Townhouse Center for Rehabilitation & Nursing

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (2631774), the facility did not ensure that all alleged incidents of a staff-to-resident abuse was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #1) of three residents reviewed for abuse. Specifically, on 08/27/2025 Family Member #1 reported to the facility that Resident #1 alleged Certified Nursing Assistant #2 was rough with them and pulled their arms. The facility did not report the alleged abuse to the New York State Department of Health (NYSDOH).

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for two (Resident #223 and Resident #171) of two residents reviewed for the Resident Assessment Task. Specifically, Resident #223's Discharge Minimum Data Set assessment was not submitted within 14 days from the completion of the Minimum Data Set assessment. Resident #171's quarterly Minimum Data Set assessment was not submitted within 14 days from the completion of the Minimum Data Set assessment. The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification and Abbreviated Survey (NY 00347071) initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure that each resident's comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #146) of one resident reviewed for Skin Condition. Specifically, Resident #146 had a diagnosis of Hyperkeratosis (a condition that causes thick, rough, patches of skin) of the bilateral feet; however, there was no care plan developed for the Hyperkeratosis until 1/21/2025. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025 the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was identified for one (Resident #115) of three residents reviewed for Skin Conditions. Specifically, Resident #115 was recommended to use an orthotic carrot device (a device shaped like a carrot that supports the hand, prevents injury, and improves function) for their left hand by the Occupational Therapy Department on 4/7/2023. A Physician's order for the use of an orthotic carrot device was never obtained, therefore, Resident #115 was never offered and did not use the orthotic carrot device. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all drugs and biologicals were labeled in accordance with professional standards of practice. This was identified for one (Unit 3 North medication cart A) of eight Medication Carts reviewed during the Medication Storage task and for one (Resident #498) of five residents reviewed for Accidents. Specifically, 1) the Unit 3 North medication cart was observed with two unlabeled medication cups, with medication tablets, in the top drawer. Licensed Practical Nurse #2 stated they stored the pre-poured medications in the medication cart because Resident #41 and Resident #105 had refused their medications during the medication administration pass. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure it provided timely laboratory services to each resident. This was identified for one (Resident #398) of two residents reviewed for Mood and Behavior. Specifically, Resident #398's Physician ordered a Urinalysis (a test that checks urine for signs of health issues like infections and kidney problems) STAT (without delay/prioritized with urgency) on 1/18/2025 to rule out Urinary Tract Infection. The results of the test were not reported by the laboratory to the facility timely. The finding is: The facility's policy titled Laboratory Services, Results, and Physician Notification, dated 5/2024 documented the facility will provide and/or obtain laboratory services in a timely manner to meet the needs of its residents. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey initiated on 1/15/2025 and completed on 1/23/2025, the facility did not ensure the Binding Arbitration Agreement explicitly granted the resident and their representative the right to rescind the agreement within 30 calendar days of signing the agreement. This was identified for two (Resident #139 and Resident #238) of two residents reviewed during the Arbitration Task. Specifically, the Binding Arbitration Agreement signed by Resident #139 and Resident #238's representatives did not specify that the resident/representatives had 30 calendar days to rescind the agreement. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure proper sanitation and food handling practices to prevent the outbreak of food born illnesses. This was identified during the initial kitchen observation. Specifically, a high-temperature automatic dishwashing machine was observed on two occasions on 5/3/2023 with a final rinse temperature below the manufacturer's recommended 180 degrees Fahrenheit (F). Additionally, there was no sanitizing agent attached to the dishwashing machine which would have automatically dispensed when the recommended 180 degrees temperature was not achieved during the final rinse cycle. The finding is: The facility's dishwashing machine manual documented the unit is a high-temperature dishwashing machine. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure that each resident received care and necessary treatment and services in accordance with professional standards of practice to prevent pressure ulcers. This was identified for one (Resident #144) of six residents reviewed for Pressure Ulcers. Specifically, 1) Resident #144, who was ventilator dependent and required total assistance for bed mobility, was assessed at high risk for developing pressure ulcers. Resident #144 was assessed by the Dermatologist for a scabbed lesion to the right side of the scalp in March 2023 and was diagnosed with a Neoplasm (lesion). The Wound Care Physician categorized the lesion as a Stage II Pressure Ulcer on 3/24/2023. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023 the facility did not ensure that staff implemented and provided care and services according to resident needs and professional standards of practice for each resident with a feeding tube. This was identified for one (Resident #144) of five residents observed during the Medication Administration Task. Specifically, during Resident #144's medication administration observation, Licensed Practical Nurse (LPN) #2 did not check placement of the resident's feeding tube prior to administering the medications through the feeding tube. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023 the facility did not ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This was identified for one (Resident #33) of five residents observed during Medication Administration Task. Specifically, during Resident #33's medication administration observation, the Licensed Practical Nurse (LPN) #1, medication nurse, drew up an injectable medication at the medication cart in the hallway and walked with the exposed needle to the resident's bedside. The finding is: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 5/3/2023 and completed on 5/9/2023, the facility did not ensure it established and maintained 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 #50) of four residents reviewed for Respiratory Care. Specifically, during the observation of Resident #50's tracheostomy (trach) care, the Respiratory Therapist (RT)#1 did not perform hand hygiene after glove changes and did not perform hand hygiene prior to replacing the sterile inner cannula back into the tracheostomy tube. The finding is: The facility's policy titled, Trach Care last reviewed 1/2023, documented a goal of trach care is to prevent infection; [...]

Inspectors wroteBased on observations, record reviews, and staff interview during the recertification survey the facility did not ensure that a comprehensive person-centered care plan was developed for each resident. This was identified for one (Resident # 226) of six residents reviewed for pressure ulcer. Specifically, Resident # 226 had a Physician's order dated 9/9/2020 for Diathermy Treatment (an electrically induced heat used to stimulate increase of blood flow) over the Sacrum for 20-30 minutes, and there was no documented evidence that a Comprehensive Care Plan (CCP) was developed for this treatment modality. The finding is: Resident #226 was admitted to the facility on [DATE] with diagnoses including a Stage III Sacral Pressure Ulcer (PU) and Urinary Tract Infection (UTI). A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. [...]