Dunkirk Rehabilitation & Nursing Center

Inspectors wroteBased on observations, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for one (1) (Resident #9) of two (2) residents reviewed for accidents. Specifically, Resident #9's wheelchair left pedal was in disrepair and missing the leg rest, exposing a sharp edge at the hinge point. The sharp edge was noted at times pressing against the residents left lower leg. The finding is: The policy titled Assistive Devices and Equipment dated 2/2025 documented the facility maintained and supervised the use of assistive devices and equipment for residents. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00312696) during the Standard survey completed on 12/1/23, the facility did not ensure residents had the right to be free from physical abuse for one (Resident # 31) of three residents reviewed for abuse. Specifically, the facility did not ensure Resident #31 was free from physical abuse when Resident #12 punched them resulting in a hematoma (collection of blood under the skin) above their eye. The residents had a history of physical altercations. The finding is: The policy and procedure titled Abuse-Investigation, Protection, and Reporting dated 10/24/22, documented resident to resident physical altercations must be reported and include any willful action that results in injury. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/1/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Resident #32) of two residents reviewed. Specifically, there was lack of glove changes and hand hygiene after providing bowel incontinence care and applying a clean brief. Additionally, the Certified Nurse Assistant (CNA) touched objects (resident's bed linen, and heel booties) while wearing the same gloves used to provide incontinence care. The finding is: The policy and procedure titled Personal Protective Equipment dated 7/2021 documented gloves should be changed after providing incontinent care and before putting on clean briefs and to wash hands after removing gloves. 1. [...]

Inspectors wroteBased on record review and interviews conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had Full Code status for one (Resident #86) of three residents reviewed. Specifically, on [DATE] Resident #86 was found unresponsive by Certified Nurse Aide (CNA #1) at approximately 4:30 AM. At that time, CNA #1 notified Licensed Practical Nurse (LPN #1). LPN #1 observed Resident #86, who was unresponsive without a pulse, respirations, or blood pressure and had bubbling excretions from their mouth. LPN #1 failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 (EMS) system, and failed to provide CPR efforts for a resident who was a full code. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Specifically, reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on multiple dates December 4, 2021 through March 6, 2022, and an RN was not designated as DON from 12/30/21 through 3/7/22.

Inspectors wroteBased on interview and record review conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure a Registered Nurse (RN) was scheduled eight consecutive hours per 24-hour period as required and did not designate a full time Director of Nursing (DON) when the DON was off for an extended period. In addition, the Administrator did not ensure there was an effective system in place when there was no RN coverage in the building to respond to an emergency in accordance with facility policy and protocols.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not inform the resident's representative of a change in physical status and a transfer to the hospital for one (Resident #34) of one resident reviewed for notification of change. Specifically, the resident's representative was not notified when Resident #34 tested positive for COVID -19 on 12/31/22 and was subsequently transferred to the hospital on 1/6/22.

Inspectors wroteBased on observation, interview and record review conducted during an Extended Standard survey completed on 3/11/22, the facility did not ensure each resident was free from exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) for one (Resident #18) of two residents reviewed. Specifically, Certified Nurse Aide (CNA) #4 requested and accepted money from Resident #18 to provide the resident with sexually explicit photos. The finding is: The facility policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting dated 6/2021 documented all accidents and incidents occurring within and related to the facility will be investigated. The investigation should rule out or confirm abuse, exploitation or neglect. [...]

Inspectors wroteBased on observation, interview and record review conducted during an extended standard survey completed on 3/11/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #18) of two residents reviewed. [...]