple complaints were received by the Department of Health that reported the facility was short staffed; 2) Several nursing staff reported there was lack of staff to provide all cares to the residents; 3) facility nursing staff sheets reviewed from 05/19/2026 to 06/13/2026 documented the facility did not staff multiple units at minimum levels daily and did not meet the daily projected staff needs for certified nurse aides and nursing staff as documented in the Facility Assessment for 26 of the 26 dates reviewed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure a clean and homelike environment or take reasonable measures to protect the belongings of residents. Specifically, 1) multiple observations were made of debris and soiled linens on the floors, sticky floors, odors, and walls in disrepair; and 2) personal items were not inventoried on admission for Resident #19 and #40.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey, the facility did not ensure that injuries of unknown origin and unwitnessed falls were investigated thoroughly for two (2) of nine (9) residents (Residents #45 and #46) reviewed for accidents. Specifically, 1) Resident #45 was assessed to have leg pain, sent to hospital for evaluation, and diagnosed with a hip fracture. A thorough investigation was not completed to determine the cause of the fracture and rule out abuse; and 2) Resident #46 sustained an unwitnessed fall on 01/22/2025 and was discovered in the bathroom pulseless and cyanotic. A code was called, and the resident was transferred to the hospital. There was no documented evidence of an accident and incident report or investigation for the unwitnessed fall.

Inspectors wroteBased on observation, record review, and interviews conducted during the abbreviated survey NY3005545 from 06/02/2026 to 06/16/206, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for five (5) of 13 residents (Resident #5, #7, #11, #37, and #50) reviewed for Activities of Daily Living. Specifically, 1) Resident #11 had multiple observations of a scaly scalp and dandruff flakes observed on clothing and bilateral long, dirty and jagged fingernails. 2) During a review of Resident #5's certified nurse aide task completion documentation there was missing or no documented evidence that Resident #5 received turning and positioning or toileting cares as per resident care plan throughout shifts for dates ranging from 04/12/2026 through 04/14/2026. [...]

Inspectors wroteBased on observation and interviews conducted during the abbreviated survey, the facility did not ensure that necessary care was provided to ensure the administration of tube feeding according to established criteria for accuracy and prevention of complications for three (3) (Residents #50, #61 and #62) of seven (7) residents reviewed with feeding tubes. Specifically, for Residents #61 and #62, feeding formula was not labeled properly with resident's name, date and time hung, rate of feeding, or the nurse's initials; and for Residents #61 and #50 infection control practice was compromised by observations of a dirty feeding tube syringe and an enteral feeding tube clog remover uncovered at the bedside.

Inspectors wroteBased on observation and interviews conducted during the survey, the facility did not ensure residents were provided with food and drink that was palatable, and at a safe and appetizing temperature. Specifically, the lunch meal on 07/21/2026 was not at a palatable appetizing temperature.

Inspectors wroteBased on observations, interviews, and record reviews during the abbreviated survey, the facility did not ensure the inclusion of the family/resident representative in the development of the plan of care for two (2) of eight (8) residents reviewed for resident rights. Specifically, 1)Resident #8 was on one-to-one supervision for safety for behaviors and fall history. The facility removed the one-to-one supervision on 11/13/2025 without discussion with, or notification of, the family, and 2) Resident #6's representative was not included in the care planning process and did not hold an initial team care plan meeting until six (6) weeks after Resident #6's admission to the facility.

Inspectors wroteBased on record review and interview during survey, the facility failed to ensure the resident's/ resident representative's right to make choices about aspects of life that were important to the resident for one of two residents reviewed for discharge planning. Specifically, Resident #19's representative requested referrals be sent to other facilities for the resident to transfer to. The resident representative made the request in June 2025 and there was no documented evidence of any referrals started until 09/09/2025.

Inspectors wroteBased on record reviews and interviews during the abbreviated survey, the facility did not ensure that a resident's representative was promptly notified of a change in status for one (1) of five (5) residents (Resident #6) reviewed for skin breakdown. Specifically, Resident #6's designated representative was not made aware the resident had been readmitted from a hospitalization on 03/27/2026 with moisture associated skin damage. Subsequently, on 04/08/2026 the wound was documented as unstageable. The designated representative was not aware of skin breakdown until Resident #6 was sent to the hospital on [DATE].

Inspectors wroteBased on record review and interviews, the facility did not ensure each resident was free from verbal and mental abuse for one of five residents (Resident #13) reviewed for abuse. Specifically, on 10/19/2025 Resident #13 reported that Certified Nurse Aide #19 stated to them that they did not like them and used vulgar language to describe their bowel incontinence.

Inspectors wroteBased on interviews and record reviews conducted during the abbreviated survey, the facility did not ensure baseline care plans were developed and communicated for resident two (2) (Residents #6 and #37) of 11 residents reviewed for resident rights. Specifically, there was no documentation that the baseline care plan was given to the Resident and/or a Resident Representative.

Inspectors wroteBased on record review and interview, the facility did not ensure residents were provided treatment and care in accordance with professional standards of practice for one of three residents (Resident #18) reviewed for respiratory care. Specifically, when Resident #18 was unresponsive, in respiratory distress and had elevated blood pressure, there was no documented times as to when the physician was called, when symptoms started and the orders given. When nitroglycerin was given for elevated blood pressure, the order was not documented, the time given and vital signs before and after administration were not documented. Additionally, there was no documentation of the involvement of the Medical Director or their conversation with the family member. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the abbreviated survey, the facility did not ensure that residents received care consistent with professional standards to prevent pressure ulcers for two of eight residents (Resident #8 and #19) reviewed for pressure ulcers. Specifically, 1) Resident #8 developed a pressure ulcer while in the facility, turning and positioning was inconsistently signed for, and Resident #8 was observed without pressure relieving devices in place as indicated on the care plan during the onsite visit from 06/02/2026 to 06/04/2026. 2) Resident #19 developed pressure ulcers and care plan interventions were not implemented timely including an air mattress that was added to the care plan on 06/01/2025 and not put in place until 06/20/2025; during that time the pressure ulcer worsened.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that needed services were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one of three residents (Resident #6) reviewed for position and mobility. Specifically, range of motion maintenance program was not provided for Resident #6 for two weeks as per Care Plan.

Inspectors wroteBased on observations, interviews, and record review during survey, the facility did not ensure all residents were provided the appropriate treatment and services to achieve or maintain as much normal bladder/bowel function for two of two (Resident#1, Resident#38) residents reviewed for bowel and bladder. Specifically, 1) Resident #1 had no documentation that bowel movements or the need for intervention was monitored; and 2) Resident # 38 had an indwelling foley catheter, was diagnosed with a urinary tract infection on 08/28/2024 and on 02/28/2025. Resident # 38's treatment administration record for August 2024 and February 2025, revealed numerous occasions where there was no documented evidence that the facility staff provided catheter care or irrigated the resident's foley catheter.

Inspectors wroteBased on observation, interview and record review the facility did not ensure the resident was provided the necessary care to maintain, to the extent possible, acceptable body weight for one of two residents (Resident # 1) reviewed for nutrition and hydration. Specifically, daily weights were not implemented as per the 05/06/2026 physician order.

Inspectors wroteBased on record review and interview, the facility did not ensure medications were available to meet each resident's needs for one of five residents (Resident #18) reviewed for medications. Specifically, Resident #18 was admitted to the facility with orders including Clonazepam (a controlled substance) and the facility did not administer the medication or call the pharmacy to notify them the automated medication dispensing cabinet was out of Clonazepam. The physician was notified the medication was out of stock and ordered another medication; there was no documented evidence the substitute medication was given. Resident #18 was admitted to the facility on [DATE] with diagnoses including respiratory failure, anxiety disorder, and was ventilator dependent. A physician order dated 1/12/2026 at 4:17 PM documented Clonazepam 0.5 milligrams via gastrostomy tube, one time for anxiety. [...]

Inspectors wroteBased on observation, record review and interview during survey, the facility did not ensure necessary dental services were provided in a timely manner for one (1) of two (2) residents (Resident #7) reviewed for Dental Services. Specifically, Resident #7 was admitted to the facility on [DATE] and not provided routine dental services.

Inspectors wroteBased on observation and interviews conducted during the abbreviated survey, the facility did not ensure that the food was prepared and served in accordance with professional standards for food service safety. Specifically, staff were observed not wearing hair restraints and beard guards while in the kitchen.

Inspectors wroteBased on observations, interviews and record review during survey, the facility failed to ensure that the environment remained free of accident hazards and that residents received adequate supervision to prevent accidents for one of three residents (Resident #3) reviewed for elopement. Specifically, Resident #3 who was assessed at risk for elopement exited the facility through the front door on 01/10/2026 at 5:38 PM without intervention by staff assigned to monitor activity at the exit. The facility was unaware that Resident #3 was missing until being notified by law enforcement at 8:08 PM. This resulted in Immediate Jeopardy Past Non-Compliance for Resident #3.

Inspectors wroteBased on observations, record review and interviews conducted during the Abbreviated Surveys (NY00370876 and NY00370334) the facility did not provide sufficient nursing staff to consistently meet the needs of all residents. The Facility Assessment staff ratio levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the nursing daily staffing schedule sheets from 6/10/25-6/25/25 revealed staffing was not adequate across various shifts based on the unit needs and the staffing needed as documented in the facility assessment.

Inspectors wroteBased on observations, record review and interviews conducted during an Abbreviated Survey (NY00370876 and NY00370334), the facility did not ensure that its facility assessment included staffing levels necessary to competently provide and meet the needs of the residents based on census, conditions and levels of care both during their day-to-day operations and during emergencies. Specifically, the undated Facility Assessment provided by the facility during the onsite visit did not include the minimum staffing requirements for Certified Nurses' Aides and Licensed Practical Nurses on the weekends. 2)The Facility Assessment did not include the number of staff needed for behavioral healthcare services necessary to meet resident needs. [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (NY00371330), the facility did not ensure each resident each resident was treated with respect and dignity for 1(Resident #22) of 3 residents reviewed. Specifically, on 6/23/2025, Resident # 22 was handed a syringe with Insulin by Registered Nurse #2 on 3 South Wing Nurses station and was observed by the surveyors in the hallway injecting the insulin into their abdomen with Registered Nurse #2, unit manager, 2 surveyors and other residents present.

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated survey (NY00368528), it was determined that the facility did not include all facility staff in their training program on behavioral health care that is appropriate and effective as determined by staff need and the facility assessment. Specifically, agency staff Certified Nurse Aide #1 was not trained to help Resident #1 with their behaviors and instead held Resident #1's arms down and prevented them from leaving their bedroom as per their request and they did not let go of the Resident #1's arms until told to multiple times.

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated survey (NY00368528), the facility did not ensure 1 (Resident #1) of 3 residents reviewed for abuse, had the right to be free from abuse, neglect, or mistreatment. Specifically, Resident #1 was heard yelling from behind their closed room door and when multiple staff entered the room, they observed Certified Nursing Assistant #1 pushing Resident #1, holding their arms down, and preventing Resident #1 from leaving their room. Staff attempted to intervene with no success. Certified Nursing Assistant #1 did not let go of Resident #1 until Licensed Practical Nurse #1 arrived and told them to let go. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated survey (NY00368528), it was determined that the facility did not ensure that staff were competent and trained in providing care to a resident with behavioral health diagnoses of traumatic brain injury, post-traumatic stress disorder and persistent mood disorder. Specifically, Certified Nurse Aide #1 was not trained to help Resident #1 with their behaviors and instead held Resident #1's arms down and prevented them from leaving their bedroom as per the Resident's ir request and they did not let go of the Resident #1's arms until told to multiple times. [...]

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00348027, NY00343016, NY00340876, NY00346752, and NY00344233) from 11/13/24 to 11/21/24, the facility did not ensure that the residents and/or resident representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood for 2 of 8 (#676 and #677) residents reviewed for hospitalization, and the facility did not notify the Ombudsman for 8 of 8 residents (Residents #233, #676, #677, #234, #573, #164, #199, #211) reviewed for hospitalization.

Inspectors wroteBased on interview and review of facility records during the recertification and abbreviated surveys (NY00348027, NY00343016, NY00357012) conducted from 11/13/24 through 11/21/24, the facility did not ensure consistent sufficient nursing staff was provided to meet the needs of residents on all shifts. Specifically, 1) Resident and family complaints received by the Department of Health reported the facility was short staffed, (F tag 677 for Resident #177 was cited as no showers were documented from 6/24/24-7/21/24), 2) Several nursing staff reported there was lack of staff to provide care to the residents, and 3 actual nursing staff sheets from 10/19/24 to 11/19/24 showed on multiple occasions the facility was below the projected levels documented on the Facility Assessment.

Inspectors wroteBased on observation, record review, and interview during the recertification survey from 11/13/24 to 11/21/24, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure that an infection surveillance plan identifying symptom tracking of infection was implemented prior to the start of antibiotics for Resident #26 and #233.

Inspectors wroteBased on observation and staff interview during the recertification survey from 11/13/24 to 11/21/24, the facility did not ensure residents were provided with a dignified dining experience. Specifically, Certified Nurse Aide # 18 was observed standing while feeding 2 of 17 residents (Resident #42 and #239) reviewed for dining, The finding is: On 11/18/24 at 12:05 PM, Certified Nurse Aide #18 was observed standing while feeding Resident #42 their lunch meal. During observation Certified Nurse Aide #18 was directed to sit down by another staff and stated prior to sitting, Oh my back was hurting and I'm short. On 11/18/24 at 12:36 PM Certified Nurse Aide #18 was observed standing while feeding Resident #239. During an interview on 11/19/24 at 12:39 PM, Certified Nurse Aide #18 stated they forgot about sitting down when feeding the residents. 10 NYCRR 415.5(a)

Inspectors wroteBased on record review and interview during the recertification survey from 11/13/24 to 11/21/24, the facility did not ensure residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, for two of three residents (Resident #8 and #104) reviewed for Beneficiary Protection the facility did not ensure the Notice of Medicare Non-coverage form CMS-10123 was provided to the resident and/or representative at a minimum of two days prior to the end of Medicare Part A covered services.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 11/13/24 to 11/21/24, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided. Specifically, 1) room [ROOM NUMBER] A/B had soiled walls with chipped paint/scratches/holes, garbage can was soiled/privacy curtains were stained and 2) feeding tube pumps and/or poles contained dried formula for five residents (#35, #193, #172, #215, #150) on the VENT unit.

Inspectors wroteBased on observation, interview, record review conducted during the recertification and abbreviated (NY00348027 and NY00340876) from 11/13/2024 to 11/21/2024, the facility did not ensure baseline care plans were developed and implemented for each resident. This was evident for 3 (Resident #676, #677, and #208) of 41 total sampled residents. Specifically, 1) a baseline care plan was not developed for Resident #676 upon their admission to the facility on 5/17/2024, 2) a baseline care plan was not developed for Resident #677 upon their admission to the facility on 4/10/2024, and 3) a baseline care plan was not developed within 48 hours of Resident #208's admission to the facility.

Inspectors wroteBased on observation ,record review and interview conducted during the recertification and abbreviated (NY00344233 and NY00340876) surveys from 11/13/2024 through 11/21/2024, the facility did not ensure 3 of 3 residents (#573, #677 and # 87) reviewed for quality of care received treatment and care in accordance with the professional standards of practice. Specifically, 1) a follow-up Urology appointment was not provided for a newly placed suprapubic catheter for Resident #573, 2) Resident #677 did not receive a Neurology consultation as recommended in their hospital discharge instructions and 3) Resident #87 with limited range of motion of bilateral lower extremities was observed in a high back chair, sliding down with their buttocks resting at the end of the seat, both knees were bent/both feet were positioned behind the knees.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 11/13/2024 to 11/21/2024, for one (Resident #208) of ten residents reviewed for nutrition, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status. Specifically, for Resident #208, weight measurements were not obtained timely as per physician order when a significant change in weight occurred.

Inspectors wroteBased on staff interviews and review of facility records during the recertification and abbreviated surveys (NY00348027, NY00343016, NY00357012) from 11/13/24 through 11/21/24, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, two of five randomly selected Certified Nurse Aides (#19, #20) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey from 11/13/24-11/21/24, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates. Specifically, expired medications and a Lantus Insulin Pen not discarded after 28 days of being open were found in one of the five medication storage rooms and one of eight medication carts (Vent Unit) observed for medication storage. Additionally, one medication refrigerator behind a locked door containing Lorazepam (a controlled substance) was not secured to a permanent fixture in the room.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00346752) from 11/13/2024 to 11/21/2024, the facility failed to ensure the plan of care for each resident was followed and that adequate supervision and/or assistance was provided to prevent accidents for 1 of 8 residents (Resident #234) reviewed for Abuse. Specifically, Resident #234 required a 2- person assist for transfers and the Certified Nurse Aide #25 attempted to transfer the resident without assistance of another staff member. Subsequently, Resident #234 fell and sustained a laceration (a cut or tear in the skin) to the back of their head which required eight staples. This resulted in actual harm that is not immediate jeopardy for Resident #234.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated surveys (#NY00340049 and #NY00351730) from 11/13/24-11/21/24, the facility did not make prompt efforts to resolve grievances or inform the complainant of the grievance investigation outcome for 2 (Resident #177 and #72) of 2 residents reviewed for grievances. Specifically, 1) for Resident #177, there was no evidence that grievances were documented on the tracking log in the grievance book, or that the complainant was notified of the outcome of the grievance and 2) Resident #72's friend stated they made a verbal complaint to the social worker and no grievance was initiated.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY 00350609) from 11/13/24-11/21/24, the facility did not ensure resident's rights to be free from abuse for 2 of 8 residents (Residents #102 and #73) reviewed for abuse. Specifically, interventions were not implemented as per care plan and/or physician order for Resident #102 with a history of physical aggression and documented episodes of verbal aggression on 8/6/24 at 3:00PM, 4:00 PM and 5:00 PM, resulting in Resident #102 punching Resident #73 on the right side of their head on 8/6/24 at 7:00 PM.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated (NY00349188, and NY00349049) surveys from 11/13/24 to 11/21/24, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #212 and #177) of 9 residents reviewed for Activities of a Daily Living. Specifically, Resident #212 and #177 who required dependent assistance with Activities of Daily Living, did not receive showers as scheduled for multiple months according to the Certified Nurse Aide documentation.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated (NY00348027) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident received care to prevent pressure ulcers. This was evident for 1 (Resident #676) of 7 residents reviewed for Pressure Ulcers. Specifically, Resident #676 was admitted to the facility with redness to their buttocks and did not receive a comprehensive skin assessment until they developed a stage 3 facility-acquired sacral pressure sore.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated (NY00340876) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident's total program of care, including medications and treatments, were reviewed at each visit. This was evident for 1 (Resident #677) of 41 total sampled residents. Specifically, Nurse Practitioner #1 did not review and ensure the accuracy of transcribed medication orders upon Resident #677's admission to the facility.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated (NY00340876) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care. This was evident for 1 (Resident #677) of 5 residents reviewed for Behavioral/Emotional Status out of 41 total sampled residents. Specifically, Resident #677 was diagnosed with a mental illness, received antipsychotic medication, and was not evaluated by a psychiatrist in accordance with a Physician Order.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336137) from 3/22/2024 to 3/25/2024 the facility did not ensure residents rights to be free from physical abuse for 1 (Resident #1) out of 3 residents reviewed for abuse. Specifically, on 3/15/2024, Certified Nursing Assistant(staff #2) and Licensed Practical Nurse(staff #1) witnessed Resident # 1 being hit in the face by a Community Support Specialist(staff #3), after Resident #1 threw their food on them. The community support staff's job description and tasks did not include assisting/passing of trays to residents.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336137), the facility did not report the results of the investigation of a physical abuse allegation to the New York State Department of Health in accordance with State law within 5 working days of the incident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not submit the 5-day investigative report until 3/26/2024 for an incident that occurred on 3/15/2024.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336137), the facility did not ensure a comprehensive person-centered care plan was developed or implemented for 1 (Resident #1) out of 3 residents reviewed for care plans. Specifically, Resident # 1 who was assessed for mood and behaviors indicating they were at risk for abuse by staff and other residents but there was no comprehensive care plan developed with interventions to prevent the resident from being abused.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00329990, NY00329232) the facility did not ensure pharmaceutical services that assure timely acquiring, receiving, and administering medications met the needs of 2 of 3 residents (Resident #2 and #5) reviewed for medication administration. Specifically, Resident #2 was prescribed Dronabinol (an appetite stimulant) 2.5 milligram, 2 capsules twice a day. Resident #2 missed 46 doses when the medication was unavailable. Resident #5 was prescribed Bupropion300 milligram tablet by mouth daily for depression and 8 doses of the medication was not administered. There was no documentation for reasons why doses were missed.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00329990, NY00329232), the facility did not ensure that residents are free of significant medication errors. This was evident for 2 of 3 residents (Resident #2 and #5) reviewed for medication administration. Specifically, Resident #2 was prescribed Dronabinol (an appetite stimulant) 2.5 milligram, 2 capsules twice a day. Resident #2 missed 46 doses when the medication was unavailable. Resident #5 was prescribed Bupropion300 milligram tablet by mouth daily for depression and 8 doses of the medication was not administered. There was no documentation for reasons why doses were missed.

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (NY00329232, NY00329990 and NY00326047), the facility did not ensure a resident's actual food, dietary needs and choices were met for 1 out of 5 residents (Resident #5) reviewed for food and meals. Specifically, Resident #5, did not receive double portions as per his dietary recommendations, physician order, and meal ticket.

Inspectors wroteBased on observation and interview conducted during an abbreviated survey (NY00326047) the facility did not ensure proper storage of refrigerated food in accordance with professional standards for food safety. Specifically, food items in the walking refrigerator were unlabeled and undated.

Inspectors wroteBased on record review and staff interview during an abbreviated survey (#NY00326982), the facility did not ensure 2 of 4 residents (Residents # 1 and 4) reviewed, had the right to be free from abuse and neglect. Specifically, on 7/8/23 Resident #1 and Resident #4 had a verbal altercation and were separated. Later that day they had a resident-to-resident altercation involving Resident #1 punching Resident #4 in the face, which resulted in Resident #1 being injured with a bleeding lip.

Inspectors wroteBased on record review and interviews during abbreviated survey (NY00326982), the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 (Resident #1 ) of 4 residents reviewed for abuse and neglect. Specifically, the facility did not report allegations of resident-to-resident abuse involving Resident #1 and Resident #4.

Inspectors wroteBased on observation, record reviews and staff interviews on an abbreviated survey (NY00326982), the facility did not ensure that necessary monitoring was performed to maintain weight and prevent loss for 1 (Resident #1) of 3 residents reviewed for nutrition. Specifically, Resident #1, who had a history of weight fluctuations since 1/23, had MD orders for monthly weights but were not carried out as prescribed.

Inspectors wroteBased on observation and interviews during the Recertification survey conducted from 5/16/22- 5/25/2022, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 1 of 1 resident units (Vent Unit) and 1 of 1 resident (Resident #61) reviewed for tube feeding. Specifically, on the Vent unit in room [ROOM NUMBER] there were sticky floors; old, dried tube feeding on the floor under the tube feeding pole and, on the tube, feeding pole and machine.

Inspectors wroteBased on record review, observations, and interview during the Recertification Survey conducted from 5/16/2022-5/25/2022, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with quality of care includes measurable objectives and time frames to meet a resident nursing, mental and psychosocial needs for 2 (residents # 108 and # 403). Specifically, 1. the facility did not ensure that a personalized care plan was developed and implemented for cleaning the resident's room for Resident #108 with a history of refusal of care and 2. the facility did not ensure a comprehensive care plan was developed and implemented to address the use of a long call bell for Resident # 403 with aggressive behaviors. The Findings Are: [...]

Inspectors wroteBased on record review and interview conducted during a Recertification and Abbreviated Survey (Complaint #NY00281259) conducted from 5/16/2022-5/25/2022, it was determined the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. This was evident for 1 of 1 residents (R#253) reviewed for change of condition. Specifically, Resident #253 who was being treated with medication for constipation was discharged to the hospital with a diagnosis of bowel obstruction. Record review revealed facility staff did not consistently document resident's bowel movement in the electronic medical record (EMR). Additionally, the facility did not update the Physician timely as per Care Plan interventions when the resident had a change in bowel status.

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification and Abbreviated Survey (NY00295316) conducted form 5/16/2022-5/25/2022 the facility did not ensure they provided an environment that is free from accident hazards for 1 of 5 Residents (#18) reviewed for accidents. Specifically, the facility did not provide maintenance to Resident#18's electric wheelchair as per the manufacture's specification.

Inspectors wroteBased on interviews and record reviews conducted during the most recent recertification survey, the facility did not ensure for 4 of 4 residents (#149, #181, #212, #265) reviewed for hospitalization/discharge that the resident, resident's representative and/or the Office of the State Long-Term Care Ombudsman were notified in writing of transfers to the hospital, including the effective date of transfer, location of transfer, and reason for transfer.

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that residents or their representatives were notified in writing of the facility bed hold policy prior to discharge or transfer. This was evident for 4 of 4 residents reviewed for discharge. (Residents # 149, #181, # 212, # 265).

Inspectors wroteBased on observations and interviews conducted during the most recertification survey, the facility did not exercise reasonable care for the protection of resident's property from loss or theft for one of twelve residents (Resident #36 ) reviewed for personal property. Specifically, Resident #36 reported that eight months ago when he was admitted all his new clothing was lost. The facility did not ensure that the system in place to protect residents' clothing was implemented for this resident.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not report to the State agency in a timely manner an incident of alleged sexual abuse. Specifically, this allegation of sexual abuse involving Resident #219 and Resident #43 was not reported within the required time frame of two hours after the facility became aware of it.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care was provided to prevent pressure ulcers for 1 of 3 residents (#194) reviewed for pressure ulcers. Specifically, the use of off loading booties recommended by the physician was not implemented for a resident at risk for pressure ulcers.

Inspectors wroteBased on observation and interview conducted during a recertification survey, the facility did not ensure food was prepared in accordance with professional standards for food service safety. Specifically, Dietary staff did not perform proper hand hygiene while performing tasks in the kitchen.