Gramercy Court

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three sampled residents (Resident 2) when Resident 1 hit Resident 2's face with his hand. This failure resulted in Resident 2 not being free from abuse and had the potential to negatively impact Resident 2's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) were free from abuse, when: 1. Resident 2 threw a cup of coffee onto Resident 3;2. Resident 1 pushed his walker into the back of Resident 4's legs;3. Resident 1 put his lit cigarette butt on Resident 5's face;4. Resident 1 hit Resident 2's face with his fist; and5. Resident 7 hit Resident 6 in the back of the head with his hand. These failures had the potential to negatively impact Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews, and record review, the facility failed to protect one of five sampled residents' (Resident 1) right to be free from physical abuse by another resident when Resident 2 punched Resident 1 in the face. This failure had the potential to cause physical and mental harm to Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to protect one of four sampled resident's (Resident 4) from abuse when Resident 3 threw a chair at Resident 4 who attempted to deflect the chair and sustained an injury. This failure resulted in slight pain and a minor fracture to the ring finger.

Inspectors wroteBased on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for four of 11 sampled residents (Resident 1, Resident 4, Resident 5, and Resident 7), when:1. Resident 2 slapped Resident 1 in the back of the head; 2. Resident 3 hit Resident 4 in the face;3. Resident 4 slapped Resident 5 in the face; and4. Resident 6 pushed Resident 7. This failure caused Resident 1 to feel upset, Resident 4 to feel afraid, Resident 5 to have a cut lip, and Resident 7 to have leg pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the right to be free from physical abuse for three of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when: 1. On 12/13/25, Resident 1 spat at Resident 2 in the hallway;2. On 12/24/25 in the dining room, Resident 1 slapped Resident 3 on the back of the head; and3. On 12/26/25 in the dining room, Resident 1 slapped Resident 4 on the face. This failure compromised the residents' ability to maintain their highest practicable physical, emotional and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage and preparation, in accordance with professional standards for food service safety, was provided to residents in a census of 101, when: 1. Floors, rolling racks, equipment, pots/pans, grill/stove panel, refrigerator doors, water pitcher preparation area, garbage cans, can opener, and towels were found unclean and unsanitary; 2. Food, and staff's personal food and drink, items were found in refrigerators and in the dry storage room, opened, not labeled, not securely covered, dented, and expired; and 3. Kitchen staff did not know how to explain or demonstrate the proper procedures for testing sanitizing solutions, and expired test strips were being used. These failures had the potential to cause food-borne illnesses in a vulnerable population. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable room temperatures for three out of 28 sampled residents (Resident 61, Resident 62, and Resident 120) when:Resident 62's and Resident 120's shared room temperature was below 71 F (degrees Fahrenheit); and Resident 61's room temperature was below 71 F.These failures resulted to Resident 61, Resident 62, and Resident 120 verbalizing that their rooms were cold and very uncomfortable.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate handling, storage, disposal, and documentation of controlled medications (medications with high potential for abuse or addiction) were provided for residents in a census of 101, when:1. There was no efficient system in place to accurately document and secure disposed controlled medications when two stored bags containing controlled substances were easily retrievable; and 2. There was no accurate documentation on controlled medication for Resident 98, when the administration date was missing, and two bottles of controlled substances were documented on only one controlled drug record with a discrepancy on the remaining quantity of the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 2 pushed Resident 1 which caused a fall to the floor. This failure resulted in an injury to Resident 1's left leg.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 1 was punched in the face by Resident 2. This failure caused injury to Resident 1's lip. Resident 1 was admitted to the facility early 2024 with diagnosis which included a mental health disorder marked by hallucinations and delusions, anxiety, impulse disorder, and mood disorder. During a review of Resident 1's Order Summary Report [OSR], order date 3/11/24, the OSR indicated, Resident is Incapable Of Understanding Rights, Responsibilities, And Informed Consent. Resident 2 was admitted to the facility mid 2025 with diagnosis which included a mental health disorder marked by hallucinations, delusions and extreme mood swings. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 slapped Resident 1 on the left cheek. This failure resulted in Resident 1 experiencing feelings of unsafety, disrespect and physical pain.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1 and hitting Resident 1's head into a wall which resulted in Resident 1 sustaining a skin tear. This failure resulted in Resident 1 not free from abuse by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one of 35 sampled residents (Resident 1), when Resident 1 eloped (left the facility unsupervised without prior authorization) through an unsecured exit gate. This failure decreased the facility's potential to maintain residents' safety and prevent accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly for a census of 107, when: 1. Staff stored personal belongings inside Hall C medication room; 2. Expired medications were found in two medication carts; 3. Two multi-dose liquid protein bottles without open dates and an expired inhaler were found in one medication cart; 4. Medication was left at Resident 404's bedside table; and 5. Treatment cart was left unlocked. These failures decreased the facility's potential to safely store medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity for one of 30 sampled residents (Resident 27), when Resident 27 was wearing a gown while sitting in a wheelchair with her back and side of body exposed. This failure decreased the facility's potential to maintain residents' dignity and privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained for the use of psychotherapeutic drug (a medication to control a resident's behavior) for one of 30 sampled residents (Resident 43), when Resident 43 was prescribed three psychotherapeutic drugs without an informed consent. This failure had the potential for Resident 43 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for one of 30 sampled residents (Resident 43), when Resident 43's medications were accessible and left stored on top of bedside table. This failure increased Resident 43's potential to unsafely self-administer medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge Minimum Data Set (MDS-a federally mandated resident assessment tool) was completed in accordance with the regulatory timeframe required for one of 30 sampled residents (Resident 76), when Resident 76's discharge assessment was not submitted within 14 calendar days of discharge. This failure decreased the facility's potential to complete residents' assessments in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of 30 sampled residents (Resident 254), when Resident 254 did not have a care plan for hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). This failure decreased the facility's potential to meet Resident 254's hospice care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for three of 30 sampled residents (Resident 254, Resident 255, and Resident 257), when: 1. Resident 254's physician order to admit to hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was not transcribed to the order summary record (OSR); 2. Resident 255's physician's order of heparin sodium (a medication used to prevent blood clots in blood channels in the body) was incorrectly recorded in OSR; and 3. Resident 257 was not given metformin hydrochloride (metformin HCl-a medicine to treat high blood sugars) as prescribed by the physician. These failures increased the residents' potential to have unmet health needs.

Inspectors wrote2. A review of an admission record, indicated Resident 30 was admitted to the facility in June 2020 with a diagnosis of dementia (a progressive state of decline in mental abilities) with agitation. A review of Resident 30's Order Summary Report, indicated an order dated 2/17/24 for lorazepam one mg to be given every four hours as needed (PRN), with no stop date. A review of Resident 30's Medication Administration Record, indicated the PRN order for lorazepam was administered from 2/17/24 to 7/23/24. During a concurrent interview and record review on 12/4/24 at 11:02 a.m. with the Director of Nursing (DON) and ADON, Resident 30's Medication Regimen Review for February 2024 and progress notes were reviewed. Both DON and ADON confirmed that the doctor's order did not include a rationale/reason to continue Resident 30's order for lorazepam from February 2024 to July 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide weekly and alternate menus to three of 30 sampled residents (Resident 204, Resident 24, and Resident 38). This failure decreased the facility's potential to meet the residents' nutritional and cultural preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 46) was provided with necessary adaptive equipment (special eating equipment) for meals as ordered. This failure decreased the facility's potential to meet the resident's nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store food in accordance with professional standards for food safety for a census of 107, when: 1. Two expired food products were stored in the spice shelf; 2. One box of expired food was stored in the dry storage area; 3. A 12 pack box of expired lactose free drink was stored in the walk-in refrigerator; and 4. Undated food products were stored in the walk-in refrigerator and dry storage area. These failures increased the potential for food-borne illnesses among the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management consistent with professional standards of practice for one of two sampled residents (Resident 1), when the facility did not administer Resident 1's pain medication for several hours upon admission and pain was not assessed in a timely manner for effectiveness of the pain medications. This failure resulted in Resident 1 experiencing uncontrolled pain and suffering for prolonged periods of time, which had the potential to negatively impact his daily activities, rest and sleep.

Inspectors wroteBased on interview and record review, the facility failed to complete and report the results of an investigation of a Resident-to-Resident altercation to the State Survey Agency within 5 working days of the incident for two of three sampled Residents, (Resident 1 and Resident 2). This failure to complete the report investigation had the potential for residents to be subjected to further incidents of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity for one of four sampled residents (Resident 1), when staff did not keep an accurate inventory of Resident 1's property. This failure resulted in the unrecovered loss of Resident 1's personal mobile phone while Resident 1 was residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement the cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) policy for one of three sampled residents (Resident 1), when two certified nursing assistants (CNA 1 and CNA 2) provided CPR to Resident 1 without maintaining a current CPR certification. This failure decreased the facility's potential to provide low quality CPR for residents during emergencies.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate monitoring and supervision for one of three sampled residents (Resident 1), when Resident 1 eloped (departed health facility unsupervised and undetected) during a group outdoor walking activity. This failure had the potential to increase Resident 1's risks for experiencing harm while away from the facility unsupervised.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when he was struck in the face by Resident 2. This failure resulted in Resident 1 sustaining a swollen eye, severe headache and vomiting requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide safe pharmaceutical services for one of four sampled residents (Resident 1) when the Licensed Nurse left Resident 1's brimonidine eye drops (medication to treat vision loss by lowering pressure) in his room unsupervised. This failure had the potential for abuse or misuse of the medication and the potential for not meeting the resident's therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe smoking practices for 17 residents (Resident 42; 196; 27, 78, 29, 72, 80, 2, 90, 82, 49, 75, 54, 74, 58, 73, and 71) for a census of 93 when: 1. Resident 42 and Resident 196 were in possession of cigarettes and a lighter and were smoking independently prior to the completion of a smoking assessment; 2. Resident 27 smoked without supervision, did not wear a smoking apron, and possessed cigarettes and a lighter; and, 3. Residents 78, 29, 72, 80, 2, 90, 82, 49, 75, 54, 74, 58, 73, and 71 smoked without using a smoking apron per signed consent/policy. These failures had the potential to jeopardize the residents' safety.

Inspectors wrote,Based on observation, interview, and record review, the facility failed to safely store medications for a census of 93 when emergency kits (E-kits) were stored beyond their expiration date and were not replaced in a timely manner. These failure decreased the facility's potential to safely administer medications during emergency situations. Findings During a concurrent observation and interview on 1/30/24 at 1:23 pm with Director of Nursing (DON) at Medication Storage room [ROOM NUMBER], an Antibiotic E-kit had been opened with multiple E-kit logs, dated from the months of September 2023, October 2023, November 2023, December 2023 and January 2024. DON confirmed that the E-kit had been opened and should have been replaced by pharmacy within 72 hours. During a concurrent observation, record review and interview on 1/30/24 at 1:59 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and dated correctly for a census of 93. This failure decreased the facility's potential to safely store medications. Findings During a concurrent interview and observation at 1/30/24 at 12:18 p.m. with Licensed Nurse 6 (LN 6) at Medication Cart 1, the following medications were observed: - an unused and unopened multi-dose insulin (a medication to lower blood sugar) vial found with an open date of 1/29/24; and, - a used multi-dose insulin bottle found with an open date of 1/28/24 and a discard date written as 42 days; LN 6 stated that the unopened insulin vial should be in the fridge if it isn't in current use and the discard date should be in 28 days, not 42 days. During a concurrent interview and observation at 1/30/24 at 1:34 p.m., with LN 7 at Medication Cart 2: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a sanitary manner for a census of 93 when: 1. A snack was stored past its use by date; 2. Several food items were opened and not dated with their open date in the walk-in refrigerator and reach-in freezers; 3. The double ovens were observed with burnt, blackened debris on their bottoms; 4. Food items were opened, undated and did not include use by dates in the dry storage area; 5. The ice machine's interior was dirty; and, 6. The floor beneath the ice machine had areas of blackened debris along the bottom of the wall and between the tiles. These failures had the potential to result in foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents' health information for a census of 93 when tray tickets were disposed of in the trash. This failure decreased the facility's potential to protect residents' personal health information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement for three of 24 sampled residents (Resident 1, Resident 34, and Resident 36) specifically provides for the selection of a neutral arbitrator and convenient venue. This failure decreased the facility's potential to provide residents a neutral and fair arbitration process.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected one of 24 sampled residents' (Resident 47) status when Resident 47's pressure ulcer was not documented. This failure had the potential for inadequate wound care management.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their Baseline Care Planning (BCP, identifies the resident's care needs immediately upon admission) policy and procedure for one of 24 sampled residents (Resident 296) when Resident 296 was not provided a written summary of the baseline care plan. This failure had the potential to limit communication concerning the resident's goals, medications, diet, and therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for three of 24 sampled residents (Resident 42, Resident 36, and Resident 296 ) when: 1. Resident 42 was not given a medication as ordered by the physician; 2. Oxygen was administered to Resident 36 without a humidifier as indicated in physician's orders; and 3. Resident 296 administered own insulin injection without a physician order. These failures increased the residents' potential to have unmet health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care for one of 24 sampled residents (Resident 296) when a Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open during sleep) machine had not been applied at bedtime as ordered by the physician. This failure had the potential to negatively impact Resident 296's respirations during sleep.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a manner to maintain nutritive value for 19 residents receiving a therapeutic diet (foods of altered texure) for a census 93 when foods were prepared approximately 3 hours in advance and held in a 300 degrees Fahrenheit (F, a unit of measurement) oven. This failure had the potential to decrease the nutritive value of the foods being served.

Inspectors wrote2. A review of Resident 86's admission record indicated he was originally admitted on 12/2023 and readmitted on 1/2024 with diagnoses including type 2 diabetes (a chronic disease that occurs when blood sugar is too high). Makes own health care decisions without memory problems. During a concurrent observation and interview on 1/31/2024, at 7:35 a.m., during breakfast, observed Resident 86's meal tray was served by Certified Nurse Assistant 4 (CNA 4) and confirmed the meal tray consisted of 1 glass of milk, scrambled eggs, a piece of toast and a bowl of oatmeal. A concurrent observation, interview, and record review on 1/31/2024, at 7:40 a.m., with Resident 86, he complained he already requested the kitchen staff not to send oatmeal on his breakfast tray, but the tray still included a bowl of oatmeal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure trash was properly disposed for a census of 93 when the facility's dumpster lids were left open. This failure had the potential to attract unwanted pests and vermin.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control practices for one of 24 sampled residents (Resident 47) when the Housekeeper did not apply the required Personal Protective Equipment (PPE, gloves gown and/or goggles/face shield if risk of splash and spray) while cleaning her room. This failure had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides received 12 hours of annual in-service which included dementia management and abuse prevention training for a census of 93 when documentation of the nurse aide in-services could not be provided for one of 5 sampled employees. This failure had the potential to affect the quality of care and services provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient preparation for discharge for one of four sampled residents (Resident 1), when Resident 1 was sent home without written instructions for medication administration. This failure had the potential to result in incorrect administration of medications and lack of coordination of care after discharge for Resident 1.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for Resident 1 and Resident 4 when a broken piece of sink linoleum and a pair of discarded gloves were found in the residents' bathroom. This failure had the potential for the residents to be injured, experience an unsanitary environment, and negatively impact residents' highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the proper medication administration policy was followed when a licensed nurse gave Resident 1 a medication that was taken from another resident's supply. This failure decreased the facility's potential to ensure safe medication administration for Resident 1. During a phone interview on 9/18/23 at 9:58 a.m., with Resident 1's husband, he stated one of the nurses stated he was going to give his wife medication that he took from another resident. During a record review of progress notes, dated 9/9/23 at 1:07 p.m., the health status note indicated on 9/8/23, the pm [after noon] shift nurse was administering meds and mentioned to the resident that one of the meds was borrowed from another resident. During an interview on 9/18/23 at 1:13 p.m. [...]