Sutton Park Center for Nursing and Rehabilitation

Inspectors wroteBased on observation and interview conducted during the recertification survey and abbreviated surveys (686919, 2690393) from 01/20/2026 to 01/28/2026, the facility did not maintain a homelike environment for two of four (third and sixth floor) nursing units, and a tub room on the 4th floor. Specifically, 1) resident rooms # 302 a-b, 307 a-d, 315 a-d, 316 a-d were not personalized, lacked adequate visitor seating, 2) fifteen resident rooms (602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 614, 616, 617, 619, and 620) were observed stark and bare without personalization; and 15 resident rooms (603, 604b, 605a, 606a-b, 609a, 610, 606 a-b, 607a-d, 609a, 610, 616a-d, 617a, 618b, 619a-b, and 620) did not contain a chair for resident/visitor use; and 3) the tub room on the 4th floor, had window insulation that was coming out and a cold draft was coming from the window.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of seven (7) residents (Resident # 51) reviewed for Activities of Daily Living and one (1) of one (1) residents (Resident #158) reviewed for non-pressure skin conditions. Specifically, 1) Resident #158 did not have their daily wound dressing changed for 7 days and did not receive treatment according to the physician order. 2) Resident # 51 dislocated their hip and did not have an orthopedic follow-up as recommended in the hospital discharge summary.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure that all alleged injuries of unknown origin, were reported to the State Agency for one (1) of seven (7) residents. (Resident #51) reviewed for abuse. Specifically, Resident #51 had an x-ray that confirmed the dislocation of the right femoral head (top of long bone in the thigh) prosthesis (hip replacement). The 01/18/2025 Accident/Incident Report documented the date, location, and time of occurrence as unknown, and there was no documented evidence that the injury of unknown origin was reported to the State Agency.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (2569922) surveys from 01/20/2026 to 01/28/2026, the facility did not ensure a thorough and complete investigation was done to rule out abuse, neglect, or mistreatment for one (1) of seven (7) residents (Resident # 51), reviewed for abuse. Specifically, Resident # 51 had their right hip replacement dislocated, and the facility did not thoroughly investigate to determine if the care plan was followed when determining a root cause analysis for the dislocated hip.

Inspectors wroteBased on observation, record review and interview during the recertification survey from 01/20/2026 to 01/28/2026, the facility did not ensure residents received necessary treatment and services consistent with professional standards of practice, to prevent new pressure ulcers from developing and/or promote healing of pressure ulcers for two (2) of eight (8) Residents (Resident #125 and #94) reviewed for pressure ulcers. 1) Specifically, Resident #125 who had Stage 4 pressure ulcers to their right hip and sacrum and was at high risk for further development of pressure ulcers, was observed on multiple occasions without physician-ordered bilateral heel boots in place and/or their heels were not offloaded while in bed. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey from 01/20/2026 to 01/28/2026, the facility did not ensure that needed services, care, and equipment 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 (1) of three (3) residents (Resident #125) reviewed for position and mobility. Specifically, Resident #125 had a contracted left hand and was observed on multiple occasions without a physician ordered left-hand hand roll device in place.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 01/20/2026-01/28/2026 it was determined for 1 of 2 residents (Resident #8) the facility did not ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, Specifically, Resident #8, who had a tracheostomy, (an surgical opening into the trachea to provide an airway for easier breathing) did not have an Ambu bag (and a self-inflating bag resuscitator) and an extra tracheostomy replacement provided in the resident room to be used in the event of accidental extubation.

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey from 11/7/23-11/14/23, the facility did not ensure residents were treated with dignity for 2 of 4 residents (#71 and #119 ) reviewed for dignity. Specifically, 1) staff were not seated when feeding Resident #71; and 2) staff were observed entering Resident #119's room without knocking on the door.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 11/7/2023 through 11/14/2023 the facility did not ensure that resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 1 of 5 residents (Residents # 109) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the resident, or the resident representatives and that notification was sent to the State Ombudsman.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00325370) conducted from 11/6/2023 to 11/14/2023, 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 of 6 residents (Resident #120) reviewed for accidents, 1 of 3 residents (Resident #10) reviewed for hospitalization and 1 of 4 residents (Resident #46) reviewed for dignity. Specifically, 1) the facility did not ensure a person-centered care plan was developed for Resident #120 to be able to self-administer medications. 2) Staff did not implement interventions as per care plan for Resident #10 with a history of falls. 3) Staff did not develop a care plan to address Resident #46's refusal to wear clothes.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey 11/7/2023-11/14/2023 the facility did not ensure medications were provided to meet the needs of each resident for 2 of 2 residents (#119 and #116) reviewed for insulin. Specifically, long-acting insulin was not administered consistently as per physician order for Residents #119 and #116.

Inspectors wroteBased on record review and interview during the recertification survey from 11/6/2023 to 11/14/2023, the facility did not ensure certified nurse aide (CNA) performance reviews were completed at least once every 12 months or that they provided regular in-service based on outcomes of such reviews for 5 of 5 reviewed for staffing (CNA #8, 9, 10, 11,and 12). Specifically, there were no performance evaluations provided when requested.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 11/8/23 to 11/16/23, the facility did not ensure that food was stored in accordance with acceptable standards for food safety practice. Specifically, perishable foods in kitchen freezer #1 and freezer #2 were not labeled and/or dated properly.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (#NY 00315269), the facility did not immediately inform the physician or nurse practitioner of the resident's refusal to take prescribed medications. Specifically, Resident # 67 had multiple consecutive refused dosages of Latanoprost and artificial tear eye drops.

Inspectors wroteBased on record review and interview conducted during recertification and abbreviated survey (NY00308547), the facility did not ensure a thorough and complete investigation was conducted for 1 of 6 residents (Residents #95) reviewed for accidents. Specifically, the facility did not complete a timely and thorough investigation after Resident #95 reported a 5/8/2023 incident in which the shower chair broke while Resident # 95 was being transferred into it.

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that a Significant Change Minimum Data Set (MDS; a comprehensive resident assessment and screening tool) was conducted for 1 of 5 residents (#54) reviewed for ADLs.

Inspectors wroteBased on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 2 residents (#18) reviewed for activities was provided an ongoing program of activities designed to meet the interest of and to support the psychosocial well-being of the resident. Specifically, a resident with severe cognitive impairment was kept in bed during the day with no activity program designed to prevent social isolation and address the resident's activity preference and provide sensory stimulation on an ongoing basis.

Inspectors wroteBased on interview and record review conducted during the recertification survey the facility did not ensure that two of five randomly reviewed certified nursing assistants (CNAs), CNAs #1 and #2, received the required 12 hours of annual in-service training. In addition, one of five randomly reviewed CNAs, CNA #1, did not receive annual in-service(s) related to resident abuse prevention.