The Five Towns Premier Rehabilitation & Nursing Ce

Inspectors wroteBased on record review and interviews during the survey, the facility failed to ensure that all alleged allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. This was identified for one (Resident #6) of two residents reviewed for accidents. Specifically, Resident #6 had an unwitnessed fall on 11/15/2025 that resulted in injuries. The facility's accident and incident investigation report did not include statements from all staff involved. Additionally, the staff statements that were obtained were inconsistent and did not accurately indicate staff's response to the incident.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Designated Representative was notified when the need to start a new form of treatment was identified. This was identified for one (Resident #5) of three residents reviewed for Notification of Change. Specifically, Resident #5 was started on amoxicillin 875 milligrams-potassium clavulanate 125 milligrams (an antibiotic to treat infections) on 08/07/2025 for cough. There was no documented evidence that Resident #5's designated representative was notified of the resident's change in condition and the need to start a new treatment of antibiotic until 08/12/2025.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident requiring dialysis services received such services consistent with professional standard of practice. This was identified for one (Resident #3) of three residents reviewed for dialysis. Specifically, Resident #3, who receives dialysis treatment at the facility three times per week, was not provided dialysis treatment on their scheduled day on 06/20/2026 due to lack of communication between the facility staff and the dialysis center staff.

Inspectors wroteBased on observation, interviews and record review during an abbreviated survey conducted (complaint# 2633955) the facility failed to ensure one (1) (Resident #1) of three (3) residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan. Specifically, on 09/30/2025, Resident #1 fell out of bed. Registered Nurse Supervisor #1 assessed Resident #1 and assisted lifting them into bed using a Hoyer lift. Registered Nurse Supervisor #1 failed to document the fall in Resident #1's Electronic Medical Record, failed to complete a facility Occurrence Report, failed to notify Physician of the fall, and failed to notify Resident #1's family. As a result, Resident #1 was not monitored for pain or injury by the facility following the fall and the physician did not see Resident #1 for follow-up. [...]

Inspectors wroteBased on record review and interviews during the recertification survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that the Minimum Data Set assessment accurately reflected each resident's status. This was identified for one (Resident #190) of three residents reviewed for Communication. Specifically, Resident #109 utilized hearing aids as per the physician's orders; however, the annual Minimum Data Set assessment for Resident #109, dated 8/17/2024, did not accurately reflect the use of hearing aids or other hearing appliances. The finding is: The facility policy titled MDS Assessments, dated 1/2024 documented that the Resident Assessment Coordinator was responsible for ensuring the Interdisciplinary Team conducted timely and appropriate resident assessments. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, during Resident #19's wound care observation on 11/25/2024, Licensed Practical Nurse #1 did not apply the physician-ordered treatment to the wound and the peri-wound (the skin around the wound) area. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, Resident #19 had a physician's order for a collagen wound treatment product that included silver as an ingredient. The treatment product delivered by the Pharmacy had a label affixed to the box by the pharmacy that corresponded with the physician's order (included silver as an ingredient); however, the actual wound care product provided did not include silver as an ingredient. The finding is: [...]

Inspectors wroteBased on record review and interview during the recertification survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This was evident during Kitchen and Dining Tasks. Specifically, during the kitchen tour on 11/20/2024 tuna salad dated 11/12/2024 was observed in the walk-in refrigerator. Additionally, the temperature of the egg salad, macaroni salad, and potato salad served during the lunch meal was above acceptable standards for safe serving temperatures. The finding is: The undated facility policy and procedure titled Food Storage Temperatures and Storage Life Guidelines documented that foods will be stored at appropriate temperatures and for a specified duration to assure freshness and nutritional adequacy. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, during Resident #19's wound care observation on 11/25/2024, Licensed Practical Nurse #1 placed rested the normal saline soaked gauze pads directly on the exposed skin of the resident's right hip and then used the same gauze pads to cleanse the resident's right buttock pressure ulcer. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility did not ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #565) of one resident reviewed for insulin usage. Specifically, Resident #565, who had diagnosis of Diabetes Mellitus (DM), had physician's orders to receive insulin as a standing dosage with sliding scale coverage. The facility staff did not identify the site of the insulin administration for the daily insulin administration (standing order), did not identify the amount of insulin administered, or identify the site of the insulin administration for the sliding scale coverage on multiple occasions. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/9/23 and completed on 2/15/23 the facility did not ensure that resident records were accurately documented in accordance with professional standards of practice. This was identified for one resident (Resident #72) of three residents reviewed for Respiratory Care. Specifically, the facility did not have documented evidence that Colostomy care was provided to Resident #72 as per the facility protocol. The finding is: The facility policy titled Colostomy care dated 9/2022 included to document changes and any unusual observation in the Electronic Medical Record (EMR). Resident # 72 was admitted with diagnoses that include End-Stage Renal Disease, Bilateral Above Knee Amputation (AKA), and Paraplegia. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00300997) initiated on 2/9/2023 and completed on 2/15/2023, the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, not later than 24 hours, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the New York State Department of Health (NYSDOH). This was identified for one (Resident #368) of five resident reviewed for Accidents. Specifically, Resident #368 sustained a fractured left humerus that was identified by the facility on 8/9/2022. The origin of the injury was unknown. The facility did not report the injury to the NYSDOH until 8/12/2022. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00300997) initiated on 2/9/2023 and completed on 2/15/2023, the facility did not implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #368) of five residents reviewed for Accidents. Specifically, Resident #368 required total assistance of two persons for bed mobility. On 8/9/2022, Resident #368 was found to have a left humerus (arm) fracture. During the facility investigation it was determined that the Certified Nursing Assistants (CNAs) caring for the resident did not follow the plan of care and utilized a draw sheet with one person assistance for bed mobility to move Resident #368 in bed rather than utilizing two-person assistance. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #10) of five residents reviewed for Accidents and for one (Resident #140) of seven residents reviewed for Nutrition. Specifically, 1) Resident #10, who had a diagnosis of Dysphagia and had a physician's order for Aspiration Precautions, was observed in bed eating their pureed breakfast meal with their finger. The resident was observed slouched in bed and there was no staff member in the vicinity to provide supervision. 2) Resident #140 who had a diagnosis of Dysphagia and a Physician's order for Aspiration Precautions was observed in bed with all food items on the breakfast tray opened in front of them. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility failed to ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #315) of five residents reviewed for Pressure Ulcers. Specifically, during a wound care observation for Resident #315's Stage IV Pressure Ulcer, the Registered Nurse (RN) #8 did not perform hand hygiene after cleansing the wound and prior to donning (putting on) clean gloves. The finding is: The facility's Policy and Procedure for Aseptic Dressing Technique dated 7/2022 documented to apply new gloves and cleanse the wound from the center outward and to avoid touching wound directly with gloved hands. [...]

Inspectors wroteBased on observation, record review and staff interview during the recertification survey the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team to meet the needs of each resident. This was identified for one (Resident #46) of four residents reviewed for Infection. Specifically, Resident #46 had a left arm midline catheter for Antibiotic Therapy related to a Bacterial infection. The CCP lacked documented evidence of goals and interventions for the use and monitoring of the left arm midline catheter. The finding is: Resident #46 was readmitted to the facility on [DATE] with diagnoses that included Bacteremia, and Urinary Tract Infection. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long memory problems and was severely impaired for daily decision making. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. This was identified for 1 (Resident #189) of 6 residents observed during medication administration. Specifically, during the medication administration observation for Resident #189, the Registered Nurse (RN) medication nurse prepared to administer the 9 AM dose of twice a day Tramadol (a narcotic) to the resident; however, the Tramadol blister pack did not match the Physician's order. In addition, the resident had a second Physician's order for Tramadol to be administered three times a week one hour before dialysis; [...]