Van Duyn Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 60 residents reviewed. The facility failed to provide oversight, monitoring, and effective communication between staff and practitioners. Specifically, Resident #118 did not have a hematology consultation that was ordered and laboratory tests were completed 14 days after they were ordered. This resulted in actual physical harm for Resident #118 that was not Immediate Jeopardy.

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to obtain physician ordered laboratory tests to meet the needs of its residents for one (1) (Resident # 118) of three (3) residents reviewed. Specifically, the laboratory test ordered for Resident #118 on [DATE] and [DATE] were not completed as ordered. The laboratory test was not completed until it was ordered for a third time on [DATE], which resulted in critical levels requiring hospitalization for a blood transfusion. This resulted in actual physical harm for Resident #118 that was not Immediate Jeopardy.

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure timely completion of each resident's quarterly review assessments for 17 of 19 residents (Resident #s 25, 82, 115, 141, 184, 203, 211, 225, 255, 263, 275, 284, 356, 369, 383, 394, and 396) reviewed during the Resident Assessment Facility Task. Specifically, the residents' Quarterly Minimum Data Sets (a resident assessment tool) were not completed within 92 days after the previous Quarterly Minimum Data Set assessment and/or not signed off as completed within 14 days of the assessment start.

Inspectors wroteBased on observations, record review, and interviews conducted during survey, the facility failed to properly store food items according to professional standards for food safety. Specifically, on 05/05/2026, the main kitchen had opened, undated and/or unlabeled food items with no use by date; areas were visibly dirty; one handwashing sink was not maintained; and on 05/12/2026, the automatic dishwasher final rinse temperature was observed at 178 degrees Fahrenheit and was documented as not meeting or exceeding final rinse temperature of 180 degrees Fahrenheit from 05/01/2026 through 05/11/2026. This was observed in the main kitchen and had the potential to negatively impact all residents, staff and visitors who consume facility-prepared food.

Inspectors wroteBased on record review, observation, and interviews conducted during survey, the facility failed to maintain an effective pest control program. Specifically, (a.) on 05/05/2026, a live cockroach was in the kitchen storage room. The kitchen storage room and main kitchen adjacent to the room were visibly soiled and unkept with discarded garbage substances. (b.) on 05/11/2026, ants and a spider were observed alive within the facility's first floor Northern bathroom. This was noted in the main kitchen and on the first floor.

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure care and services were provided in a manner that promoted dignity and respect for three of eight residents (Resident #207, #230, and #241) reviewed for dignity. Specifically, staff did not intervene to maintain Resident #207's dignity when the resident's hands were visibly soiled with bodily waste and then ate their pudding with their soiled bare hands; Resident #230's dignity was not maintained when staff pulled the resident up by their pants. During observations on 05/06/2026, 05/08/2026, and 05/12/2026, two residents (Resident #76 and #136) were observed being transferred by their arms and pants without the use of a gait belt. Resident #241's dignity was not maintained when staff referred to the resident as a feeder. [...]

Inspectors wroteBased on observation, interviews and record review conducted during survey, the facility failed to maintain a clean and homelike environment. Specifically, on 05/07/2026, Resident #118's recessed light had no light bulb. On 05/05/2026, Resident #27's room walls were dirty, and Resident #126's overbed table had a full, odorous urinal on it. Observations on 05/05/2026 noted sticky floors including Resident #118's room door and floor, the 7th floor nurses station floor, and the 3rd floor common area/core floor.

Inspectors wroteBased on observations and interview conducted during survey, the facility failed to ensure the resident call system was maintained in working order and readily accessible to permit residents to summon staff assistance for three of three residents (Resident #86, #353, and #162) reviewed for accessibility of resident call systems and for one resident (Resident #241) identified during observations. Specifically, on 05/06/2026, Resident #86 was observed with a nonfunctioning call light located out of reach on the bedside table and in need of repair. On 05/05/2026 and 05/11/2026, Resident #353 and Resident #162's call bells were observed as not being within reach. This deficient practice placed residents at risk for delayed staff response and urgent care needs.

Inspectors wroteBased on observation, record review, and interview conducted during survey, the facility failed to ensure restraint use was monitored and implemented in accordance with a physician order and resident needs for one of one resident reviewed for restraints (Resident #13). Specifically, Resident #13 was observed wearing a physician-ordered harness seatbelt during mealtimes that was not released as required.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse. Specifically, Resident #230 reported to a Registered Nurse Supervisor an allegation of abuse, stating that Certified Nurse Aide #18 abruptly rolled them over and pulled them up by their pants and threw them in their wheelchair.

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure comprehensive person-centered care plans were developed and implemented in accordance with professional standards of practice for two residents (Resident #118 and #248) out of three residents reviewed. Specifically, (a.) Resident #118 received medications for unspecified anemia, iron deficiency, and dry eye syndrome and a care plan was not developed and implemented for the diagnoses; and (b.) Resident #248 was involved in a resident-to-resident physical altercation on 01/20/2026 at 6:50 AM, and a comprehensive care plan for abuse was not developed and implemented. Additionally, Resident #248 had oral surgery on 01/21/2026 and a care plan was not developed and implemented.

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure each resident's person-centered, comprehensive care plan was reviewed and revised timely for two (Resident #379 and Resident #162) out of 60 residents reviewed for care plan revisions. Specifically (a), Resident #379's care plan for psychotropic drugs was not revised when the medication Risperidone (an antipsychotic medication) was reduced from 0.25 milligrams twice daily to once daily on 01/07/2026, nor was the care plan revised when this medication was discontinued for the resident on 03/26/2026; (b) Resident #162's nutrition care plan was not revised when the resident lost their upper denture, requested ground meat instead of a regular consistency meal due to difficulty chewing their food.

Inspectors wroteBased on observations, record review, and interviews conducted during survey, the facility failed to ensure ongoing provision of programs to support residents in their choices of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two (Resident #3 and #243) of two residents reviewed. Specifically, Resident #3 and Resident #243 both required the use of a mechanical lift to get out of bed, and were not provided with meaningful, accommodating activities to maintain their highest quality of life.

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure that its medication error rate did not exceed 5 percent for two (Resident #230 and #245) of five residents observed during medication administration with 33 observations. This resulted in a medication error rate of 6.06 percent.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure residents received routine and/or emergency dental services, including assistance in obtaining dental evaluation and treatment for two of three residents (Resident #155 and #162) reviewed. Specifically, (1.) Resident #155 was discovered to have a broken front tooth by family and was not referred to dental services to rule out any potential issues/problems. (2.) On 04/15/2026, Resident #162 was known to be missing upper dentures but their diet was not adjusted to account for this factor until five days later on 04/20/2026, when a dental consult documented to adjust diet as needed. Resident #162's full upper denture impressions were not completed until 05/10/2026. [...]

Inspectors wroteBased on record reviews and interviews conducted during survey, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for one (Resident #412) of three residents reviewed. Specifically, the facility failed to ensure overall systems were established for documentation of all meals by nursing staff and were being maintained according to standards of practice and facility policy when they failed to document breakfast, lunch, and dinner for Resident #412 between the dates of 11/01/2025 through 11/30/2025.

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to provide drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration for one (Resident # 118) of three residents reviewed. Specifically, the facility failed to ensure Resident #118 received water and ice per their preference to maintain hydration.

Inspectors wroteBased on observations, record review, and interviews conducted during survey, the facility failed to properly dispose of garbage and refuse. Specifically, on 05/05/2026, three garbage receptacles located within the main kitchen had no liners and contained refuse. One of the garbage cans was next to a wall that had dried, liquified spatter covering approximately two square feet of the wall above it. Additionally, dirty garbage lids were observed in the main kitchen storage utility room. This was observed in the Main Kitchen during the initial tour.

Inspectors wroteBased on observation, record review, and interview conducted during survey, the facility failed to ensure appropriate infection prevention and control practices were followed for one of eight residents (Resident #138) reviewed for infection control practices. Specifically, Certified Nurse Aide # 6 failed to remove personal protective equipment prior to exiting the room of Resident #138 who was on special contact droplet precautions and the facility failed to provide a receptacle for disposable of used personal protective equipment inside the resident's room. This deficient practice had the potential to affect residents through increased risk of transmission of infectious agents.

Inspectors wroteBased on observations, record review, and interviews conducted during survey, the facility failed to ensure that meals were provided at regular times comparable to normal mealtimes in the community, nor did the facility provide suitable, nourishing alternative snacks for residents waiting for meals. Specifically, dinner service on 05/11/2026, on the 4th floor took over two hours to complete, resulting in residents sitting at tables waiting for food while others ate, and the snack pantry was found to be without nourishing options. This was evident for all residents on the 4th floor.

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #1) reviewed. Specifically, from 12/15/2025-01/30/2026 Resident #1 had acute medical complaints including urinary symptoms. Urinalysis reports on 12/19/2025 and 01/01/2026 were not adequately addressed by nursing and medical; the resident was treated multiple times with a cephalosporin (antibiotic) without obtaining a urine culture and sensitivity; and a urology consult was not reviewed. The resident continued with frequent complaints of not feeling well and was hospitalized on [DATE] and admitted to the intensive care unit for urosepsis (life threatening response to a urinary tract infection) and metabolic acidosis (acid build up in the blood). [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey the facility failed to ensure residents were free from abuse for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1's head was forcefully pushed backward by Certified Nurse Aide #2 during care resulting in scratches and redness to Resident #1's face. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 418 residents in the facility at risk for the likelihood of serious injury, serious harm, serious impairment, or death.

Inspectors wroteBased on record review and interview during the survey the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1's care plan documented the resident was to have no male caregivers. During the night shift (11:00 PM-7:00 AM) on 02/03/2026, male Certified Nurse Aide #2 was assigned to provide 1:1 supervision for Resident #1. On 02/04/2026 at 7:00 AM Certified Nurse Aide #2 was witnessed by Certified Nurse Aide #1 abusing Resident #1. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure an incident of staff abuse toward a resident was immediately reported to the State Agency, law enforcement, and the Administrator for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Certified Nurse Aide #1 witnessed Certified Nurse Aide #2 abuse Resident #1, and the incident was not reported to facility Administration, law enforcement, and New York State Department of Health until approximately five (5) hours after the incident occurred. Additionally, the required five (5)-day investigative report was not submitted until 12 days following the witnessed abuse. Refer to: F600 Free from Abuse and Neglect F656 Develop/ Implement Comprehensive Care Plan.

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure residents were free from abuse for one (1) of three (3) residents reviewed (Resident #1). Specifically, Resident #1 had a history of verbal behaviors of using racial slurs directed at others and had multiple physical behaviors directed toward others, including the following:-on 09/10/2025 Resident #1 threw coffee at staff, hitting another resident. -on 09/30/2025, Resident #1 hit Resident #3 in the face. -on 11/10/2025, Resident #1 refused medications and started swinging at staff. -on 12/24/2025, Resident #1 threw a glass vase at staff. -on 12/25/2025, Resident #1 hit Resident #2 in the head with a wheelchair leg rest. There was no documented evidence effective/adequate interventions were put into place after each incident to protect residents from potential abuse by Resident #1. [...]

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (1) of three (3) residents (Resident #11) reviewed. Specifically, on [DATE] between 5:00 AM and 5:30 AM, Resident #11 had labored breathing and an oxygen saturation level (amount of oxygen in the blood) of 40 percent (normal is 95 -100 percent). The oxygen flow rate was increased to 10 liters per minute without a physician order and the resident's oxygen saturation level dropped to 26 percent on 10 liters of oxygen. The physician was not notified of the resident's significant change in respiratory status. [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #11) reviewed. Specifically, on 11/25/2025, Resident #11's respiratory complaints were not appropriately addressed, and physician's orders were not followed. On 11/26/2025, Resident #11 was not adequately monitored when they exhibited respiratory distress and were left unsupervised while waiting for Emergency Medical Services arrival. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #11 and placed all residents with potential changes in health status at risk for serious harm, serious impairment, serious injury, or death.

Inspectors wroteBased on record review and interviews during the abbreviated survey the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #2) reviewed for elopement. Specifically, Resident #2 who was cognitively intact and had a history of suicidal ideations, opioid dependence, and mental health disorders, eloped from the facility on 02/24/2025 at an unknown time. Resident #2 was allegedly last seen by facility staff on 02/24/2025 at 2:00 PM and the resident's absence was not discovered until 5:45 PM. The resident was contacted via telephone by law enforcement on 02/25/2025 at 12:11 AM after the facility called emergency services to report the resident missing on 02/24/2025 at 11:16 PM. The resident would not disclose their location to law enforcement and did not return to the facility. [...]

Inspectors wroteBased on observations, record review, and interviews during the survey, the facility failed to develop, implement, and maintain an effective compliance and ethics program that is likely to be effective in preventing and detecting criminal, civil, and administrative violations and promoting quality of care. Specifically, the facility failed to create and promote a program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure incidents of abuse were reported to the State Agency as required for one (1) of three (3) residents (Resident #1) reviewed. Specifically, on 09/10/2025 Resident #1 threw coffee at staff and subsequently hit another resident seated at the table; on 09/30/2025 Resident #1 hit Resident #3 on the cheek when Resident #3 attempted to take food from Resident #1's plate. The facility failed to report the resident to resident altercations to the New York State Department of Health as required.

Inspectors wroteBased on record reviews and interviews conducted during the survey, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 exhibited escalation of behavioral symptoms including resident-to-resident altercations, and physical and verbal abuse directed toward others and there was no documented evidence of a comprehensive care plan addressing the resident's behavioral symptoms with specific interventions to be implemented.

Inspectors wroteBased on interviews and record review conducted during the survey, the facility failed to ensure allegations of neglect were thoroughly investigated for one (1) of three (3) residents (Resident #2) reviewed. Specifically, on 02/24/2025, Resident #2 left the facility undetected, was last seen by staff at 2:00 PM, and their absence was not discovered until 5:45 PM. Resident #2 left the facility without their required oxygen and did not receive their medications or evening meal as ordered. There was no documented evidence of a thorough investigation when Resident #2 eloped from the facility on 02/24/2025.

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure that it provided respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #11) of three (3) residents reviewed. Specifically, the facility did not ensure Resident #11 was administered four (4) liters of oxygen as prescribed, when assessed by the Respiratory Therapist for shortness of breath during the evening shift on 11/25/2025. This is evidenced by: Cross-referenced to F580: [...]

Inspectors wroteBased on record review and interview during a survey, the facility failed to ensure it maintained medical records in accordance with accepted professional standards and practices, and that medical records on each resident were complete, accurately documented, readily accessible, and systematically organized for one (1) (Resident #11) of three (3) residents reviewed. Specifically, there was no documentation in the medical record of [a.] an assessment of Resident #11 by Registered Nurse #8 when the resident had respiratory and mental status changes on 11/26/2025, [b.] the resident's response to oxygen treatment provided by Registered Nurse #8 and Licensed Practical Nurse #4 on 11/26/2025, and [c.] the resident's vital signs (heart rate, blood pressure, respiratory rate, and temperature) on 11/26/2025. This is evidenced by: Cross-referenced to F580: [...]

Inspectors wroteBased on record review and interviews during the survey the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #2) reviewed for accidents. Specifically, Resident #2 had an active physician order for a 1:1 supervision safety watch (for prior smoking violations and behavioral symptoms directed toward others) that was not implemented when the resident was readmitted from a hospital stay on 01/15/2025. Subsequently, on 01/17/2025 Resident #2 was found with a self-inflicted laceration to their neck and superficial vertical cuts to both wrists. This resulted in actual harm to Resident #2 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality for seven (7) of seven (7) anonymous residents reviewed. Specifically, seven (7) anonymous residents stated staff use foul language, ethnic slurs and laugh at other residents in the hallways and around residents, making them feel uncomfortable.

Inspectors wroteBased on observations and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on five (5) of five (5) resident units. Specifically, the facility did not ensure that resident rooms and common areas were clean and in good repair.

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure services provided by the facility met professional standards of quality. Specifically, medication pass times were broad and carried a risk of over medicating or under medicating five (5) (Residents #1, 7, 11, 98, and 527) of five (5) residents reviewed. This affects all residents receiving medication at the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for six (6) (4th floor North Medication Cart C and D; 5th floor North Medication Cart A; 6th floor North Medication Cart C and D; 6th floor North Treatment cart used as a medication cart) of ten (10) medication carts reviewed, and five (5) (3rd floor North Medication Room; 4th floor North Medication Room C and D; 6th floor North Medication Room C and D) of nine (9) medication rooms reviewed. Specifically, (a.) five (5) insulin pens were not labeled and or dated; (b.) medication room refrigerator temperatures were not recorded; (c.) narcotic books were not reconciled each shift; (d.) narcotics were not secured in a double lockbox until use. [...]

Inspectors wroteBased on observations and interviews conducted during the survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meal on 12/08/2025 and breakfast meal 12/09/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal of 12/08/2025 and breakfast meal on 12/09/2025. Additionally, seven (7) anonymous residents during a resident council meeting and seven (7) residents (Resident's #4, 121, 175, 211, 238, 277, 493) separately interviewed stated the food did not taste good and was cold.

Inspectors wroteBased on observation and interview conducted during the survey, the facility failed to ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for five (5) of five (5) resident unit kitchens and the main kitchen. Specifically, the automatic dishwashing machine was not sanitizing, the chemical sanitizer for manual equipment washing was too concentrated, and equipment and surfaces were not clean and/or in good repair.

Inspectors wroteBased on observation and interviews during the survey, the facility failed to ensure garbage and refuse was disposed of properly. Specifically, the trash compactor loading area was unclean and heavily soiled.

Inspectors wroteBased on observations and interviews conducted during the survey, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, administration failed to ensure residents' rights to a safe, clean, comfortable and homelike environment. Administration failed to ensure that their infection prevention and control program was developed and implemented to prevent the spread of infectious diseases for all residents, staff, volunteers, and visitors.

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure that medical records were kept in accordance with professional standards. Specifically, (a.) documentation for oxygen tubing for Resident #143 was not kept in an accurate and professional record; and (b.) full access to medical records was not granted on request as required by regulation.

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure a Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility did not implement systems that ensured the care and services it delivered met acceptable standards of quality in accordance with recognized standards of practice. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) (Resident #11 and Resident #336) of two (2) residents reviewed. Specifically, Resident #11 and Resident # 336 were observed with their urinary drainage bag on the floor without a barrier separating the floor from the drainage bag; the sink in room [ROOM NUMBER] was not functioning for the duration of the survey, and the resident (Resident #5) in room [ROOM NUMBER] was on enhanced barrier precautions. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the survey, the facility failed to ensure the comprehensive person-centered care plan was implemented to ensure a resident's nursing needs were met for three (3) (Residents #1, #7, and #98) of 38 residents reviewed. Specifically, a.) Resident #1's comprehensive care plan for dementia was not person-centered and there were no care plan addressing activities, b.) Resident #7's comprehensive care plan did not address the use of anticoagulants, and insulin, and c.) Resident #98 did not have a care plan initiated for oxygen use.

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to provide ongoing programs to support each resident in their choice of activities for two (2) (Resident #15 and #163) of two (2) residents reviewed. Specifically, Resident #15 was not offered meaningful activities that included their interests and preferences, and Resident #163 was not included in activities of their preference.

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to ensure that residents with limited mobility received the appropriate services, equipment, and assistance to maintain mobility and prevent complications for two (2) (Residents #15 and #301) of two (2) residents reviewed. Specifically, Resident #15 did not consistently receive a hand device (palm guard) to right hand and Resident #301 did not consistently receive a rolled cloth to left hand for hand contractures (shortening of the muscles, tendons, and skin) to prevent complications per Occupational Therapy recommendations and as ordered by the physician.

Inspectors wroteBased on observation, record review, and interview during the survey, the facility failed ensure residents who required dialysis services, received such services consistent with professional standards of practice for one (1) (Resident #14) of one (1) resident reviewed for dialysis. Specifically, Resident #14 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and/or after dialysis treatments.

Inspectors wroteBased on observation, interview and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #303 and Resident #352) of five (5) residents observed during a medication pass for a total of 28 observations. This resulted in a medication error rate of 10.71 percent. Findings Include:The facility's policy and procedure titled General Medication Administration last reviewed 05/2025, documented medications will be administered by a Licensed Practical Nurse or a Registered Nurse. All medications will be administered and documented using the Electronic Medical Record. Check all resident orders carefully before administering the medications. Keep the basic rules of safe administration in mind: [...]

Inspectors wroteBased on observations and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment on three (3) of five (5) resident units. Specifically, strong urine odors were detected in several areas throughout the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident reviewed (Resident #314). Specifically, Resident #314 was observed on 12/03/2025 and 12/05/2025 with a bottle of unprescribed Clinical Treat Anti-Fungal Powder (treats fungal or yeast infections of the skin) NDC #5332916979 sitting on their bedside table in their room. There was no documented evidence of an assessment in the medical record and/or a physician order for the resident to self-administer the medication. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to ensure resident's right to make choices about aspects of his or her life in the facility that are significant for one (1) (Resident #211) of one (1) resident reviewed. Specifically, Resident #211 was not provided with food items recommended by the nutritionist's meal plan and resident's preferences, requiring the resident to purchase recommended items from an outside source.

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to ensure each resident's right to file a grievance and/or prompt efforts were made to resolve grievance for one (1) (Resident #380) of three (3) residents reviewed for grievances. Specifically, there was no documented evidence that a grievance was filed, an investigation was conducted, and/or a grievance was resolved when Resident #380's responsible party reported to staff the resident was missing a new pair of sneakers and multiple clothing items. The finding is:The policy titled Lost or Missing Items, review/revision dated 05/16/2025, documented the facility will review and investigate all lost and missing items and unauthorized use or removal of resident's property. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Resident #1 was observed to have an old bandage on their left forearm with no documentation in the resident's medical records.

Inspectors wroteBased on observations, record review, and interviews conducted during the survey, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' physician orders for one (1) (Resident #143) of four (4) residents reviewed. Specifically, Resident #143 was observed with oxygen tubing dated [DATE] and not changed as ordered. The finding is: The facility policy Oxygen Therapy Policy and Procedure revised [DATE] documented nasal cannula or OxyMask were labeled and dated when set up. Nasal cannulas or OxyMasks were changed every two (2) weeks or as needed if visibly soiled. When the nasal cannula or OxyMask was changed it was labeled, dated, and documented in the administration record. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00361295), the facility did not ensure they provided or obtained routine and emergency medications and biologicals in order to meet the needs of each resident for 2 of 3 residents reviewed (Residents #2 and 4). Specifically: Resident #2 had physician orders for Lithium (psychotropic medication for mood stabilization), the Lithium was not obtained timely and as a consequence, the resident had a low Lithium blood level. Resident #4 was a newly admitted and had physician orders for Sevelmer and cinacalcet ( for kidney disease) and the medications were not obtained timely (11 days).

Inspectors wroteBased on observations, record review, and interviews during the extended recertification and abbreviated (NY00376311) surveys conducted 4/6/2025 - 4/18/2025, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of three (3) residents (Resident #50 and #162) reviewed. Specifically, Residents #50 and #162 were Deaf and were not provided their preferred method of communication and thus were unable to communicate their needs and preferences to staff, socialize with other residents, or participate in meaningful activities. This resulted in actual psychosocial harm to Resident #50 that was Immediate Jeopardy and Substandard Quality of Care.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025 - 4/18/2025, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (6) of eight (8) residents (Residents #160, #417, #425, #461, #485, and #790) reviewed. Specifically: - Resident #485 was on contact precautions for clostridium difficile (a resistant contagious bacterium) colitis (inflammation of the colon) and droplet precautions for COVID-19 (a contagious respiratory disease) and did not have the appropriate isolation precaution signs, precautions were not consistently followed, and contaminated laundry items were not separated from general population laundry. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00374160) surveys conducted 4/6/2025 - 4/18/2025, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality for two (2) of three (3) residents (Residents #170 and #335) reviewed. Specifically, Residents #170 and #335 were continent (able to control bladder and bowel), placed in incontinence briefs, and were told by staff to urinate/defecate in the briefs instead of using the toilet and/or bedpan. This resulted in psychosocial harm to Residents #170 and #335 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00325460) surveys conducted 4/6/2025 - 4/18/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (2) of three (3) residents reviewed (Residents #274 and #461). Specifically, Resident #274 was not provided a wound vacuum machine (vacuum assisted closure using negative pressure to assist in wound healing) or the back-up wet to dry dressing treatment as ordered; and Resident #461 did not receive timely follow-up care for their dehisced wound (a surgical incision that reopens) This resulted in harm to Resident #461 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00358079) survey conducted 4/6/2025-4/18/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for five (5) of five (5) resident floors (3rd, 4th, 5th, 6th, and 7th floors). Specifically, the 4th, 5th, 6th, and 7th floors had unattended and unlocked treatment/medication carts; the 3rd, 4th, and 7th floors had medication refrigerators without daily temperature monitoring; the 3rd, 5th, and 6th floors had medications without open dates; and the 4th and 7th floors medication rooms had an excessive number of discontinued medications.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen, and 1 of 2 (Northwest Unit) kitchenette nourishment areas. Specifically, food was held at the improper temperature for service during two (2) meals observed that could have affected all residents, eight (8) of nine (9) handwashing sinks were not properly equipped in the food production and service areas and improper handwashing was observed.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for four (4) of six (6) resident units (Units 3 North and South, Units 4 North and South, Units 6 North and South, and Unit 7) reviewed. Specifically, several residents' rooms and common living areas were unclean, had scraped or cracked walls, dirty soiled linens left on the floors, dirty tables and chairs, several pieces of paper trash collecting on resident floors, and there were unpleasant/offensive odors.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 4 of 6 residents (Residents #27, #167, #274, and #419) reviewed. Specifically, Resident #27 had an order not to receive straws due to oral phase dysphagia (difficulty swallowing) and was observed using straws; Resident #167 had medications left at their bedside; Resident #274 had a used needle and vacuum from a blood draw disposed of in the trash can in their room; and Resident #419 sustained a burn after using a microwave independently to heat food.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) of three (3) meals reviewed (Lunch meals on 4/6/2025 and 4/8/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 4/6/2025 and two (2) lunch meals on 4/8/2025. Additionally, 12 anonymous residents during a resident council meeting and six (6) residents (Resident #80, 160, 285 336, 355, and 425) interviewed stated the food did not taste good and was cold.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted from 4/6/2025-4/18/2025, the facility failed to ensure each resident received food that accommodated resident allergies, intolerances, and preferences for three (3) of five (5) (Resident #306, 336, and 704) reviewed. Specifically, Resident #306 was missing food items including their nutritional supplements at meals; Resident #336 was missing food items at meals; and Resident #740 was missing food items including their nutritional supplements at meals. Additionally, 12 anonymous residents during a resident council meeting and five (5) residents (Resident #80, 160, 210, 355, and 480) interviewed stated their meal trays were frequently missing food items.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for the administrative area and for 3 of 7 units (3rd, 4th, and 6th floors) reviewed. Specifically, there were fruit flies observed in the administrative area, and the 3rd, 4th, and 6th floors.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure the interdisciplinary team determined a resident's ability to appropriately self-administer medications for one (1) of one (1) resident (Resident #50) reviewed. Specifically, Resident #50 had medications in their room they stated they could self-administer.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure a resident's right to be free from misappropriation of property/funds for two (2) of two (2) residents (Residents #50 and #102) reviewed. Specifically, Activity Aide #5 had possession of Resident #50's money; and Resident #102 had multiple bags of deposit cans redeemable for cash removed from their room and did not receive the deposit money.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for one (1) of nine (9) residents (Resident #50) reviewed. Specifically, the facility did not complete a timely investigation when they were notified a facility staff member was in possession of Resident #50's money (see F 602) and did not report the incident to the New York State Department of Health as required.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025 - 4/18/2025, the facility did not ensure the accuracy of resident assessments reflective of the resident's status during the observation period of the Minimum Data Det assessment for one (1) of three (3) residents (Resident #200) reviewed. Specifically, the most recent Minimum Data Set Resident Assessment inaccurately documented the resident as nonverbal and severely cognitively impaired.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of two (2) residents (Resident #372) reviewed. Specifically, Resident #372 did not have their wheelchair leg rests applied or included in their care plan as recommended by physical therapy. The facility policy Care Planning/Care Conference, issued 8/7/2024 documented the Comprehensive Care Plan should describe the resident's medical, nursing, physical needs and preferences and how the facility would assist in meeting those needs and preferences. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure that services were provided to meet professional standards of quality for five (5) of five (5) resident units (Units 3, 4, 5, 6, and 7) reviewed. Specifically, direct care staff wore electronic earbuds; were scrolling or talking on their personal phones in resident care areas; and were observed in the breakroom for extended periods longer than documented break/mealtimes or at the end of their shifts. Additionally, 12 of 12 residents present at the Resident Council Meeting complained staff did not answer their call bells timely, were rude, and made them feel disrespected.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00374160) surveys conducted 4/6/2025-4/18/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (2) of five (5) residents (Residents #160 and #336) reviewed. Specifically, Residents #160 and #336 were not provided with oral hygiene or hair care.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for two (2) of three (3) residents (Residents #71 and #114) reviewed. Specifically, Resident #71's and #114's physician orders for alternating air mattresses (a specialty mattress providing air flow to relieve pressure) did not include individualized settings and the mattresses were not monitored to ensure appropriate settings for the resident's current weights.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of two (2) Residents (Residents #306 and #740) reviewed. Specifically, Resident #306 had significant weight loss and did not receive fortified cran-apple juice, Magic Cups (fortified frozen dessert) and double portioned entrees as planned; and Resident #740 had significant weight loss and planned preferred food items for weight maintenance were missing from their meal trays. Additionally, Resident #306 was not assisted with eating in a dignified manner. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice for one (1) of one (1) resident (Residents #179) reviewed. Specifically, Resident #179 did not have their prescribed pain patch placed as ordered and the pain patch was signed as administered.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not provide on-going assessment and monitoring of bed rails (side rails) for one (1) of one (1) resident (Resident #41) reviewed. Specifically, Resident #41 had bed rails on both sides of the bed and did not have an order for bed rails, a comprehensive care plan that included the use of bed rails, regular maintenance inspections for entrapment, or regular assessments to ensure the bed rails remained appropriate.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure a resident's total program of care, including medications and treatments, was reviewed by the medical provider for one (1) of one (1) resident (Resident #322) reviewed. Specifically, Resident #322 was readmitted to the facility from the hospital with sliding scale insulin (the amount of insulin administered was based on the blood glucose readings) instructions that were not initiated, the resident's finger sticks (blood glucose readings) were not consistently done as ordered and there was no evidence the provider was aware. Subsequently, the resident was readmitted to the hospital with hyperglycemia (above normal blood glucose levels).

Inspectors wroteBased on observations, record review, and interviews during the recertification surveys conducted 4/6/2025-4/18/2025, the facility did not ensure that residents were free of any significant medication errors for one (1) of one (1) resident (Resident #1098) reviewed. Specifically, Resident #1098 was administered lispro insulin (a fast-acting insulin) and was not provided food.

Inspectors wroteBased on observations, interviews, and record review during the recertification and abbreviated (NY00358079 and NY00376311) surveys conducted 4/6/2025-4/18/2025, the facility did not assist residents in obtaining routine and emergency dental care for two (2) of three (3) residents (Residents #102 and #336) reviewed. Specifically, Resident #336 did not receive their dentures as planned and Resident #102 was not scheduled for an outside dental consult for a tooth extraction as recommended by the in-house dentist.

Inspectors wroteBased on record review, and interviews during the abbreviated survey (NY00351636), the facility failed to protect the resident's right to be free from sexual abuse for one (1) of five (5) residents (Resident #5) reviewed. Specifically, Resident #5, who was not competent to give consent, was sexually assaulted by Resident #4. The facility's failure to protect residents from sexual abuse resulted in harm past non-compliance, that was not Immediate Jeopardy for Resident #5.

Inspectors wroteBased on observation, record review, and interview during the abbreviated survey (NY00325653) the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 4 nursing floors (4th and 5th floors) reviewed. Specifically, there was evidence of cockroaches on the 4th and 5th floors.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00322098 and NY00323044) the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for 2 of 3 residents reviewed (Residents #1 and 2). On 9/11/2023, immediate jeopardy was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety include the provider's failure to provide a safe and orderly discharge for Residents #1 and 2 which had the potential for serious harm for both residents. Residents #1 and 2 were discharged to the Department of Social Services (DSS), which is not a dischargeable location, without a plan for shelter or services; without a discharge plan; without notice, and without following the proper 30-day notice requirements. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00323044, NY00322098) the facility did not ensure that the Office of the State Long Term Care Ombudsman received a written notice of transfer or discharge at least 30 days before the resident was transferred or discharged for 2 of 3 residents reviewed (Residents #1 and 2). Specifically, Residents #1 and 2 were issued facility-initiated discharge notices and the Office of the State Long Term Care Ombudsman were not provided the notifications. Findings incude: The Discharge Planning policy revised 3/2018 did not contain any information related to notification of the Office of the State Long Term Care Ombudsman when residents were discharged . [...]