Sarah Neuman Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews conducted during abbreviated surveys #2607851 and #2580703 the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for two (2) of three (3) residents (Residents #1 and #2) reviewed for accidents. Specifically, 1) on 09/03/2025 Resident #1 was transferred via Hoyer lift (mechanical device) by Certified Nurse Aide #1 and Private Aide #1, who was not approved to provide clinical or nursing care functions. Subsequently, Resident #1 sustained a hematoma (collection of blood) to the back of their head, and 2) on 08/03/2025 Resident #2 was transferred by Certified Nurse Aide #2 without the use of a Sara lift (mechanical sit-to-stand device) and an additional staff member as care planned. [...]

Inspectors wroteThe Facility did not take actions aimed at performance improvement, including the methods by which the facility will systematically identify, report, track, investigate, analyze, and use data and information to develop activities to prevent adverse events. Specifically, on 12/22/2025 during the onsite post survey, the facility did not convene a QAPI meeting to determine the root cause analysis for the deficient practice cited during the survey exited 10/23/2025. The last QAPI meeting was convened on 10/17/2025. The facility did not complete their Directed Plan of Correction imposed with a Category 1 remedy and failed to implement their Plan of Correction as directed by the State Agency by their deadline. As a result the Plan of Correction was not fully implemented by the credible alleged date of compliance of 12/16/2025. [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey(NY00375662), the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1(Resident #1) of 3 reviewed for behaviors. Specifically, Resident #1 had a history of behaviors that included resisting Activities of a Daily Living cares from staff, and the facility was unable to provide documented evidence that a Behavior Care Plan was in place prior to 3/25/25.

Inspectors wroteBased on observations, record review and interviews conducted during an Abbreviated Survey (NY00375662), the facility did not ensure that adequate supervision and effective use of the facility's monitoring program to prevent falls and injuries were provided for 1 (Residents #1) of 3 residents reviewed for accidents. Specifically, on 3/20/2025, Resident #1 who had a history of falls and balance problems and required one-person assistance for toileting was left alone in the bathroom by Certified Nurse Aide #1. Resident #1 fell backwards which caused them to hit their head and sustain an abrasion to the posterior scalp with some bleeding.

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated survey (NY00374143) the facility did not ensure residents were free from abuse, neglect or mistreatment for 1(Resident #1) of 3 reviewed. Specifically, on 3/5/2025, Registered Nurse Supervisor#1 observed Certified Nurse Aide #1 pushing Resident #1 who is severely cognitively impaired, from the front in the hallway. Resident #1 stumbled backwards but did not fall. Certified Nurse Aide #1 was asked why they pushed the resident, and they responded, because he does not listen.

Inspectors wroteBased on interviews and record review conducted during the recertification and abbreviated surveys (NY00350448, NY0035998, NY00343310, NY00351372) from 1/22/2025-1/29/2025, the facility failed to ensure that four (4) of six (6) residents' (Resident, #534 #70, #207, #65) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically: 1. Resident #534 was not supervised to prevent a fall from a wheelchair, which resulted in three (3) fractured ribs and a fractured scapula (shoulder blade); 2. Resident #70 required a mechanical lift and two-person physical assist for transfers. Certified Nurse Aide #24 used a sit to stand assistance device and one person for the transfer, resulting in a painful bruise on the left side of the forehead; 3. [...]

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey from 01/22/2025 through 01/30/2025, the facility did not ensure residents had the right to a dignified dining experience for 3 of 35 sampled residents (Residents #585, #165, and #72). Specifically, Certified Nurse Assistant #17 and #21 referred to Resident #585 as a feeder during lunch service on 1/22/25, Certified Nurse Aide #36 was observed standing over Resident #165 while feeding them a lunch meal, and Certified Nurse Aide #37 was observed standing over Resident #72 while feeding them their meal.

Inspectors wroteBased on record review and interview conducted during recertification and abbreviated survey (NY00364240, NY00341828 and NY00353718)) from 1/22/25 to 1/30/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule from December 22 2024 through January 29 2025, the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the residents.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey from 1/22/25 to 1/30/25, the facility did not ensure a person centered comprehensive care plan was developed and/or implemented for 1 of 1 resident (#78) reviewed for Hospice Care. Specifically, there was no documented evidence that a care plan was developed when Residents #78 was put on hospice care on 1/15/25.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey from 1/22/2025-1/30/2025, the facility did not ensure each resident maintained, to the extent possible, acceptable parameters of nutrition and hydration status for one of two residents (Resident #163) reviewed for Nutrition. Specifically, for Resident #163 there was no documented evidence for the implementation of 960ml per day fluid restriction as per physician order. The finding is: The Policy & Procedure titled Nursing Intake and Output; Management of Fluid Restriction revised 12/2024 documented the purpose is to maintain an accurate record of resident's fluid intake and output with risk for dehydration or fluid overload. Procedure: Nurse initiates intake and output sheets and determines with the dietician the amount of fluids to be provided with meals, between meals, and with medications. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted from 1/22/2025 to 1/30/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #163) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #163 who received hemodialysis treatments at a community-based dialysis center.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 1/22/25 to 1/30/25, the facility did not ensure annual performance reviews for nursing staff were completed at least once every 12 months. Specifically, the facility was unable to provide annual performance reviews for 2 of 5 Certified Nurse Aides (#14, #16) reviewed.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/22/25 to 1/30/25, the facility did not ensure the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted in a prominent place, readily accessible to residents and visitors on 3 of 6 days reviewed.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 1/22/25-1/30/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. Specifically, 1) there was no evidence that a facility risk assessment was completed or that a water management plan was in place to prevent and control legionella and 2) an observation was made of Environmental Staff# 28 entering a contact isolation room to empty garbage bags without donning a gown or washing hands with soap and water before and after contact with the resident environment.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 1/22/25 to 1/30/25, the facility did not ensure certified nurse aides were provided required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 3 of 5 Certified Nurse Aides (#18 #20 and #21) reviewed for nurse aide in-service training were provided 12 hours of mandatory annual in-service training.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 1/22/25 to 1/30/25, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for 2 of 2 residents reviewed for Minimum Data Set (Resident #129, Resident #225).

Inspectors wroteBased on observation, record review and interview during the recertification survey and abbreviated survey (NY00339514) from 1/22/25 to 1/30/25, the facility did not ensure that each resident's right to privacy and confidentiality of their personal and medical records was maintained. Specifically, the health information of another resident was attached to Resident #535's discharge summary and given to Resident #535's designated representative.

Inspectors wroteBased on observation, interview, and record review conducted during Recertification and Abbreviated Survey (NY00358858, NY00369058) conducted from 01/22/25-1/30/25, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours to the state survey agency for 2 of 3 residents reviewed for Abuse (Resident #110 and Resident#186). Specifically, 1) Resident #110 was noted to have a bruise on 10/27/24 that was not reported to the state agency until 10/30/24. and 2) Resident # 186 was noted to have a bruise on 1/12/25 that was not reported to the state agency until 1/16/25.

Inspectors wroteBased on record review and interview conducted during Recertification and Abbreviated Surveys (NY00361430) from 1/22/25 to 1/30/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #127) who was transferred/discharged to the hospital.

Inspectors wroteBased on record review and interview conducted during the Recertification and Abbreviated Surveys (NY00361430) from 1/22/25 to 1/30/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 1 of 3 residents (Resident #127) reviewed for hospitalization. Specifically, Resident #127 was transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives.

Inspectors wroteBased on observation, record review and interview during a recertification survey and abbreviated survey (NY00343310) conducted 01/22/25-01/30/25, the facility did not ensure residents received quality of care in accordance with professional standards of practice for 1 of 4 Residents (#534) reviewed for accidents. Specifically, timely assessment and treatment were not provided for Resident #534 who had a 5/24/24 unwitnessed fall that was not reported by Certified Nurse Aide #43 and Licensed Practical Nurse #44. Subsequently, on 5/25/24 after bruising was noted on their back Resident #534 was transferred to the hospital where it was determined Resident #534 had a fractured scapula and fractured ribs #4,#5 and #6.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336811), the facility did not ensure residents rights to be free from abuse for 1 (Resident #7) of 8 residents reviewed for abuse. Specifically, on 3/21/2024 Resident #7 alleged that Certified Nursing Assistant #4 threw towels at them when asking for assistance and yelled at them to say please the next time. Certified Nursing Assistant #4 walked out on the resident without completing care. The facility removed Certified Nursing Assistant #4 from caring for Resident #7, but Certified Nursing Assistant #4 continued to care for other residents for the rest of their shift. Licensed Practical Nurse did not report the incident to their supervisor. The facility investigation concluded abuse occurred as Certified Nursing Assistant #4 would not confirm or deny the allegation.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00336811 and NY00325082), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 2 of 7 residents (Resident #1 and #7) reviewed for abuse and mistreatment. Specifically, on 09/27/23 Certified Nurse Aide #2 reported to Licensed Practical Nurse #1 that Resident #1 was noted with a skin injury to the right side of their head. Licensed Practical Nurse #1 did not check for the injury and failed to notify their supervisor. The facility did not report the incident to the New York State Department of Health until 09/29/23 at 10:36 AM; 2) Resident #7 reported an alleged abuse by that Certified Nurse Aide #4 to Licensed Practical Nurse #3 on 03/21/24. [...]

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (NY00347206), the facility did not ensure the residents right to be free from abuse for 1 (Resident #1) of 3 reviewed for abuse. Specifically, on 7/2/2024 the Therapeutic Recreational Specialist witnessed Resident #1 looking frightened after Certified Nurse Aide #2 aggressively grabbed their arm while being transported in the dayroom. Certified Nurse Aide #2 was asked by the Therapeutic Recreational Therapist to assist with seating the resident. The Therapeutic Recreational Specialist and the Certified Nurse Aide #2 reported the incident to the Registered Nurse Supervisor #1. Certified Nurse Aide #2 completed their shift on 7/2/2024 and was suspended on 7/3/2024. [...]

Inspectors wroteBased on observations, record review and interviews conducted during an abbreviated survey (NY00326450), the facility did not ensure that residents received adequate supervision and assistance to prevent accidents. Specifically, Resident #4 who was care planned as requiring two persons assist for transfer was transferred by Certified Nurse Assistant #1 by themselves, and Resident #4 hit their head on Hoyer-lift bar. Resident #4 complained of pain and discomfort at the time of incident. No injuries were noted.

Inspectors wroteBased on observation and interview conducted during a recertification survey the facility did not provide the housekeeping and maintenance services necessary to maintain a clean, comfortable and homelike environment for multiple residents throughout the facility.

Inspectors wroteBased on record review and interview conducted during a recertification survey the facility did not ensure that 1 of 3 residents (R#153) reviewed for care planning was given the opportunity to participate in the development, review, and revision of her care plan. Further, the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 1 of 1 residents (R#153) reviewed for pain and 1 of 7 residents (R #123) reviewed for Accidents. The findings Are: 1) Resident #153 was admitted on [DATE] with diagnoses including Fibromyalgia, Diabetes, and Deep Vein Thrombosis. The 10/22/18 admission Minimum Data Set (MDS- a resident assessment and screening tool) indicated the resident scored 14 out of 15 on the BIMS (Brief Interview for Mental Status; [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, medication was administered for excessive duration without adequate indication for ongoing use to one randomly observed resident during pressure ulcer treatment (Resident #287). Specifically, a topical antibacterial agent used for the treatment of wounds and burns was applied and maintained in contact with intact skin.

Inspectors wroteBased on interviews and record review conducted during a recertification survey the facility did not ensure 1. the provision of medications and/or biologicals, as ordered by the prescriber, to meet the needs of each resident; and 2. the facility and the pharmacist did not ensure that procedures were developed and implemented so that all medication orders were processed consistently and accurately through the stages of ordering, receiving, and administering medications. Specifically, a medication prescribed for Addison's disease (also known as primary adrenal insufficiency) for Resident #312 was unavailable for administration for a period of 5 days (5/17/18 to 5/21/18 inclusive).

Inspectors wroteBased on interview and record review conducted during a recertification survey the facility did not ensure that medication was administered without significant error for one of six residents (Residents #26, #45, #177, #293, #306 and #312) reviewed for medication use. Specifically, a medication prescribed for Addison's disease (also known as primary adrenal insufficiency) for Resident #312 was not administered in accordance with the physician's order for a period of 5 days (5/17/18 to 5/21/18 inclusive). Resident # 312 was admitted on [DATE] with diagnoses including but not limited to: Primary Adrenocortical insufficiency, Pressure Ulcer of sacral region, and spinal stenosis. The admission Minimum Data Set (MDS - a resident assessment and screening tool) dated 3/21/18 revealed the resident was cognitively intact and active diagnosis included primary adrenocortical insufficiency. [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, the medical record was not accurately documented for one randomly reviewed resident(Resident #287). Specifically, pressure ulcer treatments that were not performed were documented as done.