Prestige Nursing Care & Rehab Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that residents' right to a safe, homelike environment was maintained. This was evident in two (2) shower rooms observed during the Environmental Task. Specifically, two (2) clear overhead lighting fixture coverings in the Six (6) [NAME] unit shower room were observed to be cracked or had broken circular areas, and the faucet on a sink in the Four (4) East unit was loose and became partially detached from the sink's base when used.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This was evident for three (3) of five (5) kitchen refrigerators that were observed during the initial kitchen tour. Specifically, walk-in refrigerator #1 was observed to contain unlabeled and undated cups of almond milk, walk-in refrigerator #2 was observed to contain outdated cooked food and undated defrosting food, and the kitchen pantry refrigerator contained four (4) ounce fruit and pudding cups that were undated and/or outdated.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure each resident was treated with respect and dignity. This was evident for one (1) (Resident #4) of two (2) residents reviewed for Activities of Daily Living out of a total sample of thirty-eight (38) residents. Specifically, Resident #4 was transferred via Hoyer Lift through the doorway, to a bariatric Geri chair.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one (1) resident (Resident #60) reviewed for Dental out of a total sample of 38 residents; specifically, a person-centered comprehensive care plan was not developed and implemented to address the resident's dental care needs. Additionally, a comprehensive care plan was not developed and implemented for Resident #73's use of plastic utensils in the resident's Activity of Daily Living or Behavior care plans.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to act upon the recommendations documented in the drug regimen review for one (1) (Resident # 347) of five (5) residents reviewed for unnecessary medications out of 38 total sampled residents. Specifically, the irregularity noted in the drug regimen review for Resident #347, dated 02/09/2026, was to consider a gradual dose reduction of Olanzapine five (5) milligrams; the physician did not document a rationale for not changing the medication order in the resident's medical record.

Inspectors wroteBased on observations, record review, and staff interviews, the facility did not ensure that the resident's drug regimen is free from unnecessary drugs. This was evident for one (1) resident (Resident #131) out of a total sample of thirty-eight (38) residents. Specifically, Resident #131 was ordered Morphine fifteen (15) milligram extended-release tablets to be given with frequency of as needed, which is not an adequate indication or duration for its use.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that a resident received dental services in a timely manner. This was evident for one (1) resident (Resident #60) reviewed for Dental out of a total sample of thirty-eight (38) residents. Specifically, Resident #60 was not provided with dental services to meet the needs of the resident since resident was admitted to the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00335650), the facility failed to provide adequate supervision to a resident to prevent accidents. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on [DATE] at 11:00 AM, Resident #1 fell off their bed onto the floor while Certified Nursing Assistant #1 was providing bed mobility care by themself. Registered Nurse Supervisor #1 assessed Resident #1 to have swelling of their right elbow, and complaints of pain to their head, right arm, elbow, and back. Resident #1 was transferred to the hospital on [DATE] at 2:55 PM and was admitted to the hospital with diagnoses of right arm and pelvis fracture. The Resident Nursing Instructions dated [DATE] documented Resident #1 was dependent (two (2) or more helpers are required) for bed mobility. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint (NY00324696 and NY00318663) survey from 3/3/2024 to 3/8/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 3 (Resident #265, #181, and #66) of 38 total sampled residents. Specifically, 1) Resident #265's abrasion and bruise to their face and head of unknown origin were not reported to the New York State Department of Health, and 2) a resident-to-resident altercation between Resident #181 and #66 was not reported to the New York State Department of Health within 2 hours of occurrence.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 3/3/2024 to 3/8/2024, the facility did not provide an environment that is free from hazards. This was evident for 1 (Resident #274) of 6 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #274 was provided with a disproportionately smaller mattress atop a wider bedframe, a hazard increasing the resident's risk for falling from bed.

Inspectors wroteBased on record reviews and interviews conducted during the Recertification and Abbreviated survey (NY00259038 and NY00252716), the facility did not ensure that an alleged violations involving Abuse and serious bodily injury were reported to the New York State Department of Health (NYSDOH) within 2 hours. Specifically, (1) allegations of resident-to-resident abuse were not reported within 2 hours, and (2) incidents of resident-to-resident abuse and a fracture of unknown source were not reported. This was evident for 7 of 8 residents reviewed for Abuse (Resident #130, #131, # 191, #199, # 205, #536, and #386).