Ghent Health and Rehabilitation

Inspectors wroteBased on observations, resident and staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a clean and homelike environment for residents across four of the facility's four units, which constituted substandard quality of care (SQC).

Inspectors wroteBased on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide COVID-19 vaccinations to residents 2025 and failed to maintain COVID-19 staff vaccination status.

Inspectors wroteBased on resident and staff interviews, the facility staff failed to respect residents' personal clothing and to ensure items were returned after laundering for 3 of 80 residents (Residents #20, #107, and #58) in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide ADL care for six dependent residents (Resident #9, Resident #106, Resident #109, Resident #12, Resident #35, and Resident #169) in a survey sample of 80 residents. The finings include:1. The facility staff failed to ensure Activity of Daily Living (ADL) care and incontinent care was carried out appropriately. Resident #106 was originally admitted to the facility 5/12/25 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Urinary Tract Infection. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. [...]

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to monitor fluid intake for one of 80 residents, Resident #137 (R137).

Inspectors wroteBased on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 80 residents in the survey sample, Resident #53 (R53).

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to provide leadership and oversight to ensure effective systems were in place to assure the quality of life for the residents in the area of Safe/Clean/Comfortable/ Homelike Environment.

Inspectors wroteBased on staff interviews and review of facility documents, the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective systems were in place to assure the quality of life for the residents in the area of Safe/Clean/Comfortable/ Homelike Environment.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies if the area of Safe/Clean/Comfortable/Homelike Environment.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to follow infection control practices, increasing the chances of infection, illnesses, and diseases, and the facility staff failed to follow enhanced barrier precautions (EBP) during an observation of wound care on 2/4/26 having the potential to infect others in the facility and specific to 1 of 80 residents (Resident #129) in the survey sample.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, it was determined that the facility staff failed to maintain a safe, functional, and comfortable environment in the facility's shower rooms.

Inspectors wroteBased on resident/staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to maintain an effective pest control program so that the facility is free of pests and rodents.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a call bell accessible from the floor in the bathroom for one of 80 residents in the survey sample, Resident #6.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide reasonable access to private use of the telephone to one of 80 residents in the survey sample, Resident #84.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility's staff failed to ensure the resident was allowed privacy while talking on the facility telephone located at the nurses' station for one (1) of 80 residents (Resident #82), in the survey sample.

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to resolve grievances for one of 80 residents in the survey sample, Resident #125 (R125).

Inspectors wroteBased on resident and staff interviews, a review of the clinical record, and facility documents, the facility staff failed to protect the residents' right to be free from verbal and physical abuse for 1 of 80 residents (Resident #3) in the survey sample.

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to investigate an allegation of abuse for one of 80 residents in the survey sample, Resident #170 (R170).

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for two of 80 residents, Resident #173 and Resident #137.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a surgical wound for 1 of 80 residents, Resident #173.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications while utilizing an indwelling catheter for 1 of 80 residents (Resident #106), in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for a urostomy consistent with professional standards of practice for one of 80 residents in the survey sample, Resident #125.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services to implement a complete pain management program for 1 of 80 residents, Resident #173.

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to obtain an assessment and consent for the use of bed rails for one of 80 residents in the survey sample, Resident #125 (R125).

Inspectors wroteBased on observation and a review of facility menus, the facility staff failed to serve portions of food planned on the facility's menu for 1 of 80 residents (Resident #109) in the survey sample.

Inspectors wroteBased on observations, resident/staff interview, and facility document review, it was determined that the facility staff failed to provide snacks to residents who want to eat at non-traditional times for three of 80 residents, Resident #12 (R12), Resident #14 (R14) and Resident #137 (R137).

Inspectors wroteBased on staff interviews and a review of the clinical record, the facility staff failed to have a hospice-coordinated plan of care for 1 of 80 residents (Resident #155) in the survey sample.

Inspectors wroteBased on staff interview, clinical record review, facility document review, the facility staff failed to conduct bed and bed rails inspections for one of 80 residents in the survey sample, Resident #125 (R125).

Inspectors wroteBased on observation, resident interviews and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 2 of 6 residents (Resident #1 and Resident #2), in the survey sample.

Inspectors wroteBased on observation and staff interviews the facility staff failed to maintain a comfortable environment for residents, staff, and the public.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a Do Not Resuscitate resident wishes were in place for 1 of 6 residents (Resident #6), in the survey sample.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to protect residents from abuse resulting in harm for two residents of five residents (Resident (R) 191, and R89) reviewed for abuse in a total sample of 65 residents. Specifically, physical altercations resulted in R89 requiring an evaluation at the hospital for treatment of open wounds and R191 requiring hospital evaluation and sutures.

Inspectors wroteBased on observation, interview, and review of policies, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to ensure community spaces, shared shower rooms, and sinks were in good repair. These failures had the potential to affect all 195 residents residing in the facility.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to maintain an effective pest control program to ensure the building remained free of pests, specifically the facility failed to follow recommendations from the pest control company. This failure had the potential to affect all 195 residents living in the facility.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to provide ensure a homelike environment for three (Resident (R) 75, R188, and R196) residents and failed to provide housekeeping services to ensure shared resident bathrooms were clean and in good repair on two of four units.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure four residents out of 65 sampled residents (Resident (R) 147, R188, R254, and R253) had baseline care plans developed. This had the potential for staff not to be aware of the associated care needs of the residents who were newly admitted .

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to revise the comprehensive care plan related to restorative services for one resident of three (Resident (R)13) reviewed for rehabilitation and restorative services; and related to falls/safety for two residents of five (R34 and R197) reviewed for accidents/falls in a total sample of 65 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that two residents of three residents (Resident (R) 109 and R81) reviewed for limited range of motion (ROM), received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion; and that one resident of three residents (R85) reviewed for rehabilitation restorative care received services to maintain or improve mobility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff maintained appropriate infection control measures for the safe handling, cleaning, and storage of respiratory equipment for four residents of five residents (Resident (R)13, R44, R90 and R189) reviewed for respiratory care in a total sample of 65 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly label and initial three multi-vial medications from two of the four medication storage rooms located on the first and second floor. Additionally, the facility failed to monitor refrigerator temperatures daily for two of the facility's five medication refrigerators on the first and second floor. This had the potential to affect any resident who may receive medication which has been stored in these medication refrigerators.

Inspectors wroteBased on observation, interview, review of facility policies and review of Center for Disease Control (CDC) guidance, the facility failed to: ensure all staff don (put on) proper personal protective equipment (PPE) prior to providing care and encountering R253 who potentially was exposed to COVID-19 while in the hospital; store and label resident personal items in shared restrooms in a manner to prevent cross-contamination; maintain infection control practices in the laundry area of the facility; and failed ensure staff members wore face masks appropriately to prevent the spread of COVID-19.

Inspectors wroteBased on observation and interview the facility failed to ensure equipment located in the laundry services areas were in safe operating condition, specifically washing machine filters were not cleaned daily as indicated on the manufacturer's instruction label, dryer number two was not in working order, and the laundry room sink was not in working order. This failure has the potential to affect 187 of 195 residents in the facility whose laundry was cleansed onsite.

Inspectors wroteBased on observation, record review, and review of facility policies, the facility failed to ensure two residents (Resident (R) 194 and R22) were assessed for the self-administration of prescribed medications out of a survey sample of 65. Specifically, the nursing staff left medications at the bedside for R194 and R22. In addition, the facility failed to properly assess each resident and identify the decision-making process to show the capabilities of each resident to self-administer medications. Findings Include: Review of a facility policy and procedure titled Self-Administration of Medication at Bedside, dated 11/30/14, documented The resident may request to keep medications at bedside for self-administration. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician of a change in condition for one (Resident (R) 66) of three reviewed for change in condition in a total sample of 65 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a thorough investigation for one of three resident-to-resident altercations reviewed. Specifically, Resident (R)1 and R89 were involved in a physical altercation and the investigation lacked witness interviews and times.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed for one resident of eight residents (Resident (R)196) reviewed for PASRR II in a total sample of 65 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Activities of Daily Living (ADLs) related to nail care for one resident of four (Resident (R)15) reviewed for ADLs in a total sample of 65 Residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident out of 65 (Resident (R)187) sampled residents was seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.

Inspectors wroteBased on facility document review, staff interviews, and policy review, the facility failed to ensure three Certified Nursing Assistants (CNAs) of five CNAs (CNA23, CNA8, and CNA16) reviewed were provided annual performance reviews. Additionally, the facility failed to ensure CNA 23 completed 12 hours of annual education which included dementia training, and other areas in which CNA 23 showed an area of weakness. The deficiency could result in a decreased quality of life or quality of care for the residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of an anti-psychotropic (Seroquel) medication for one of five residents (Residents (R) R 147) reviewed for unnecessary psychotropic medication use.

Inspectors wroteBased on observation, interview, and policy review the facility failed to adequately provide call light assistance for two) of 65 sampled residents (Residents (R)110 and R159). Findings Include: During an interview on 11/09/21 at 8:58 AM, R159 stated the ring bell was on table before but has no idea where it is now. R159 then pushed the call light attached to the wall and no light came on to alert staff. R159 stated the call light did not work and has not worked for a while and maintenance was aware. R159 confirmed the use of a wheelchair for mobility and pointed to the wheelchair next to bed. Record review R159 minimum data set (MDS) with an Assessment Reference Date of 10/15/21 found in the electronic healthcare Record (EHR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on observation and interviews the facility failed to ensure daily staffing was posted in which the posting contained the daily census of the facility. This had the potential to not provide residents and family members information regarding staffing and current census.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of the facility's policy, the facility staff failed to ensure that pain management was provided for 1 of 62 residents (Resident #80) in the survey sample. The facility staff failed to administer the scheduled opioid pain medication (Hydrocodone-Acetaminophen tablet 5/325 milligrams) to Resident #80, for over 16 consecutive hours; resulting in unnecessary and debilitating pain, constituting harm.

Inspectors wroteBased on observations and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment. Multiple resident rooms were not clean and had wall damage. The activity room wall paper was not maintained.

Inspectors wroteBased on resident interview, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for 1 of 62 residents (Resident #183) in the survey sample who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #183 was offered and received a scheduled twice-weekly showers to maintain good personal hygiene.

Inspectors wroteBased on information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed to ensure 1 of 62 residents was free from unnecessary drugs (Resident #68), in the survey sample. The facility staff administered 18 doses of Ciprofloxacin (an antibiotic) to Resident #68, for a bacteria resistant to the drug.

Inspectors wroteBased on information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed, for 1 of 62 residents (Resident #68) in the survey sample, to implement their antibiotic use protocol/policy. The facility staff administered a course of Ciprofloxacin (an antibiotic) to Resident #68 for a urinary tract infection however, the bacteria was resistant to the drug.

Inspectors wroteBased on observations and staff interviews the facility staff failed to provide a safe, comfortable environment for residents and the public. Multiple resident room and general doors within the facility had chipped sharp edges.

Inspectors wroteBased on observations, facility record review, and staff interview, the facility staff failed to maintain an effective pest control program. Roaches and/or mice were seen in the resident rooms, the courtyard, dining room, supply closets, refrigerator, nursing desk drawer, hallways, and conference room.

Inspectors wroteBased on observation, staff interviews, and facility document review, the facility staff failed to provide privacy during a wound dressing change for 1 of 62 residents (Resident #183) in the survey sample. The facility staff failed to ensure Resident #183's door was closed during a left heel wound care observation, allowing public view from the hallway.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility staff failed to provide care plan information to the receiving provider at the time of transfer to the hospital for 1 of 62 Residents in the survey sample, Resident #94 The facility staff failed to convey Resident #94's comprehensive care plan goals upon transfer to the acute care hospital on 1/24/18.

Inspectors wroteBased on clinical record review, staff interview, facility document review and the facility's policy, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 62 residents (Resident #94) in the survey sample. The facility staff failed to notify the Long-Term Care Ombudsman of Resident #94's discharge and admission to a local acute care hospital on 1/24/18.

Inspectors wroteBased on clinical record review, staff interview, facility document review and the facility's policy, the facility staff failed to provide written information to residents explaining how a resident's bed is held while the resident is absent from the facility due to hospitalization for 1 of 62 residents (Resident #94) in the survey sample. The facility staff failed to provide written information to the resident or resident representative which specifies the duration of the bed-hold policy upon transfer to the local acute care hospital on 1/24/18.

Inspectors wroteBased on observations, staff interviews, clinical record review and facility document review, the facility staff failed to provide the necessary care and services to prevent and treat a pressure ulcer and promote healing for 1 of 62 residents (Resident #183) in the survey sample. The facility staff failed to identity a left heel pressure ulcer prior to it being found at an advanced stage; the pressure ulcer was found as an unstageable with 100% eschar (hard black dead tissue). And, the facility staff failed to implement pressure relieving devices as ordered by the physician.

Inspectors wroteBased on observation and staff interviews the facility staff failed to implement interventions to reduce a potential accident hazard for 1 of 62 residents (Resident #183) in the survey sample. The facility staff used a pair of sharp tip scissors to cut off Resident #183's dressing to her left foot. This could have caused potential injury by cutting or poking the resident's skin.

Inspectors wroteBased on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff only on 1 of 4 units (Unit 1-A). The facility staff failed to ensure the following medications (Vitamin B12 500 mcg, Multivitamin, Folic Acid 400 mcg, Claritin 10 mg, Magnesium Oxide 400 mg and Calcium + DS 600 mg) were stored in a secured location, accessible to designated staff only.

Inspectors wroteBased on a resident record review, staff interviews, facility document review and resident interview the facility staff failed to obtain dental services review for 1 of 62 residents in the survey sample, Resident #146. The facility staff failed to follow physician orders and obtain dental care for Resident #146.

Inspectors wroteBased on staff interview, clinical record review, and review of the Hospice policy, the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 62 residents (Resident #175), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #175, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency.

Inspectors wroteBased on observations and staff interview the facility staff failed to maintain good infection control practices for 2 of 62 residents (Residents #145, #52), in the survey sample. 1. The facility staff contaminated the clean left buttock pressure ulcer dressing with the soiled dressings left on the chux pad below Resident #145's left buttock during wound care. 2. The facility staff failed to ensure soap was in a dispenser on 3 survey days in Resident #52's room. Therefore, increasing the chances of spreading infections, illnesses and diseases.