Franklin Center for Rehabilitation and Nursing

Based on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in Resident #1's mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. Certified Nursing Assistant #1 who was present stated Resident #1 was refusing their medication.The findings are:The facility's Policy titled Abuse, Neglect, Mistreatment and Exploitation Prohibition dated 03/16/2026, documented that the facility shall not use or permit verbal, mental, sexual or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, or other mistreatment or neglect. This can be directly or…

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 interviews conducted during a survey, the facility failed to ensure that allegations of abuse were investigated thoroughly and that residents were protected from further abuse during the investigation. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026 at approximately 11:25 PM, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in their mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. The facility failed to thoroughly investigate the allegation of abuse and remove Licensed Practical Nurse #1 from direct care and access to residents after Certified Nursing Assistant #1 reported the allegations to Registered Nurse Supervisor #1. The findings include:The facility's Policy titled Abuse, Neglect, Mistreatment, and Exploitation…

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 interviews conducted during a survey, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one (1) out of two (2) residents (Resident #1) sampled for fall. Specifically, Resident #1 who has acquired bilateral below knees amputation was observed on the floor in their room on 05/01/2026. Certified Nursing Assistant #1 went into the room picked up Resident #1 and placed them back into the bed before Resident #1 was assessed by Registered Nurse Supervisor #1. On assessment Resident #1 was observed with a small scratch on their lower lip.The findings are:The facility's Policy title Resident Occurrences, dated 03/07/2023, documented all resident occurrences must be reported and investigated. Plans of correction will be developed in an attempt to prevent re-occurrence and unsafe conditions. Unusual and/or serious events will be brought to the attention of administration, in addition to following the routine procedure. Root Cause Analyses will be conducted by an…

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 survey from 02/21/2024 to 02/28/2024, the facility did not ensure that a resident and/or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. This was evident for 3 residents (Resident #31, #142, and #165) reviewed for Care Planning out of 38 total sampled residents. Specifically, 1) Resident #31 and/or their designated representative were not invited to their care plan meeting, 2) Resident #142 and/or their designated representative were not invited to their care plan meeting, and 3) Resident # 165 was not invited to their care plan meeting. The findings are: The facility policy and Procedure titled Care Planning - Conferences with approval date 04/17/2021 documented the resident had the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process. It also documented the Comprehensive…

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 Survey from 02/21/2024 to 02/28/2024, the facility did not ensure that residents were provided a safe and homelike environment and that residents received care and services safely and does not pose a safety risk. This was evident for 1 (Resident #5) of 3 residents investigated for Respiratory care out of an investigative sample of 38 residents. Specifically, on 02/22/2024, a Maintenance staff was observed cleaning the air conditioning unit while Resident #5 was in bed sleeping in their room. The findings are: The facility's policy titled Entry of Engineers and Repair Workers dated 03/03/2023 stated that before entering a resident's room, engineers and repair workers must first check in with the nurse on duty in that unit. They should provide details about the nature of the work, estimated duration, and any potential disturbances. The purpose is to ensure the safety, privacy, and dignity of our residents when engineers and repair workers…

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 (NY00330116) Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that all alleged violations involving abuse and injuries of unknown source were reported immediately but not later than 2 hours after the allegation was made to the New York State Department of Health. This was evident for 3 (Resident #655, #203, and #97) of 38 total sampled residents. Specifically, 1) On 02/12/2024, Resident #655 sustained a laceration to their right eyebrow. The injury was not witnessed, and the source of injury could not be explained by the Resident. The injury was not reported to the New York State Department of Health, and 2) On 12/18/2023 at approximately 5:45 AM, Residents #203 and #97 were involved in a resident-to-resident altercation. The alleged incident was not reported to the New York State Department of Health within 2 hours after the allegation was made. The findings are: The facility policy titled Abuse,…

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 Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that the Minimum Data Set assessments accurately reflected the residents' status. This was evident for 2 (Resident #181 and Resident#25) of 2 residents sampled for catheter care, out of 38 sampled residents. Specifically, Resident #181's Foley catheter was not documented, and Resident #25 's use of suprapubic catheter was documented as an ostomy, instead of indwelling catheter. The findings are: The facility's policy titled Minimum Data Set Assessment and Completion with an approval date of 02/01/2022 documented that the Minimum Data Set 3.0 manual is to be utilized by all disciplines participating in the completion of the Resident Assessment Instrument and that each individual completing a portion of the assessment, signs and certifies the accuracy of that portion of the assessment. Resident #181 was admitted to the facility with diagnoses of Stroke and Cardiac Arrest.…

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 observations, interviews and record review conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure a person-centered comprehensive care plan was developed and implemented to meet residents' preferences. This was evident for 1 (Resident #116) of 38 total sampled residents. Specifically, a Comprehensive Care Plan was not developed to address Resident #116's preference not to use a urinary catheter privacy bag. The findings are: The facility policy titled Care Planning-Conferences with an approval date of 04/17/2021 stated that the facility will develop and implement a comprehensive person-centered care plan for each resident. The policy stated that the comprehensive care plan must be prepared by an interdisciplinary team and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Resident #116 had diagnosis of Obstructive Uropathy, Benign Prostatic Hyperplasia, and Bipolar Disorder. The…

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 a Recertification and Complaint survey (NY00295349) from 02/21/2024 to 02/28/2024, the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for 1 (Resident #163) of 5 residents investigated for Accidents out of an investigative sample of 38 residents. Specifically, on 05/02/2022 at 7:45 PM, Resident #163 identified as at high risk for elopement, was able to exit the facility undetected through the fire exit gate on the main floor. Resident #163 was located by the New York City Police Department on 05/04/2022 at an apartment building that Resident claimed they previously lived. The findings are: The facility's policy and procedure titled Missing Persons with a review date of 05/06/2022 documented that it is the policy of the facility to ensure that conditions for security of residents and the building and the prevention of a resident from becoming a missing person is maintained at all times through…

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 conducted during Recertification survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, the most recent MDS did not accurately indicate tube feeding. This was evident for 1 out of 35 sampled residents reviewed (Resident # 34). The finding is: The facility's policy and procedure titled MDS Assessment and Completion dated 12/01/2020 states that the assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff in identifying health problems and care plan development. The policy further states that the assessment must reflect the resident's status, including the resident's strengths and needs, which must be addressed in an individualized care plan. Resident # 34 was admitted to the facility on [DATE] with diagnoses that include Hypertension, Cerebral infarction,…

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, observations, and staff interviews during the recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, (1) a resident was not provided with assistive device - right ankle orthosis and not ambulated as per discharge instructions from the rehabilitation department (2) a resident was not provided with the hand roll device as per plan of care to improve resident's contractures. This was evident for 2 out of 2 residents reviewed for Rehab and Limited ROM, (residents #41 and #106) out of total sample of 35 residents sampled. The findings are: The facility's Policy for Rehabilitation: Contractures-Range of Motion dated 04/04/2012 documented that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in…

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 and interviews conducted during the Post Survey Revisit, the facility did not ensure that drugs and biologicals used in the facility were dated when opened and discarded in appropriate time frames after opening. Specifically, (1). Two vials of Latanoprost Ophthalmic solution were observed opened and not dated to be discarded 42 days after opening, (2). Three insulin pens were not disposed of by the discard date, (3). Nursing staff were unclear about management of multi-dose vials specifically, what should be dated and when medications should be discarded. This was evident on 7 of 8 units. (Unit 1, 2, 3, 4, 5, 7 and 8) The findings are: The facility policy titled Multi-Dose Vials dated 8/10/19 documented multi dose vials for Purified Protein Derivative (PPD), Lantus Insulin and Humalog Insulin vials will be dated once opened and discarded 28 days after opening. The policy also documented all other multi-dose vials (e.g. Influenza, Insulin, Pneumovax, etc.) may be used up to the listed…

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 and staff interviews during recertification survey, the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods were not maintained at the proper temperature (at or below 41 degrees Fahrenheit), and equipment was not properly sanitized during cleaning. This was evident for the Kitchen Observation facility task. The findings are: 1). The facility's policy and procedure titled New [NAME] Food Service/Dietary Department Making Sandwiches, effective 01/2018, documented that all cold sandwiches should be prepared on ice, labeled, dated, and refrigerated immediately. The policy and procedure titled Food Service/Dietary Department Storage of Cold Food dated 01/2018 documented: The facility will hold cold food as per the parameters specified by ServSafe. Cold food will be held at 41 degrees or lower before removing from refrigeration, and the food will be discarded immediately if the…

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.