University Center for Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: Resident #3 had diagnoses upon admission that included Non-Alzheimer's Dementia, Deep venous thrombosis (DVT), and bipolar disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented that the resident's cognitive status was severely impaired. The Minimum Data Set assessment did not document that the resident was use of continuous oxygen at the time of assessment. The Physician's order, dated 11/12/2025 and renewed 03/01/2026, documented the following: Oxygen via nasal cannula at two (2) liters per minute. Monitor oxygen every shift. Nursing Quarterly Care Plan Note, dated 01/28/2026,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility's policy titled, Oxygen Therapy Administration, last reviewed 09/17/2025, documented to initiate flow of oxygen following manufacturer instructions for use, based on the type of device, and at the prescribed flow rate. The facility's Oxygen Therapy Administration policy did not include how oxygen therapy is to be monitored. Resident #3 had diagnoses upon admission that included Non-Alzheimer's Dementia, Deep venous thrombosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: Resident #50 was admitted to the facility with diagnoses that included non-Alzheimer's dementia, depression, heart failure, and diabetes mellitus. The Minimum Data Set assessment dated [DATE] documented Resident #50 had impaired cognition. The Minimum Data Set assessment also documented that the resident requires partial/moderate assistance for upper body dressing, personal hygiene and was dependent on lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility policy titled Tray Assembly Identification and Service Policy that was last reviewed in January 2024 documented tickets are used to identify correct items for resident diet and are placed at resident place setting or on tray. Food service staff will check trays for correct diets and consistencies before the food carts are transported to their designated areas. The licensed nurse will confirm individual name and diet on the tray card/ticket to verify that the meal is served to the correct person,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: A facility policy and procedure titled Food Storage which was last revised on 4/1/2024 stated that food will be stored in an area that is clean, dry and free from contaminants. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Food should be dated as it is placed on the shelves if required by state regulation. As for refrigerated food storage and frozen foods, all foods should be covered, labeled and dated. All foods will be checked to assure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: The facility policy titled Survey Results which was last revised on 12/2023 documented that a copy of at least 3 years recent standard survey, including any subsequent extended surveys, follow-up revisit reports, along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: The facility's policy and procedure titled Garbage and Rubbish with a last review date of 02/2024 documented all garbage and rubbish containing food wastes shall be kept in containers. All garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. On 5/1/2024 at 10:45 AM, an observation of the garbage dumpster area was made. There were 5 large green trash containers that were uncovered and 1 dumpster noted with exposed white trash bags. There were flies in the entrance way leading to the garbage area and above the open dumpster. On 05/01/24 at 10:45 AM, an interview was conducted with the Maintenance Director. They stated they have a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Specifically, The findings are: The facility policy titled Abuse dated 2/2022 documented notify the appropriate stat agency immediately (no later than 2 hours after allegation. Resident #89 had diagnoses of left distal radius fracture and dementia. The Minimum Data Set 3.0 dated 3/18/22 documented Resident #89 had moderately impaired cognition and required limited assistance with Activities of Daily Living. The Accident/Incident Report dated 3/23/22 documented Resident #89 was found with right hip pain on while lying in bed on 3/23/22 at 1:30 AM. X-rays were ordered, and Resident #89 was found with acute right femoral neck fracture. There were no signs of trauma and no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility policy related to Comprehensive Person-Centered Care Plans last revised 02/2022 documented a CCPs are revised as information about the resident condition changes. The Interdisciplinary Team (IDT) reviews, revise, and updates the care plan at least a quarter with each quarterly MDS. Resident #36 had diagnoses of major depressive disorder and cerebral infarction. The MDS assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: The facility policy titled Discharge - Transfer/discharge date d 02/2022 documented for discharge to the community or lateral transfer to alternate skilled nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility policy titled Discharge - Transfer/discharge date d 2/2022 documented the social worker (SW), the Interdisciplinary Care Plan (IDCP) team, and Medical Doctor (MD) will coordinate all necessary medical physical mental and psychosocial services to ensure resident has a safe transition. Resident #189 was admitted to the facility with diagnoses of right knee replacement and hypertension. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #189…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: The facility policy titled Pharmacy Consultant (PC) Medication Review dated 2/2022 documented the unit manager/designee will make sure all recommendations are acted upon and documented in the resident chart. Resident #19 was diagnosed with diabetes mellitus (DM) and bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.