Surge Rehabilitation and Nursing LLC

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated; failed to put measures in place to prevent further potential abuse, neglect, exploitation or mistreatment; and failed to report results of the investigation to the New York State Department of Health within five (5) working days of the incident. This was identified for two (2) (Resident #96 and Resident #98) of three (3) residents reviewed for Abuse. Specifically, on 11/30/2025, Licensed Practical Nurse #1 received an allegation of physical abuse concerning Resident #96 from the resident's family member. The facility Administrator was not made aware of the incident until 12/01/2025. Resident #96 was discharged from the facility on 12/10/2025. [...]

Inspectors wroteBased on record review and interviews initiated on 12/15/2025 and completed on 12/22/2025, the facility did not ensure that an established system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation is maintained. This was identified for one (1) (Resident #12) of one (1) resident reviewed for Dialysis. Specifically, Resident #12 had a Physician's order for Fentanyl (opioid pain medication) 50 microgram/hour transdermal patch (a medicated adhesive patch to deliver medication through the skin layers into the blood stream) to be applied to the chest wall every three (3) days. There was no documented evidence that on multiple days a second nurse was utilized as a witness to appropriately dispose the used Fentanyl Patch. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that each resident had secure and confidential medical records. This was identified for one (1) (Resident #112) of eight (8) residents reviewed for the Medication Administration Task. Specifically, Licensed Practical Nurse #9 left Resident #112's electronic medical record open in the hallway with the resident's personal and medical information visible to other staff, residents, and visitors. The finding is: The facility's Administration of Medication policy dated 04/28/2025 documented the medication nurse will protect [residents' medical record] privacy by lowering the laptop screen or locking the screen. Resident #112 was admitted with diagnoses including cerebral infarction (sudden blockage of an artery supplying the brain), dysphagia (difficulty swallowing), and gastrostomy (tube feeding status). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were reported immediately but not later than two (2) hours to the Administrator or the or the New York State Department of Health after the allegation was made, and failed to report results of the investigation to the New York State Department of Health within five (5) working days of the incident. This was identified for two (2) (Resident #96 and Resident #98) of three (3) residents reviewed for Abuse. Specifically, on 11/30/2025 Resident #96's family member reported an allegation of physical abuse towards Resident #96 to Licensed Practical Nurse #1. The facility Administrator was not made aware of the incident until 12/01/2025. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure that a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long Term Care Ombudsman. This was identified for one (1) (Resident #118) of two (2) residents reviewed for Hospitalization. Specifically, Resident #118 was transferred to the hospital for evaluation status post fall. There was no documented evidence that a Notice of Transfer or Discharge was sent to the Office of the State Long Term Care Ombudsman. The finding is: The facility's policy titled Transfer and discharge: Notice Requirement dated 04/28/2025 documented before the facility transfers or discharges a resident, the Social Worker or designee will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing in a language and manner they understand; [...]

Inspectors wroteBased on record review, and interviews during a Recertification Survey initiated on 12/15/2025 and completed on 12/22/2025, the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #79) of five (5) residents reviewed for Unnecessary Mediations. Specifically, Resident #79 had a physician's order for Methenamine Hippurate (a urinary tract antiseptic for a history of Urinary Tract Infection. There was no documented evidence that a comprehensive person-centered care plan was developed to address the long-term use of a urinary tract antiseptic drug. [...]

Inspectors wroteBased on observation, record review, and interviews the facility did not ensure that services provided or arranged by the facility met the current professional standards of quality. This was identified for one (1) (Resident # 112) of eight (8) residents during the medication administration task. Specifically, Resident #112 had physician's orders to flush the feeding tube before medication administration and in between each medication administration. Licensed Practical Nurse #9 was observed administering medications without flushing the feeding tube before and after the medication administration. The finding is: The facility's Enteral (feeding) Tube Feeding policy dated 11/03/2025 documented it is the policy of the facility to provide enteral nutrition and hydration when by mouth intake is not an adequate option. [...]

Inspectors wroteBased on observation, record review, and interviews the facility did not ensure a resident who is fed with enteral means receives the appropriate treatment and services to prevent potential complications of enteral feeding including but not limited to dehydration. This was identified for one (1) (Resident # 112) of eight (8) residents observed during the medication administration task. Specifically, Resident #112 had physician's orders to flush the feeding tube before medication administration and in between each medication administration. Licensed Practical Nurse #9 was observed administering medications without flushing the feeding tube before and after the medication administration. The finding is: The facility's Enteral Tube Feeding policy dated 11/03/2025 documented to provide enteral nutrition and hydration when by mouth intake is not an adequate option. [...]

Inspectors wroteBased on observations, record review, and interviews the facility did not ensure that residents requiring respiratory care were provided such care in accordance with professional standards of practice. This was identified for one (1) (Resident #9) of three (3) residents reviewed for Respiratory Care. Specifically, Resident #9 has a diagnosis of Chronic Obstructive Pulmonary Disease (lung disease characterized by persistent air flow limitation and chronic inflammation in the airways and lungs) and a physician's order for two (2) liters of supplemental oxygen to be administered as needed via a nasal cannula. On three (3) different observations, Resident #9 was observed receiving supplemental oxygen via nasal cannula at three (3) liters per minute. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections. This was identified for one (1) (Resident #112) of eight (8) residents during the medication administration task. Specifically, Resident #112 had a Percutaneous Endoscopic Gastrostomy tube (feeding tube) and a physician's order for enhanced barrier precautions. Licensed Practical Nurse #9 did not perform hand hygiene prior to going to Resident #112's room; did not utilize personal protective equipment while administering Resident #112's medications; and handled the resident's feeding tube without the use of gloves. The finding is: [...]

Inspectors wroteComplaint Investigation Survey, ACTS reference # (NY00366463) was conducted at Surge Rehabilitation and Nursing LLC from 07/25/2025 through 08/11/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Deficiencies were cited as a result of this survey. 42 CFR 483.12 Freedom from Abuse, Neglect and ExploitationBased on observation, interview and record review during an abbreviated survey (#NY00366463) the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #1) of 5 residents reviewed. Specifically, a facility employee obtained 16 checks from Resident #1, who cashed the checks for the various dollar amounts.

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 8/5/2024 and completed on 8/9/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to address each resident's medical needs. This was identified for one (Resident #81) of three residents reviewed for unnecessary medications. Specifically, Resident #81 was receiving anticoagulant medications as per the physician's orders; however, there was no comprehensive care plan developed for the use of an anticoagulant. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility must designate one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP). The IP must have completed specialized training in infection prevention and control. Specifically, the facility's designated IP did not have documented evidence of specialized training in infection prevention and control. The finding is: The facility's policy, titled Infection Preventionist, effective 10/25/2022, documented the facility will employ an infection prevention nurse with the mission of preventing the spread and managing the many infections/viruses that the facility may encounter; [...]

Inspectors wroteBased on record review, observation, and staff interviews during the Recertification Survey initiated on 11/29/2022 and completed on 12/6/2022, the facility did not implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #92) of one resident reviewed for Rehabilitation and Restorative Services. Specifically, Resident #92 had a Physician's order to utilize a right-foot Darco shoe (specialized shoe) to offload heel pressure when out of bed. Resident #92 was observed out of bed on two occasions without wearing the right-foot Darco shoe. The finding is: [...]