Baptist Health Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview during survey, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible for five (Resident #s 17, 80, 151, 161, and 162) of 18 residents reviewed for accidents. Specifically, (1) on 08/17/2025, Resident #17 was provided with an alternate meal (egg salad sandwich) upon request, which was not according to the resident's prescribed diet order of puree texture (a cohesive, smooth texture free of lumps and coarse particles that does not require chewing) diet, thin consistency fluids. As a result, Resident #17 sustained a choking occurrence, their skin turned blue, and they required the Heimlich maneuver. [...]

Inspectors wroteBased on record reviews, observations, and interviews conducted during the survey, the facility failed to provide services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, one Certified Nurse Aid was alone on unit H1 during the day shift on 06/09/2026, and one Certified Nurse Aid was left alone on unit H2 during the day shift on 06/11/2026.

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to prepare and serve food in accordance with professional standards for food service safety in the main kitchen and 6 of 6 nourishment stations. Specifically, food was not stored properly; the automatic dishwashing machine was not operating within the manufacturer specifications; the concentration of the chemical sanitizing rinse was less than that required by the manufacturer; and food preparation area equipment, floors, walls, and ceilings required cleaning & repair.

Inspectors wroteBased on observations, record reviews, and interviews during the survey, the facility failed to establish and maintain an infection prevention and control program in accordance with professional standards of practice. Specifically, a) hand hygiene between rooms was not performed; b) sanitary transport of dirty linens and garbage was not performed; c) dressing supplies that were to be used were placed on the floor; d) urinary catheter drainage bags were observed to be resting on the floor.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. Specifically, (a) during a dining observation on 06/08/2026, plastic utensils were provided to residents during the lunch meal. (b) Resident #65's urinary catheter drainage bag was observed to be not covered by a dignity bag. (c) Resident #201's urinary catheter drainage bag was observed to be not covered by a dignity bag.

Inspectors wroteBased on record reviews and interviews conducted during the survey, the facility failed to ensure residents were given the right to be informed in advance, of the risks and benefits of the proposed treatment, and the ability to choose the alternative or option they preferred by the physician or other practitioner for three of five residents reviewed. Specifically, Resident #s 12, 19, and 87, were prescribed psychotropic medications without consent obtained.

Inspectors wroteBased on observation and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on six of 6 resident units and the service areas. Specifically, floors, walls, ceilings, and dining tables were not clean and/or maintained; plumbing was in disrepair.

Inspectors wroteBased on observations, record reviews, and interviews during the survey, the facility failed to ensure drug records were in order. Specifically, narcotic shift to shift count sheets were not completed every shift for two of five narcotic shift to shift count books reviewed. The policy and procedure titled Controlled Substances, dated 12/2021, stated that each narcotic dose is removed from the package to be noted on the control record as follows: date, time, dose, balance of remaining, and name/title. The policy and procedure titled Controlled Medication Storage, effective 08/2025, stated, At the beginning and end of each shift, all controlled substances would be accounted for by having two nurses (one from the present and one from the oncoming shift) count and sign the appropriate accountability records. [...]

Inspectors wroteBased on observations, record reviews, and interviews during the survey, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls. Specifically, treatment carts were left unlocked, a medication (pain-relieving cream) was left unattended on top of a cart, an inhaler was undated and unlabeled, and temperature logs were not completed on two of three medication refrigerators.

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Specifically, (a.) five out of five residents during the resident council meeting on 06/09/2026 stated that the food was cold; (b.) Resident #80 stated that cold food was room temperature and hot food was cold; (c.) Resident #99 stated that sometimes the food was cold; and (d.) for Resident #110, food was not served at an appetizing temperature during a lunch meal on 06/11/2026 and stated that food was cold.

Inspectors wroteDuring observations on 06/12/2026 at 11:35 AM, the facility grounds were overgrown with vegetation as follows:Weeds were growing in the gap between the asphalt and the building foundation. Weeds, grape vines, and tree saplings were growing in the landscape gardening found at the facility entrances and in the resident garden sanctuary courtyard. A large tree sapling was growing over the pad-mounted electrical transformer. During an interview on 06/12/2026 at 12:09 PM, Director of Facilities #1 stated that they would address the landscaping overgrowth. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)Based on observation and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building and grounds were not maintained.

Inspectors wroteBased on interviews and record review conducted during a survey, the facility failed to promptly notify the resident and the resident representative when there was a change in room for one (Resident #138) of two residents reviewed. Specifically, Resident #138 had a room change and the residents' representative was not given prior notice. The facility policy titled Resident Rights effective 10/2017, documented it was the facility's policy to protect the rights of all residents which included, but was not limited to the right to a dignified existence and self-determination. All residents must be supported and promoted, their right to self-determination in order to assist them in achieving their highest, practicable well-being. The resident representative had the right to exercise the resident rights to the extent those rights are delegated to the representative. [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that all alleged violations involving abuse were reported immediately, or no later than two hours after the allegation was made for one out of four incidents reviewed for abuse. Specifically, the facility did not report an incident with the allegation of sexual abuse between Resident #131 and Resident #151 within the two-hour reporting timeframe.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented for residents according to professional standards for three (Resident #'s 12, 15, and 87) of 41 residents reviewed. Specifically, (a.) Resident #87 did not have a care plan for their respiratory diagnosis or use of oxygen; (b.) Resident #15 had a 16.25% weight loss from 10/28/2025-04/15/2026 and there was no care plan for it; (c.) Resident #12 was care planned for super-pubic urinary catheter care including daily dressing changes; it was not implemented in 10/2025 when the dressing was not changed for multiple days.

Inspectors wroteBased on observation, interview, and record review, during the survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary assistance with eating, maintaining personal hygiene, and adequate grooming, for two (Residents #77 and #188) of five residents reviewed. Specifically, Resident #77 was observed unkept with dirty fingernails; Resident # 188 was not offered or provided the opportunity to get out of bed until the surveyor pointed it out to the assigned Certified Nurse Aide at lunchtime, despite the resident being awake and wanting to eat breakfast. The resident was observed on 6/08/2026 throughout the morning to be pleasantly confused, awake, in bed and to have a breakfast tray that remained in the room, until lunchtime when staff replaced it with a lunch tray. [...]

Inspectors wroteBased on record reviews, observations, and interviews conducted during a survey, the facility failed to ensure residents were provided with treatment and care in accordance with professional standards of practice for two of 41 residents reviewed, Residents #12 and #208. Specifically, (a) Resident #208, the bowel protocol was not initiated per physician orders after more than three days of the resident not having a documented bowel movement and (b) Resident #12 had a super-pubic catheter placed with dressing changes ordered daily, the dressing change was not changed over a period of 10 days, and a culture was obtained as ordered labeled with the wrong location causing a delay in care and the resident to be prescribed broad spectrum antibiotics empirically.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure a medication error rate of less than 5 percent. Specifically, medication error rate was observed to be 12.5 percent.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey and abbreviated surveys (NY00281127 and NY00322303) dated 10/16/2023 through 10/24/2023, the facility did not provide effective housekeeping services on five (5) of 5 resident units, the resident common areas, and nurse stations. Specifically, floors were soiled, 3 floor tiles had brown stains; a corridor wall fan was soiled; ceiling tiles were stained or soiled; walls were soiled with splatter marks, drip marks, and dirt; wall surfaces were chipped; a 5-inch diameter section of wall surface was ripped; drill holes were found in the corridor walls; the paint was chipped on the heater register; handrail surfaces were worn; and coving base was missing. This is evidenced as follows: During observations on 10/18/2023 from 11:15 AM through 12:39 PM: [...]

Inspectors wroteBased on observations and interviews during the recertification survey from 10/16/2023 through 10/24/2023, the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards on 3 of 6 medication carts. Specifically, for the Homeward Bound (HB) Unit, the facility did not ensure medications on HB Medication Cart #2 (an opened, unlabeled insulin pen and an expired bottle of bisacodyl) were stored in accordance with facility policy and accepted professional principles, for the H2 unit, the facility did not ensure medications on H2 Medication Carts #1 (an opened, unlabeled insulin pen) and #2 (an opened, unlabeled insulin pen and an unrefrigerated bottle of cephalexin) were stored in accordance with facility policy and accepted professional standards. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 10/16/2023 through 10/24/2023, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for five (5) of 5 resident unit kitchenettes and the main kitchen. Specifically, a can of cherry pie filling with a dent with metal touching metal was found ready for use in the dry storage area speed rack. When checked, the concentration of quaternary ammonium compound (QAC) in use for sanitizing food contact surfaces was found to be 100 parts per million (ppm) when measured at 80 degrees Fahrenheit (F). The following areas in the main kitchen were soiled with food particles, food splatters, and/or grime: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 09/16/2023 through 09/24/2023, the facility did not have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for five (5) of 5 resident units. Specifically, the facility did not have a policy regarding foods brought to residents that included a procedure to ensure all residents had the necessary assistance in accessing and consuming food, did not ensure that family and visitors that bring food to residents were provided with information to understand safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 10/16/2023 to 10/24/2023, the facility did not ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the resident's status. This was evident for 2 (Resident #'s 15 and #102) of 34 residents reviewed. Specifically, the Discharge Tracking MDS was not completed for 2 residents within 7 days. This is evidenced by: The policy and procedure titled MDS Completion and Submission Timeframe's revised 9/2023 documented the following time frames will be observed by the facility, please refer to the RAI (Resident Assessment Instrument- tool used to assess clinical and functional characteristics of resident in long term care setting in order to measure and assess a resident's level of care needs) manual guidelines Chapter 2 time frames. A documented titled Chapter 2: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 10/16/2023 through 10/24/2023, the facility did not dispose of garbage and refuse properly. Specifically, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with paper waste. This is evidenced as follows: During observations on 10/16/2023 at 11:26 AM, the trash compactor access door and portal to the compactor were heavily soiled with a caked-on build-up of black grime, and the grounds around dumpsters were littered with paper waste. During an interview on 10/16/2023 at 11:27 AM, the Director of Facilities stated that the facility was in the process of replacing the door as the warning labels were no longer readable. [...]

Inspectors wroteBased on observation, record review and interview during an abbreviated survey (Case #NY00305238), the facility did not ensure that each resident was treated with respect and dignity for 3 (Resident #s 11, 12, and 16) of 5 residents reviewed. Specifically, during the survey, Resident #s 11, 12, and 16 on the N2 unit reported they were displeased that their meals were frequently served on paper plates or in disposable containers and that they had to use plastic cutlery. This is evidenced by: The Policy and Procedure titled Residents' Rights dated 1/28/2020, documented residents had the right to be treated with respect and dignity. Review of Resident Council Meeting Notes documented the following: [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (Case #NY00305238), the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 1 (Resident #14) of 6 residents reviewed. Specifically, the facility did not ensure Resident #14 on the N2 unit received their AM personal care on 9/21/2023. This is evidenced by: Resident #14: Resident #14 was admitted to the facility with diagnoses of urinary tract infection (UTI), hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebrovascular disease affecting left dominant side, and depression. The Minimum Data Set (MDS - an assessment tool) dated 6/29/2023, documented the resident was cognitively intact. [...]

Inspectors wroteBased on observation and interviews during abbreviated survey (NY00324646) dated 09/26/2023, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen. Specifically, the floor in the main kitchen was soiled with food particles and grime; the main kitchen was soiled with dirt under equipment; the adjoining stockroom was soiled with dirt under the shelving. This is evidenced as follows: During observations on 09/26/2023 at 9:46 AM, the floor in the main kitchen was soiled with food particles, grime, and dirt under equipment in the main kitchen and under the shelving in the adjoining stockroom. The undated document titled associate daily and weekly cleaning schedule listed floors were to be swept and mopped daily. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean on 4 of 5 resident units. This is evidenced as follows. The floors were spot checked on 08/09/2021 at 10:30 AM and again on 08/10/2021 at 9:30 AM, revealing that floors at the base of door frames in resident rooms H170, H175, H177, H255, S307, S308, S313, S335, N2254, and HB3341 were soiled with dirt and a brownish build-up. The Housekeeping Supervisor stated in an interview on 08/09/2021 at 11:30 AM, that the facility will make sure that the floors are cleaned in the resident doorways. The Administrator stated in an interview on 08/10/2021 at 11:21 AM, that the facility will audit the floors in resident rooms to ensure that they are clean. 483.10(i)(2)