Ghent Rehabilitation & Nursing Center

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Specifically, (a) for Resident #31, food was not served at an appetizing temperature during a lunch meal on 07/21/2026 and stated that food was cold; (b) for Residents #37, #50, and #3, food was not served at an appetizing temperature and/or palatable; and (c) six anonymous residents during a resident council meeting on 07/16/2026 stated the food was not that good, often cold, and was undercooked.

Inspectors wroteBased on observation, record review, and staff interview conducted during the survey, the facility failed to implement and maintain an effective infection prevention and control program, by failing to ensure Contact Precautions were implemented and maintained for one resident (Resident #28) with a draining wound. Specifically, on 07/17/2026 Resident #28 who was on Contact Precautions, was observed seated in a wheelchair at a table in the dining area with another resident while the resident's wound dressing was visibly leaking drainage. Staff were observed in the area, and no redirection or interventions attempted to address the situation. The surveyor informed the Infection Preventionist who spoke with the resident, the resident was cooperative and headed back to their room for a dressing change to be performed. [...]

Inspectors wroteBased on observation, interview, and record review conducted during survey, the facility failed to ensure the resident and/or resident representative were notified of a change for one resident, Resident #111. Specifically, Resident #111 and their resident representative were not notified when one of their pain medications was discontinued, then restarted two days later as needed.

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure the resident's environment remained free of accident hazards as is possible. This was identified for one (Resident #1) of 20 residents reviewed. Specifically, Resident #1 was injured from their bed's installation hardware (bolt for a bed rail, which is an adjustable metal or rigid plastic bar that attach to the bed) that protruded beyond its frame. On 05/22/2026, Resident #1 sustained a cut to their right lower leg from the hardware on the bed while Registered Nurse #1 assisted the resident into bed. Resident #1 required hospitalization and 16 staples. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observation and staff interview during the recertification survey dated 08/28/23 through 09/01/23, the facility did not provide effective housekeeping and maintenance services for three (3) of 3 resident units and the core area. Specifically, on Unit #1, the floor was soiled with dirt in corners and next to walls in the corridors, dining rooms, nurse station, and resident room #s 101, 105, 109, 111, 118, 121, and 122; the windows were soiled with air borne debris and water stains in resident room #s 101, 105, 109, 111, and #122; the corridor wall outside the nurse aide room was soiled with drip marks, the walls were scraped in the room [ROOM NUMBER] restroom, the paint was chipped on the door frame to room [ROOM NUMBER], and wallpaper was peeling in the foyer old tub room; and the laminate on the nurse station enclosure walls was chipped. [...]

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 8/28/2023-9/1/2023, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for 4 of five test trays. Specifically, food and beverages served to the residents on the units were served at suboptimal temperatures, unappetizing in appearance and were not palatable. This was evidenced by: Food Council done separately from Resident Council documented the following concerns: - 5/17/2023 meeting documented the following: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for two (2) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, can openers and holders, sheet pan racks, plate warmer, shelving, stove drip pans, roll-in refrigerator, fire extinguishers, floor behind cooking equipment, and dishwashing area floor in corners and along the walls were soiled with food particles, food drips, and/or a black build-up; the pantry restroom fixtures were soiled with human residue or soap stains; the pantry restroom floor and walls were soiled with dirt particles along the walls and in corners. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey dated 08/28/23 through 09/01/23, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations in one (1) of 2 kitchenettes. Specifically, in the Unit #2 kitchenette refrigerator 3 packages of deli-sliced cold cuts were labeled with a resident's name and dated 7/17, 7/22, and 8/16; one package of deli-sliced cold cuts was labeled with a resident name with a date that was not discernable; restaurant meatballs that were not labeled with the resident name or date; and restaurant pizza that was not labeled with the resident name or date. This is evidenced was evidenced by: [...]

Inspectors wroteBased on record review, and interviews during the recertification survey and abbreviated survey (Case #NY00309535), the facility did not ensure all alleged violations involving abuse, neglect, including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury for 2 (Resident #'s 55 and #69) of 6 residents reviewed for accidents. Specifically, for Resident #55, the facility did not ensure the New York State Department of Health (NYSDOH) was notified about an unwitnessed fall resulting in a serious injury requiring transfer to the emergency room for further treatment and for Resident #69, the facility did not ensure to report a fall resulting in a left hip fracture to the NYSDOH within 2 hours of learning of the serious bodily injury. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with profession standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences and that services are provided by a qualified professional for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function for 1 (Resident #33) of 1 resident reviewed for respiratory care. [...]

Inspectors wroteBased on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Specifically, the facility did not provide new employee orientation to include Abuse, Neglect and Mistreatment to 5 (CNA #1, Laundry Employee #1, Maintenance Employee #1, LPN #4 and Dietary Employee #1) employees prior to their start of work in the facility. This was evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #'s 27, 53, and #96) of 24 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #27, the facility did not ensure a care plan was developed to address the resident's diagnosis of other seizures; for Resident #53, the facility did not ensure a care plan was developed to address the resident's diagnosis of hypothyroidism; [...]

Inspectors wroteBased on record review and interview during the recertification survey the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure the facility policy and procedure developed for the monthly Medication Regimen Review (MRR) included time frames for the different steps in the process. This is evidenced by: Review of the facility policy titled Medication Regimen Review dated 6/2020, did not include documentation of the time frames for the steps in the MRR process. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, food temperature thermometers were not in calibration, plumbing fixtures were not in good repair, and equipment and the floor required cleaning. This is evidenced as follows. The kitchen and unit kitchenettes were inspected on 06/03/2021 at 10:09 AM. Two of 5 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: 20 degrees Fahrenheit (F) and 29 F. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey and an abbreviated survey (Case #NY002713116), the facility did not provide effective housekeeping and maintenance services. Specifically, floors and tables were not clean and resident room walls were not maintained on 3 of 3 resident units. This is evidenced as follows. The 3-Wing, 2-Wing and 1-Wing units were inspected on 06/04/2021 at 1:15 PM. The 3-Wing unit corridors are carpeted; the carpeting in the corridors required vacuuming and were stained with black blotches throughout the unit. The 2-Wing and 1-Wing unit's flooring is entirely vinyl tile; the corridor floors, the floors behind doors in the dining and lounge areas, and where the corridor door frames meet the floors were soiled with dust, cob webs and/or dirt and grime. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, 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 #18) of 1 resident reviewed for personal funds. Specifically, for Resident #18, the facility did not ensure the resident had access to personal funds on weekends and holidays. This is evidenced by: Resident #18: The resident was admitted to the facility on [DATE], with a diagnosis of cerebral palsy, diabetes and hypertension. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make self understood. The facility's Policy and Procedure (P&P) titled Patient Personal Needs Fund (undated), documented the following objectives; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure that residents were free from physical restraints that are not required to treat medical symptoms for 2 (Resident #'s 13 and 81) of 3 residents reviewed for restraints. Specifically, for Resident #'s 13 and 81, the facility did not ensure the use of physical restraints did not inhibit a resident's freedom of movement; and for Resident #81, the facility did not ensure the resident was free from psychosocial impact (agitation) related to restraint use. This is evidenced by: Resident #13: The resident was admitted to the facility on [DATE], with diagnoses of dementia, Parkinson's Disease, and chronic kidney disease. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure 1 (Resident #19) of 1 resident reviewed for hospitalization, received a notice of the transfer or discharge and the reasons for the move in writing in a language and manner they understand, and a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Specifically, for Resident #19, the facility did not ensure that written notification of transfer/discharge was provided to the resident and/or the resident's representative(s,) and the facility did not ensure a copy of the notice was sent to the Office of the State Long-Term Care ombudsman. This was evidenced by: Resident #19: [...]

Inspectors wrote` Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care, for one of one dementia care unit (Wing 1). Specifically, the facility did not ensure a sufficient number of staff available to provide assistance with meals on 5/20/19. This is evidenced by: A facility-wide list of residents documented that 14 of those residents were appropriate to be fed by a feeding assistant and resided on Wing 1. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure food and drink was palatable, attractive, and at an appetizing temperature. Specifically, the facility did not ensure cold drinks were served cold and sandwich bread was palatable to ensure resident satisfaction. This is evidenced by: During an interview on 05/16/19 09:14 AM, Resident #103 stated the bread used at the facility is stale. During an interview on 5/16/19 at 10:37 AM, Resident #61 stated the bakery the facility uses and the quality of the bread used was not good. During an interview on 5/17/19 at 9:13 AM, Resident #21 stated the bread on the peanut butter and jelly sandwich is hard. The summer 2019 week 1 menu documented the Wednesday breakfast meal included oatmeal, bacon, banana, scrambled egg, and a fruited muffin. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced by: A Policy and Procedure (P&P), titled Food Brought by Family/Visitors dated 3/12/19, did not include documentation on providing family and visitors education on safe food handling practices (such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.). [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #'s 54, and 63) residents observed on Wing 1, and 1 (Resident #57) resident observed on Wing #3. Specifically; for Resident #'s 54, 57 and #63, the facility did not ensure that the residents' pants were not pulled up to their waist while lying in bed, and did not ensure that Resident #'s 54 and 63's briefs and bare thighs were not visible from the hallway. This is evidenced by: Wing 3: Resident #57: [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure 1 (Resident #19) of 1 resident reviewed for hospitalization, received a bed-hold notice upon transfer. Specifically, for Resident #19, the facility did not ensure that the resident and/or the resident's representative were notified in writing of the bed hold policy when the resident was transferred to the hospital. This was evidenced by: Resident #19: [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 5 (Resident #'s 41, 54, 82, 215, and #315) of 25 residents reviewed for comprehensive care plans. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure drug regimen review recommendations were acted upon for 2 (Resident's #'s 7 and 82) of 7 residents reviewed for unnecessary medications. Specifically, for Resident #'s 7 and 82, the facility did not ensure that the time frame for the step for physician intervention was met according to the facility policy for the Medication Regimen Review (MRR). This is evidenced by: A Policy and Procedure (P&P) titled Drug Regimen Review dated 12/2006, documented that drug regimen reviews that require physician intervention will be responded to no later than the next 30/60 day physician visit.

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, for four (Resident #'s 19, 21, 37 and #82) of four residents reviewed for unnecessary medications. Specifically, for Resident #'s 19, 21 and #37, the facility did not ensure the residents' pain levels were monitored prior to and after the administration of as needed (PRN) medications for pain. This is evidenced by: The facility's Policy and Procedure (P&P) titled Pain Management, revised on 2/2016, documented: The pain flow sheet (back of the Medication Administration Record (MAR) will be used to document the resident's level of pain prior to administration of the medication and to document the effectiveness of the PRN medication 15-30 minutes after administration. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure a resident fed by a feeding assistant did not have complicated feeding problems for 1 (Resident #81) of 1 resident reviewed for the feeding assistance program. Specifically, the facility did not ensure a resident with who had difficulty swallowing and risk of aspiration was assessed for appropriateness for a feeding assistant program. This is evidenced by: Resident #81: The was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, dementia, and anxiety. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could usually understand others, and was sometimes understood. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, the facility did not ensure that; dry food items were stored in an area free from contaminants, kitchenette equipment was clean, and food stored in the freezer was labeled and dated. This is evidenced by: During an observation on 5/17/19 at 8:26 AM, the Wing 1 kitchenette microwave and refrigerator were soiled, and food in the freezer was unlabeled. Micro-kill+ germicidal wipes were stored in cabinet with dry food items. A safety data sheet documented Micro-kill+ germicidal wipes should be stored in a ventilated area and stored away from incompatible materials. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized for 1 (Resident #105) of 25 residents reviewed. Specifically, for Resident #105, who was on a fluid restriction and received dialysis treatments, the facility did not ensure that the resident's daily intake was completed and accurately recorded. This was evidenced by: Resident #105: The resident was admitted to the facility on [DATE], with the diagnoses of End Stage Renal Disease (ESRD), Dialysis, and Chronic Obstructive Pulmonary Disease (COPD). The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact and he was able to make himself understood and understand others. [...]