University Center for Rehabilitation and Nursing

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for one (1) of one (1) resident (Resident #3) reviewed for Respiratory Care out of forty-six (46) sampled residents. Specifically, The Minimum Data Set 3.0 (MDS) assessment did not document Resident #3 was in use of continuous oxygen.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that residents received necessary respiratory care consistent with professional standards of practice and the comprehensive care plan. This was evident for one (1) of one (1) resident (Resident #3) reviewed for Respiratory Care out of forty-six (46) sampled residents. Specifically, Resident #3 was observed receiving oxygen via nasal cannula at a rate of four (4) liters per minute when the Physician's Order was written for oxygen to be received at a rate of two (2) liters per minute.

Inspectors wroteBased on observation, record review, and staff interviews, the facility did not ensure that the resident medical records were accurately documented in accordance with professional standards of practice. This was evident for one (1) of three (3) residents (Resident #50) reviewed for Closed Records out of forty-six (46) total sampled residents. Specifically, Resident #50 was discharged to the hospital on [DATE], but the resident's medical record revealed that the resident was seen on 03/12/2026 and 03/19/2026 by behavioral health staff despite not having returned to the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 5/1/2024 to 5/7/2024, the facility did not ensure that resident menus were followed, and food preferences were honored. This was evident for 4 (Residents #38, # 95, and # 4) of 12 total sampled residents. Specifically, 1) Residents #38, #95, and #4 did not receive food items listed on their lunch and dinner meal ticket, and 2) Resident #38 did not receive preferred food items as requested.

Inspectors wroteBased on observation, record review, and interview, during the Recertification Survey from 5/1/2024 to 5/7/2024, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, 1.) multiple food items were observed in the refrigerators without proper labeling, 2.) opened food items were not dated, 3.) expired food items were observed, and 4.) food was not stored away from rust or soiled surfaces.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 05/01/2024 to 05/07/2024, the facility did not ensure that the most recent survey result of the facility was posted in a place readily accessible to residents, family members, and legal representatives of the residents. This was evident for 1(Resident #95) of 6 residents attending the Resident Council meeting. Specifically, survey results were posted in the facility basement that was not in plain view and was not readily accessible for review. In addition, a member of the Resident Council was interviewed and stated they do not know where the survey results were posted.

Inspectors wroteBased on the observation and interviews conducted during the Recertification Survey from 5/1/2024 to 5/7/2024, the facility did not ensure garbage and refuse were properly disposed of. This was evident during the kitchen facility task. Specifically, garbage was not properly contained outside the facility to prevent the harborage and feeding of pests.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Abbreviated survey (NY00293269), the facility did not ensure a resident's injury of unknown origin was reported to the New York State Department of Health (NYSDOH) no later than 2 hours from the time of the allegation. This was evident for 1 (Resident #89) of 1 resident(s) reviewed for Abuse out of 29 total sampled residents.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey (case # NY00303443) from 11/16/2022 to 11/22/2022, the facility did not ensure a Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team after each assessment and based on changing goals. This was evident in 1 (Resident #36) of 29 total sampled residents. Specifically, the CCP related to Resident #36's discharge planning was not reviewed and revised after each quarterly Minimum Data Set 3.0 (MDS) assessment and upon a change in the resident's discharge planning goals.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey (NY00303443) from 11/16/2022 to 11/22/2022, the facility did not ensure the development and implementation of an effective discharge process that involved the resident representative and regular re-evaluation of residents to identify changes that require modification of the discharge plan. This was evident in 1 (Resident #36) of 2 resident reviewed for Discharge out of 29 total sampled residents. Specifically, Resident #36's discharge plan did not reflect a change in the discharge destination from the community to another skilled nursing facility. In addition, the record did not reflect information about referrals made, status of the referral, or follow-up with the designated representative for the status of the discharge plan.

Inspectors wroteBased on interviews and record review conducted during the recertification survey from 11/16/22 to 11/22/22, the facility did not ensure reconciliation of all pre-discharge medications with the resident's post discharge medications. This was evident for 1 (Resident #189) of 2 residents reviewed for discharge out of 29 total sampled residents. Specifically, the facility did not ensure Resident #189 was discharged from the facility with the remaining supply of or prescriptions for the medication listed on their discharge instructions.

Inspectors wroteBased on interviews and record review conducted during the recertification survey from 11/16/22 to 11/22/22, the facility did not ensure the attending physician documented in the resident's medical record that an identified irregularity in the Medication Regimen Review (MRR) has been reviewed and what, if any, action has been taken to address it in a timely manner. This was evident for 1 (Resident #19) of 5 residents reviewed for Unnecessary Medications out of 29 total sampled residents. Specifically, the Medical Doctor (MD) did not respond timely to a pharmacy MRR concern regarding Resident #19 being prescribed Basalgar Insulin (BI) when there was documentation in the medical record that Resident #19 was allergic to BI.