Achieve Rehab and Nursing Facility

Inspectors wroteBased on record review and interviews during an abbreviated survey (456441), the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices for 1 out of 3 residents (Resident #2) reviewed for documentation. Specifically, on 13 different dates in December 2024 Resident #2 was due to receive medications at 9:00am and the medication administration audit report indicates that the 9:00am medications were not administered at the scheduled time. The facility medication and administration policy last revised 10/24 documented that the facility staff will provide safe and accurate medication administration to the residents. Medications are administered by licensed nurses, with and in accordance with physician order. [...]

Inspectors wroteBased on record review during an Abbreviated Survey (456441), it was determined that the facility assessment failed to adequately identify and indicate how they maintain the resources necessary to care for its residents. Specifically, the facility assessment failed to adequately identify how the facility addresses contingency planning regarding necessary resources and failed to identify a facility plan to maximize recruitment and retention of direct care staff. The facility's assessment dated [DATE], reviewed by Quality Assurance and Performance Improvement Committee on 09/04/2025 is the most recent assessment conducted by the facility, it is the facility assessment that was reviewed as part of the Abbreviated Survey noted above, and which for these findings will be known as the facility assessment. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00333655), the facility did not ensure resident received treatment and care consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for skin conditions. Specifically, Resident #1 left leg wound care notes from 3/10/2023 to 4/14/2023 revealed the resident's right heel plantar aspect wound increased in size, and the left heel plantar aspect wound was 95% necrotic (dead tissue). Review of the Treatment Administration Record documented omissions from 3/2/2023 to 4/22/2023. Consequently, the resident was transferred to the hospital on 4/26/2023 for evaluation worsened of left heel, macerated and bleeding and right heel maceration.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY 00322762) surveys conducted 10/16/24 to 10/23/24, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, and nursing, needs for 1 of 3 residents (Resident #84) reviewed for hospitalizations, 2 of 2 residents (Residents #122 and #72) reviewed for urinary tract infections, 2 of 3 resident (Residents #179 and #98) reviewed for respiratory care, and 1 of 6 residents (Residents #281) reviewed for accidents. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY 00326169, NY 00341314, and NY 00322762) from 10/16/24 to 10/23/24, the facility failed to ensure the residents' environment remained as free of accidents hazards as possible for 3 (Residents #280, #281 and #92) of 6 residents reviewed for accidents. Specifically, 1. Resident #280 was assessed at high risk for falls, care plan interventions were not in place and Resident #280 had an unwitnessed fall and required hospitalization for two lacerations to the face and a subdural hematoma (brain bleed). The facility did not thoroughly investigate to determine if interventions were adequate, and if the plan of care was followed. 2. Resident #281 was eating dinner, became unresponsive, required cardiopulmonary resuscitation and was sent to the Emergency Department. [...]

Inspectors wroteBased on record reviews and interviews during the recertification and abbreviated (351312) surveys from 10/16/24 to 10/23/24, the facility did not ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months. Specifically, performance appraisals were not documented every 12 months for 4 of 5 Certified Nurse Aides (Certified Nurse Aides #1, #2, #3, #4) records reviewed.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 10/16/24 to 10/23/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice. Specifically, there was food stored in the walk-in refrigerator and dry storage room that was undated and past the expiration date.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00351312) surveys from 10/16/24 to 10/23/24, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, 1) the facility did not properly implement transmission-based precautions for 3 of 3 residents reviewed for infection control precautions (Residents #84, #117, #120) and 2) the facility did not ensure that an infection surveillance plan was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks for 3 of 5 residents reviewed for infection control (Residents #122, #72, #120).

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification and abbreviated (NY00351312) surveys from 10/16/24 to 10/23/24 the facility did not maintain an effective pest control program so that the facility was free of pests. Specifically, Resident #70's room had glue traps for insects and rodents, with gnats and cockroaches observed inside the trap.

Inspectors wroteBased on observation, interview and record review conducted during recertification and abbreviated (NY 00351312) surveys from 10/16/24 to 10/23/24, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for 1 (Resident #14) of 1 resident reviewed for personal funds. Specifically, the facility did not ensure residents had access to their personal funds on weekends.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 10/16/2024 to 10/23/2024 the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for 1 (Resident #179) of 3 residents reviewed for Medication Administration. Specifically, Resident #179 was found with physician ordered Ipratropium-Albuterol inhaler, Sodium Chloride nasal solution and Flonase allergy relief nasal spray in their room on their bedside table.

Inspectors wroteBased on observation and interview during the Recertification Survey from 10/16/24 to 10/23/24, the facility did not ensure that food on trays was held at palatable temperatures for 1 of 2 residents (Resident #70) reviewed for Food. Specifically, for Resident #70 food was not served at palatable temperatures.

Inspectors wroteBased on record review, and interview conducted during the recertification and abbreviated surveys (NY 00326169) from 10/16/24 to 10/23/24, the facility did not ensure that the Minimum Data Set assessments accurately reflected the residents' status at the time of the assessments for 1 (Resident #280) of 35 sampled residents. Specifically, the Minimum Data Set assessment inaccurately documented that Resident #280 who had a care plan for bed and chair alarms, was assessed to have no alarms.

Inspectors wroteBased on record review and interview during a recertification survey and abbreviated survey (NY 00322762), the facility did not ensure staff were provided with education on activities that constitute abuse, neglect, exploitation, dementia management and misappropriation of resident property for 1 of 6 staff members reviewed (Certified Nurse Aide #13) for education. Specifically, the facility was unable to provide documented evidence Certified Nurse Aide #13 received any education.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00316474), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for one of three residents (Resident #1) reviewed for accidents. Specifically, Resident #1 who had a diagnosis of dementia history of wandering and elopement exited the facility through the front door on 05/11/2023 independently undetected by staff. Resident #1 was care planned to have wander guard, but the resident had no wander guard on. Resident #1 obtained access as the receptionist was letting a visitor out the front door. Resident #1 wandered out the front door of the facility and walked along side fence and was observed by Recreation Aide (RA#1) who escorted them back into the building unharmed.

Inspectors wroteBased on observation, staff interviews and record review during a Recertification Survey and Abbreviated Survey (#272489 and #290316) conducted from 9/19/22 to 9/27/22, the facility did not ensure that residents received a safe and/or appropriate discharge. This was evident for 2 out of 2 residents reviewed (Resident #228 and #226) for discharge. Specifically, 1. the facility did not ensure Resident #228 had a safe discharge plan prior to being discharged to the community and 2. the facility did not complete the Patient Review Instrument (PRI) for Resident #226 in a timely manner for transfer to another facility.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey conducted between 9/19/22-9/27/22, the facility did not ensure that the Comprehensive Care Plan was revised for 2 of 2 residents (Resident #98 and Resident #121) Specifically, 1. The Contracture Care Plan for Resident #98 was not revised to reflect the physician prescribed use of bilateral hand rolls and bilateral knee splints and 2. The Advanced Directive Care Plan for Resident #121 was not revised to reflect the change from Full Code to Do not Resuscitate, Do Not Intubate and Comfort Measures Only.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey conducted 9/19/22- 9/27/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two of two residents (Resident #55 and #98) reviewed for Quality of Care. Specifically, 1. Resident #55 did not receive twice a week Unna boot changes to treat venous stasis of the lower extremity as ordered by the physician. Additionally, 2. (Resident #98) the use of hand rolls and knee splints were not consistently utilized as per physician orders.

Inspectors wroteBased on interviews, observations, and record review conducted during a Recertification Survey from 9/19/22 to 9/27/22, the facility did not ensure that care and treatment were provided to ensure prevention of pressure ulcers for 1 of 4 residents (Resident#98) reviewed for Pressure Ulcers. Specifically, for Resident #98, heel lift boots wre not applied as per physicians orders. The Findings Are: Resident #98 had diagnosis including but not limited to Non-Pressure Chronic Ulcer of Left Ankle with Spastic Quadriplegic Cerebral Palsy and Contracture of Muscle-Multiple Sites. Review of the Annual Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition, no behaviors noted total assistance of one-two staff for bed mobility, transfer, eating and toileting, and was at risk for development of pressure ulcers but had no pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed 9/27/22, the facility did not ensure they maintained an effective pest control program to ensure the facility was free of pests. Specifically, there were multiple observations of gnats flying around the hallway and resident rooms on unit 2 East.

Inspectors wroteBased on record review and interview the facility did not ensure that resident representatives were notified in writing of transfers from the facility to the hospital. This was evident for 5 of 5 residents reviewed for hospitalization. (Residents # 73, 19, 105, 120 and 23).

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that 1) a care plan with measurable objectives, time frames, and appropriate interventions was initiated for 1 resident reviewed for positioning and mobility (Resident #72) and 2) interventions for the care of an indwelling catheter were included in the plan of care for 1 of 4 residents (Resident #72) reviewed for hospitalization.

Inspectors wroteBased on record review and interview the facility did not ensure that a care plan that addressed care needs related to infections had been reviewed and revised to include a recent hospitalization for pneumonia. This was evident for 1 of 4 residents reviewed for hospitalization (Resident #19).

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident (Resident #120) reviewed for hospitalization was provided the necessary care to promptly address ongoing poor fluid intake to prevent dehydration. Specifically, the resident's fluid intake and output were significantly low for approximately five weeks (2/9/19 to 3/14/19) with no timely measures in place to prevent dehydration and/or electrolyte imbalance.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey the facility did not ensure that treatments and services to prevent further decrease in range of motion and/or contractures was provided for 1 resident (Resident #72) reviewed for position/mobility. Specifically, passive range of motion was not being performed for a resident with impaired mobility.

Inspectors wroteBased on record review and interview the facility did not ensure that the consultant pharmacist's recommendations were acted upon by the resident's primary care physician. This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #100).