Triboro Center for Rehabilitation and Nursing

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident for two (2) out of five (5) residents (Resident #1 and Resident #2) sampled. Specifically, on 04/17/2026 at 2:30 PM, Resident #1 unscrewed the handle from a mechanical lift and used it to strike Resident #2 on the left side of the head. Resident #2 was assessed and observed with a four (4)-centimeter raised area to the left side of the head as well as a 0.4-centimeter open area on the pad of the left index finger. Emergency Medical Services (911) was called and Resident #2 was transferred to the emergency room for evaluation and returned to the facility on [DATE]. Resident #1 was transferred to the emergency room for psychiatric evaluation and returned to the facility with no new orders. [...]

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 1 Based on record review and interviews, the facility failed to ensure each resident was free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for one (1) of six (6) residents (Resident #425) reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review, out of 38 sampled residents investigated. Specifically, Resident #425 was administered psychotropic drugs without an appropriate diagnosis, there was no documentation of behaviors to support the ongoing use of psychotropic medications, and there was no evidence of monitoring for effectiveness or side effects.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1 Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health but not later than 2 hours after the alleged occurrence. This was evident for one (1) of two (2) residents (Resident #426) reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #426 sustained an unwitnessed injury to the upper right eyelid which they could not explain, which was not reported to Department of Health.

Inspectors wroteNumber of residents sampled: 6Number of residents cited: 1 Based on record review and interviews, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the needs of the resident and in response to current interventions. This was evident for one (1) of six (6) residents (Resident #425) reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review, out of 38 sampled residents. Specifically, there was no documented evidence that Resident #425's comprehensive care plan for psychoactive medications was reviewed and revised after medications were adjusted.

Inspectors wroteNumber of Residents sampled: 5Number of Residents cited: 1 Based on observation, record review, and interviews, the facility failed to ensure a resident received adequate supervision to prevent an accident. This was evident for one (1) of five (5) residents (Resident #269) reviewed for Accidents out of 38 sampled residents. Specifically, Resident #269 was provided with one person assistance instead of two-person assistance during care on 09/12/2025. Certified Nursing Assistant #4 attempted to turn Resident #269 onto their right side at which time Resident #269 rolled off the bed sustaining a left parietal (area in the skull) hematoma (a collection of clotted blood outside a blood vessel that may occur due to injury or disease) with a laceration and right upper face skin excoriation (damage to the surface of the skin).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 2/21/2024 through 2/28/2024, the facility did not ensure reasonable accommodation of a resident's needs and preferences. This was evident for 1 (Resident #46) of 38 sampled residents. Specifically, Resident #46 was unable to transfer out of bed because the facility did not have a functioning bariatric Hoyer (mechanical) lifter.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure a resident's financial records were made available through quarterly statements. This was evident for 1 (Resident #247) of 38 total sampled residents. Specifically, Resident #247 did not receive their quarterly Resident Fund Statements in writing within 30 days of the end of the quarter.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure an activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the residents. This was evident for 1 (Resident #57) of 5 residents reviewed for Activities out of 38 total sampled residents. Specifically, Resident #57 was not engaged in meaningful activity programs in accordance with their preferences and needs.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure a resident was given psychotropic medication to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #213) of 5 residents reviewed for unnecessary medication out of 38 total sampled residents. Specifically, Resident #213 was not provided with nonpharmacological interventions to address behavior and was prescribed psychotropic medication without an appropriate diagnosis.

Inspectors wroteBased on the record review and interviews conducted during the recertification and abbreviated (NY00328119 and NY00323553) survey from 2/21/2024 to 2/28/2024, the facility did not ensure alleged violations involving abuse were reported to the New York State Department of Health immediately, but no later than 2 hours, after the allegation was made, and the investigation conclusion was reported within 5 working days of the alleged violation. This was evident for 3 (Resident #81, #456, and #293) of 38 total sampled residents. Specifically, 1) the investigation conclusion for a resident-to-resident altercation involving Resident #81 and #456 was not reported to the New York State Department of Health within 5 days of occurrence, and 2) Resident #293's allegation they were verbally abused by Licensed Practical Nurse #2 was not reported to the New York State Department of Health.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00323553) Survey from 02/21/2024 to 02/28/2024, the facility did not ensure an allegation of abuse was thoroughly investigated. This was evident for 1 (Resident #293) of 38 total sampled residents. Specifically, an investigation of Resident #293's allegation of verbal abuse against Licensed Practical Nurse #2 was not completed.

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint (NY00331431) survey from 2/21/2024 to 2/28/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #113) of 38 total sampled residents. Specifically, a comprehensive care plan related to pain was not developed to address Resident #113's chronic pain.

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification/Complaint survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) Residents' respiratory care equipment was not properly covered to prevent contamination and possible spread of infections to the residents. (2) The facility-specific water management plan for Legionella was missing required components the following components: (a) a site-specific water management plan that described the water distribution system, (b) a sampling plan for the potable water system and (c) a sampling plan for the cooling tower. In addition, the plan was not reviewed and/or revised within the last year. [...]

Inspectors wroteBased on observation, staff interview, and record review conducted during the Recertification Survey conducted 1/18/22 to 1/25/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, (1) food was stored in refrigerator/freezer without proper labeling, dating, and covers/sealing, (2) proper refrigerator/freezer temperatures were not maintained, (3) week-old prepared food was not discarded, (4) staff were not practicing appropriate hand hygiene and glove use during food preparation activities to prevent cross-contamination. This was evident for the Kitchen Observation Facility Task.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification/Complaint survey, (1) the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed after each assessment or revised with changes in the resident's condition. Specifically, the CCP was not reviewed and revised after a resident with fragile skin sustained a skin tear. (2) The facility did not ensure that Resident or Resident's representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 1 of 7 residents reviewed for Accident, (Resident #493) and 1 of 2 residents reviewed for care plan meeting (Resident #64), out of 38 sampled residents.

Inspectors wroteBased on record review and staff interview conducted during the Recertification and Abbreviated survey (NY00280550), the facility did not ensure that each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days after that. Specifically, there was no documented evidence that a resident was seen by a medical provider (physician, physician assistant, or nurse practitioner) every 30 days for 90 days after admission. This was evident for 1 of 38 sampled residents. (Resident # 444)

Inspectors wroteBased on observations, record reviews, and staff interviews conducted during a Recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, the psychiatrist recommended discontinuing Seroquel for a resident on 12/06/2021. On 01/24/2022, the Medication Administration Record shows that the resident was on Seroquel. There was no documented evidence in the clinical record to support why the resident was still on the Seroquel. This was evident for 1 of 5 residents reviewed for the Unnecessary Medication out of a sample of 38 residents. (Resident # 200).

Inspectors wroteBased on observation, staff interview, and record review conducted during the Recertification Survey conducted 1/18/22 to 1/25/22, the facility failed to dispose of garbage and refuse properly. Specifically, garbage receptacles were not covered when being removed from the kitchen area to the dumpster. This was observed during the Kitchen Facility Task.