Absolut Center for Nursing and Rehabilitation at G

Inspectors wroteBased on interviews and record reviews during a survey the facility failed to ensure the Director of Nursing served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, both the Director of Nursing #1 and the Director of Nursing #2 worked as a charge nurse when the facility had a daily average census of greater than 60.

Inspectors wroteBased on observations, interviews and record review conducted during a survey, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three (3) (Heritage unit (C/D), Main Dining Room, and Woodland Heights unit (A/B)) of three (3) test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable, and were not attractive looking. Residents #1, #2, #3, #7, #11, #21, #42, #56, #61, and #85 were involved.

Inspectors wroteBased on record review and interviews conducted during the survey, the facility failed to ensure a Pre-admission Screening and Resident Review (PASSAR), Level I identification screen, was completed prior to admission for two (2) (Residents #5 and #32) of two (2) residents reviewed. Specifically, there was no evidence that the screen was completed prior to admission for Residents #5 and #32.

Inspectors wroteBased on observation, interview, and record review conducted during survey the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #3) of two residents reviewed. Specifically, Resident #3's air/foam mattress pressure pump was disconnected from pump, and the pump was unplugged preventing air flow use with mattress.

Inspectors wroteBased on observation, interview and record review conducted during the survey, the facility failed to ensure they established and maintained 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 one (1) (Resident #2 ) of four (4) residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and one (1) of one (1) facility legionella program. Specifically, staff did not wear appropriate personal protective equipment during wound care for Resident #2 and the facility's Legionella Water Management Plan was not reviewed or revised annually.

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, Resident #1 who had severe cognitive impairment, a history of elopement, exit seeking and wandering behaviors, exited the facility through the delayed egress (security device that's restricts exit by sounding an alarm and delays a door from opening for 15-30 seconds) equipped front door on 06/19/2025 at 9:41 PM without staff's knowledge. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety.

Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey completed on 7/19/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases/infections or implement a system of surveillance designed to identify possible communicable diseases/infection before they can spread to other persons in the facility for three (Residents #3,22, and 37) of six residents reviewed. Specifically, the issues involved; staff did not wear a gown during peripherally inserted central catheter (a catheter that is inserted through a vein and advanced until the tip enters the central venous system) care; [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00319528) during the Standard survey completed on 7/19/24, the facility did not ensure that all alleged violations of abuse and neglect were thoroughly investigated for one (Resident #36) of five residents reviewed. Specifically, there was a lack of employee interviews and statements to rule out abuse regarding an injury of bruising below the resident's right eye. The finding is: The facility policy and procedure titled, Facility Incident/Abuse Investigation and Reporting, with a revision date of 6/7/23, documented the facility will conduct an immediate and thorough investigation, upon discovery of an incident including injury of unknown source. An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; [...]

Inspectors wroteBased on interview, observation, and record review conducted during a Complaint investigation (#NY00322578) conducted during a Standard survey, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #38) of two residents reviewed for accidents. Specifically, Resident #38 who was a risk for elopement, eloped from the facility without staff knowledge and was outside of the facility for 20 minutes. The finding is: The policy and procedure titled Risk of Elopement dated 1/26/22 documented that a safe environment is provided for patients/residents who are at risk to wander. The policy and procedure titled Loss of Resident/Missing Resident dated 11/09 documented that all staff will be able to follow an organized plan to enable us to locate a missing resident as quickly as possible. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 7/19/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #37) of one resident reviewed. Specifically, there was lack of voiding trial (removal of a urinary catheter to see if someone can pass urine normally) when the resident was readmitted to the facility from the hospital with a foley catheter and the lack of a urology (part of health care that focuses on diseases of the urinary system) consult. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 7/19/24, the facility did not ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #65) of one resident reviewed. Specifically, Resident #65 received Augmentin (antibiotic, Amoxicillin-Potassium Clavulanate 875-125 milligram) for osteomyelitis (bone infection) since 7/25/23 and there was no ongoing monitoring by the Antibiotic Stewardship Program including communication, tracking of its use, appropriate indications for continued use, or follow up appointment with the Infectious Disease Physician as recommended. The finding is: [...]

Inspectors wroteBased on interview and record review during a Standard survey started 9/28/22 and completed 10/4/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, one (Resident #39) of one resident reviewed for allegation of physical abuse was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy titled Abuse Reporting and Facility Incident Reporting revised date 4/1/21 documented any alleged violations involving mistreatment or abuse will be reported to the appropriate involved parties and state agencies. The facility administrator, or designee, notifies the State Licensing and Certification Agency when there is an allegation that a resident has been abused. [...]

Inspectors wroteBased on record review and interviews conducted during the Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Specifically, three (Residents #18, 25, and 49) of four residents reviewed for discharge planning lacked a referral to the local contact agency when a desire to return to the community was expressed. In addition, the facility did not develop a care plan that included the resident's discharge planning needs to address their desire to return to the community (Resident #25).

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #10) of three residents reviewed for antipsychotic medication use. Specifically, there was a lack of a GDR for a resident receiving antipsychotic medication and a lack of supporting documentation for the continued use of the antipsychotic. The finding is: The facility policy and procedure (P&P) titled Psychotropic Med Use Initiation and Gradual Dose Reduction dated 3/1/2020 documented that each resident is evaluated for the continued need of psychotropic medications and the determination of whether they are being maintained on the lowest effective dose. [...]