Grand Manor Nursing & Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents or their designated representatives received quarterly personal funds account statements. This was evident in three (Residents #15, 74, and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility was unable to provide documentation demonstrating quarterly personal funds account statements were provided to the designated representatives of Residents #74 and #101 for the quarters ending 06/30/2025, 09/30/2025, 12/31/2025, and 03/31/2026, and to Resident #15's designated representative for the quarters ending 09/30/2025 and 12/31/2025.

Inspectors wroteBased on record review and interviews, the facility failed to ensure designated representatives of cognitively impaired residents were notified when resident personal funds accounts approached or exceeded the Supplemental Security Income resource limit. This was evident in two (Residents #74 and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility failed to provide documented evidence that designated representatives were notified, or that attempts to notify them were made, when resident personal fund balances reached or exceeded the Supplemental Security Income resource limit.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents were free from misappropriation of property. This was evident in three (Residents #15, #74, and #101) of five residents reviewed for personal funds out of 29 total sampled residents. Specifically, the facility authorized withdrawals from the personal fund accounts of cognitively impaired residents to purchase clothing and shoes without documented authorization from their designated representatives.

Inspectors wroteBased on record review and interview, the facility failed to ensure that allegations of abuse and an injury of unknown origin were thoroughly investigated. This was evident in three (Resident #164, #32, and #132) of four residents reviewed for abuse out of 29 total sampled residents. Specifically, 1.) The facility failed to conduct thorough investigation after Resident #164 was transferred to the hospital on [DATE] for complaints of chest pain radiating to the left side and was subsequently diagnosed with rib fractures (broken bone). In addition, the facility failed to document findings to determine whether abuse, neglect, or other factors contributed to the injury. 2.) The facility failed to conduct a thorough investigation of a resident-to-resident altercation involving Residents #32 and #132 on 04/23/2026.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident or their representative was afforded the opportunity to participate in their care planning process. This was evident in one (Resident #101) of five residents reviewed for resident rights related to care planning out of 29 total sampled residents. Specifically, the facility failed to provide documentation that advance notice was provided to Resident #101's designated representative, or attempted to be provided, before the care plan meetings occurred.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to establish and maintain a system to accurately reconcile, verify, and oversee methadone medications received from an external opioid treatment program. This was evident for 10 (Residents #2, 16, 28, 49, 50, 53, 114, 142, 146, 177) of 23 residents enrolled and receiving methadone (a long-acting opioid used to treat opioid use disorder) through an opioid treatment program. Specifically, a review of methadone administration records revealed 10 of 23 residents received dosages inconsistent with physician's orders. The licensed nurses reported the administration process of methadone doses obtained and intended for residents registered with an external opioid treatment program did not include medication-order reconciliation. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure medications were administered in accordance with physician's orders. This was evident for 10 (Residents #2, 16, 28, 49, 50, 53, 114, 142, 146, 177) of 23 residents on methadone (a long-acting opioid medication that is used to reduce withdrawal symptoms in people addicted to heroin or other narcotic drug) maintenance therapy. Specifically, the facility administered methadone doses that differed from the physician ordered dose resulting in significant medication errors. See F-755.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the survey, the medical director failed to collaborate with the facility to develop procedures for the safe and accurate provision of medications. Specifically, the medical director failed to ensure that current standards of practice were followed regarding the development and implementation of policies to reconcile, verify, and oversee methadone medications received from external opioid treatment programs.

Inspectors wroteBased on observation, record review, and interviews during the surveythe facility failed to ensure timely assessment and evaluation of a resident's change in condition. This was evident for one (1) (Resident #7) of three (3) residents reviewed. Specifically, Resident #7 had a bruise on top of their left eyebrow extending towards the temple that was not identified, assessed, or documented until observed by the State Surveyor. The resident was identified as high risk for falls and was receiving aspirin therapy, which increases the risk for bleeding complications. The facility failed to conduct and document a skin assessment, evaluate for possible head injury, initiate monitoring, or notify the physician in accordance with professional standards of practice. This resulted in no actual harm with a potential for serious harm that is Immediate Jeopardy to all residents' health and safety.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure all alleged violations involving injury of unknown source were reported immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency. This was evident for one (1) (Resident #7) of four (4) sampled residents. Specifically, on 09/13/2025 Resident #7 was unable to stand on their left leg and was transferred to the hospital. The resident was readmitted to the facility on [DATE] with diagnoses of left femur (thigh bone) fracture (break in the bone). Resident #7 was severely impaired in cognition and was unable to explain how they sustained the fracture. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a qualified dietitian or another clinically qualified nutrition professional, including a director of food and nutrition services, was employed part-time, full-time, or as a consultant. Specifically, the facility has employed a non-registered dietician as their full-time dietician and food service director without the oversight of a registered dietician or certified food service director since September 2025.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, 1.) The walk-in refrigerator contained prepared food items and defrosting meats that were unlabeled and undated. 2.) A pantry refrigerator contained expired, undated and unlabeled resident food.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Food and Nutrition Services, Administration, Infection Control, Physical Environment, and Training Requirements. Specifically, 1.) The Administration did not monitor and enhance the quality of care and services as indicated by widespread deficiencies and repetition of deficiencies that were cited on previous recertification surveys. 2.) The Nursing Services were not administered adequately to ensure that infection prevention and control practices were maintained, and that Certified Nursing Assistants received the required 12 hours of in-service training.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program and plan with governance and leadership oversight. Specifically, the facility had widespread deficiencies in the areas of Food and Nutrition Services, Administration, Infection Control, Physical Environment, and Training Requirements. In addition, the facility had deficiencies (F656, F711, F801, F812, F835, F865, F880) from previous Recertification surveys that were repeatedly cited in the current survey whereby plans of correction were previously accepted by the New York State Department of Health, but the facility had no documented evidence of implementation or maintenance of outcomes.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was evident during the Infection Control Task. Specifically, the facility had no system to monitor antibiotic use. There was no system of reports related to antibiotic usage and resistance data.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/01/2025 to 12/09/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, during the observation of the dishwashing task and review of the associated daily temperature logs the mechanical dishwasher was below 150 degrees Fahrenheit on more than one (1) occasion. Review of the Kitchen Equipment invoice dated 11/06/2025 indicated that the mechanical dishwasher has been malfunctioning, and the facility had failed to pay the vendor to have it repaired.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. This was evident for one (1) of 11 residents (Resident #88) reviewed for accidents out of 35 total sampled residents. Specifically, Resident #88 who was identified as at risk for falls, was observed without floor mats and their bed not in the lowest position as stated in their care plan.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the physician reviewed the resident's total program of care. This was evident for one (1) of 12 residents reviewed (Resident #8). Specifically, there was no documented evidence that a physician evaluated Resident #8 after a fall incident on 07/30/2025.

Inspectors wroteBased on observation, record review, and interviews the facility failed to maintain medical records on each resident in accordance with professional standards and practices that are systematically organized and readily accessible. This was evident for five (5) of five (5) residents (Resident #'s 4, 7, 56, 68, and 88) reviewed for unnecessary medications out of 35 total sampled residents. Specifically, the residents' drug regimen review reports were not readily available for review upon request.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility failed to ensure that each resident was offered the pneumococcal and influenza immunizations. This was observed in five (5) of nine (9) residents (Residents #25, #88, #99, #153, #202) sampled for immunizations out of a total of 38 sampled residents. Specifically, there was no documented evidence that Residents #25, #88, and #202 were offered, educated, received or declined the influenza immunization, and there was no documented evidence that Residents #25, #88, #99, #153, and #202 were offered, educated, or received or declined the pneumococcal immunization.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility failed to ensure that each resident was offered the COVID-19 immunization. This was observed in four (4) of nine (9) residents (Residents #25, #99, #153, #202) sampled for immunizations out of a total of 38 sampled residents. Specifically, there was no documented evidence related to the screening, administration or declination, and education on the COVID-19 immunizations for Residents #25, #99, #153, and #202.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure there was adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This was evident for 25 out of 25 rooms on the second floor. Specifically, call bell systems did not function as designed and residents were given hand bells.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey, the facility failed to ensure that certified nurse aides were provided the required 12 hours of in-service training per year. This was evident for five (5) of five (5) Certified Nursing Assistants reviewed for nurse' aide training requirements. Specifically, the facility was unable to provide documented evidence that Certified Nursing Assistants #14, 15, 16, 17, and 18 were provided 12 hours of annual in-service training.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the resident was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for one (1) of four (4) residents (Resident #153) reviewed for hospitalization out of a total sample of 35 residents. Specifically, the facility did not complete a notice of discharge or transfer when Resident #153 was transferred to the hospital on [DATE].

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for one (1) (Resident #142) of one (1) resident reviewed for transmission-based precautions in the Infection Control task out of 38 total sampled residents. Specifically, Resident #142 who had diagnoses of Osteomyelitis (infection in a bone) and Methicillin-Resistant Staphylococcus Aureus (a type of infection resistant to several antibiotics) had no care plan to address infection and contact precaution.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure that residents are provided food that accommodates their allergies, intolerances, and preferences. This was evident for one (1) out of 38 residents (Resident #35) reviewed for food preferences. Specifically, during observation on 12/01/2025, Resident #35 who preferred chicken and fish during meals, and disliked beef and pork, was noted with pork in their lunch tray.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) unit (six (6) of five (5) resident units. Specifically, Certified Nursing Assistant #5 picked up Resident #152's pillow from the floor and placed it under Resident #152's head without changing the pillowcase.

Inspectors wroteBased on interviews, observations and record reviews and interviews, the facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by state surveyors or post them in a place readily accessible to residents and family members. Specifically, on 12/02/2025, resident interviews at the Resident Council Meeting and subsequent observations confirmed that the facility failed to ensure survey results were readily accessible to residents and the public.

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to ensure that the Facility-wide Assessment included the services provided. Specifically, the Facility Assessment continued to list Hospice as a service provided by the facility. However, an interview with the Administrator confirmed that the facility had terminated their contract with a certified hospice provider in 2021.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control that include infection preventionists role, infection surveillance, outbreak, antibiotic stewardship, and other recommended Infection prevention and control (IPC) training that must be sufficient to perform the role of an Infection Preventionist. Evidence includes: Pursuant to regulation, the facility must designate one or more individual(s) as the infection preventionist, who, among other requirements, must have completed specialized training in infection prevention and control. [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that a resident's right to privacy during medical treatment and confidentiality of medical records was maintained for one (1) (Resident #183) of 38 total sampled residents. Specifically, Registered Nurse #4 performed Resident #183's blood glucose testing (measures the level of sugar in blood), administered an insulin injection, and administered enoxaparin (an injectable that prevents blood clot) while in the hallway. Additionally, Registered Nurse #4 walked away from the medication cart without locking the computer monitor, exposing Resident #183's medical information.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (NY00377759, NY00377846), the facility did not ensure that all alleged violations involving misappropriation of resident property were reported within 24 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure that the results of all investigations were reported to the State Survey Agency within five (5) working days of the incident. This was evident in three (3) of three (3) residents (Residents #4, #5, and #6) sampled for abuse. Specifically, 1.) On 4/07/2025 at 2:30 PM, Resident #4 reported that Patient Care Assistant #1 borrowed money from them to repay a loan from Resident #5. Resident #4 alleged that Patient Care Assistant #1 did not pay them back. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to thoroughly investigate all alleged violations involving abuse for one (1) (Resident #158) of five (5) sampled residents. Specifically, the Director of Recreation received a report from Resident #158 alleging they were threatened by an unidentified Certified Nursing Assistant. An investigation was not immediately initiated, and measures were not put in place to ensure further potential abuse did not occur.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop a comprehensive care plan to address a resident's full code status for 1 (Resident #171) of 38 sampled residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that infection control prevention and practices were followed during wound care treatment for 1 of 38 sampled residents. Specifically, Registered Nurse #6 and Licensed Practical Nurse #2 failed to follow infection prevention and control practices while performing wound care treatment.

Inspectors wroteBased on observation, record review and interviews, the facility failed to address the recommendations made by the Pharmacy Consultant during medication regimen review for one (1) (Resident # 162) of five (5) residents reviewed for unnecessary medications. The medication regimen review report for Resident #162 dated 12/09/2024 documented that the pharmacy consultant was unable to locate the recent documentation of current need/effect, absence/presence of side effects, ability or lack of ability to taper current dose in chart for trazodone. The attending physician agreed to the recommendation and documented that a psychiatry consult will be ordered. However, no psychiatry consult was completed for Resident #162 to address the pharmacist's recommendation.

Inspectors wroteBased on observation, record review, and interviews the facility failed to administer all physician ordered medications for 1 of 35 sampled residents. Specifically, Resident #164 was not administered two consecutive doses of sertraline (an antidepressant) as ordered by a physician.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. The facility failed to store schedule II medications in locked compartments, failed to keep medication cart locked or under direct observation, and failed to dispose of expired supplement in 1 (3rd Floor) of 3 units observed.

Inspectors wroteBased on observation, record review, and interviews the facility failed to convey the personal funds accounts to the probate jurisdiction administering the residents' estates within 30 days of expiration for 2 (Residents #1 and #2) of 3 sampled residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that the Minimum Data Set (a resident assessment tool) accurately reflected a resident's status for two (2) (Residents #75 and #183) out of 38 total sampled residents. The Minimum Data Set assessments inaccurately documented Residents #75 and #183's medications.

Inspectors wroteBased on record review, observation, and interviews conducted during an abbreviated survey (NY00373346), the facility did not ensure a comprehensive clinical assessment was done to identify changes in a resident's condition. The facility did not ensure residents receive treatment and care in accordance with professional standards of practice. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, on [DATE], Resident #1 was observed with stuffy nose, low grade fever of 100.5-degree Fahrenheit, and restlessness. There was no documented evidence that the medical doctor was informed of the resident's change in condition. Additionally, there was no documented evidence that the resident was assessed after the acetaminophen was administered. Resident #1expired on [DATE]/2025 at 9:49 AM due to cardiac arrest secondary to coronary artery disease. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00373346), the facility did not ensure the designated resident's representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, on 02/01/2025, Certified Nursing Assistant #1 informed License Practical Nurse #1 Resident #1's had a stuffy nose. On 02/01/2025, License Practical Nurse #1 documented Resident #1 had a low grade fever of 100.5-degree Fahrenheit, and was restlessness. The medical doctor and the family were not notified.

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, NY00358811) beginning [DATE], it was determined that this Special Focus Facility failed to maintain safe and comfortable temperature levels. This was evident on five of five resident floors, where 59 out of 59 rooms sampled had temperatures below the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29. Specifically, four complaints were submitted to the State Agency regarding loss of heat in the facility from [DATE] through [DATE], naming six residents affected. An additional six residents filed grievances at the facility on the loss of heat in their rooms from [DATE] through [DATE]. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, and NY00358811), the facility failed to ensure it was administered in a manner that enables 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 failed to provide effective leadership and oversight to ensure that comfortable and safe temperature levels were maintained in residents' rooms and common areas. In addition, the Administrator failed to have an effective system in place to ensure the boiler room equipment was maintained in safe operating condition. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Abbreviated Survey and Partial Extended Survey (Complaint NY00362627, NY00363035, NY00363415, and NY00358811), the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was evident in 5 of 5 resident units Specifically, the facility failed to routinely maintain their boiler equipment. This resulted in the facility's heating system malfunctioning, causing temperatures in residents' rooms and common areas to fall below the required range. This resulted in no actual harm with likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to resident health and safety, in accordance with 42 CFR Part 483 and 10 NYCRR:

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00350179) from 11/13/2024 to 11/21/2024, the facility did not ensure that residents were free from abuse, neglect, and exploitation. This was evident in 2 (Resident #118 and #151) of 6 residents reviewed for Abuse. Specifically, Resident #118 who had history of stealing and being involved in physical altercations, was not provided supervision and monitoring despite the staff being aware of Resident #118's behavior. Subsequently, on 08/02/2024, Resident #118 snatched a $20 bill from Resident #151's hand while they were on the elevator. Resident #151 hit Resident #118's head with a cane. Resident #118 sustained head lacerations that required emergency medical intervention. Resident #118 had 14 staples to the wound. This resulted in actual harm to Resident #118 that was not Immediate Jeopardy. [...]

Inspectors wroteBased on record review, interviews, and observations conducted during the Recertification and Complaint (NY00350179) Survey from 11/13/2024 to 11/21/2024 the facility did not ensure that comprehensive care plans were reviewed and revised periodically and after each assessment including both the comprehensive and quarterly review assessments. This was evident for 3 (Resident #84, #118, and #151) of 7 residents reviewed for Catheter Care and Abuse out of 38 total sampled residents. Specifically, 1.) Resident #84's care plan for indwelling catheter/external urinary appliance was not reviewed and revised after the Resident returned from an emergency room visit due to urinary retention and pain at the urinary catheter insertion site. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (NY00347302, NY00351629, and NY00351064) conducted from 11/13/2024 to 11/21/2024, the facility did not ensure that sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1) Several residents reported the facility was short staffed of Certified Nursing Assistants, especially during the evenings, and weekends, which resulted in lack of timely staff response to residents who needed assistance with toileting, bathing, and personal care. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification Survey from 11/13/2024- 11/21/2024, the facility did not ensure performance reviews of every nurse aide was conducted at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews. This was evident for 5 (Certified Nursing Assistants #8, #15, #16, #17, and #18) of 5 Certified Nursing Assistants reviewed for nurse aides' training requirements.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Activities of Daily Living, Staffing, Infection Control, Medication Storage, and Quality Assurance. Specifically, 1.) The Administration did not ensure the facility was sufficiently staffed to meet the residents' needs. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure it has an active governing body that is responsible for establishing and implementing policies regarding the management of the facility. Specifically, based on the multiple deficient practices that were identified during the Recertification Survey, there was inconsistent communication between the facility Administrator and the Governing Body to ensure management of the facility and regulatory compliance.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that the quality assurance and performance improvement program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, resident and staff input, and other information. Specifically, the facility had widespread deficiencies in the areas of Nursing Services, Administration, and Infection Control. In addition, the facility had deficiencies from previous Recertification surveys that were repeatedly cited in the current survey (F641, F657, F725, F761, and F865). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 11/13/2024 -11/21/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 7 (Residents #69, #47, #92, #412, #87, #7, #74) of 10 residents, from 3 different units, observed for medication administration. Specifically, 1.) Licensed Practical Nurse #4 failed to sanitize the blood pressure machine and cuff after each resident use. 2.) Registered Nurse #5 failed to sanitize the glucometer (a medical device used to measure the amount of sugar in the blood) after each resident use. 3.) Licensed Practical Nurse #1 failed to sanitize the blood pressure machine and cuff after each resident use.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint Survey (NY00351064) from 11/13/2024 to 11/21/2024, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services and assistance to maintain grooming, and personal hygiene. This was evident for 2 (Residents #48 and #169) of 7 residents reviewed for Activities of Daily Living. Specifically, Residents #48 and #169 were not provided regular showers according to their plan of care.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that a resident at risk for developing pressure ulcers, receives care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #123) of 3 residents reviewed for Pressure Ulcers. Specifically, Resident #123, who had history of healed pressure ulcers and had a care plan for use of a pressure ulcer relieving device when in bed, was observed with deflated air mattress on 3 occasions.

Inspectors wroteBased on interview and record review conducted during the Recertification and Complaint (NY00350179) Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This was evident in 1 (Resident #118) of 6 residents reviewed for abuse. Specifically, Resident #118 exhibited multiple incidents of behavior symptoms such as stealing from other residents and had been involved in resident-to-resident altercations. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 11/13/2024 through 11/21/2024, the facility did not ensure that all medications and biologicals used in the facility were safely stored. Specifically, insulin pens were not stored in a sanitary manner to prevent cross-contamination. This was evident during observations (Unit 5) conducted for the Medication Storage Task.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00351064) Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident for 1 (Resident #48) of 7 residents reviewed for Activities of Daily Living. Specifically, Resident #48's bathing preference was not honored.

Inspectors wroteBased on record review, and interviews conducted during the Recertification survey from 11/13/2024 to 11/21/2024, the facility did not ensure that the assessment accurately reflected the resident's status. This was evident for 3 (Residents #462, #311, and #118) of 38 total sampled residents. Specifically, 1.) Resident #462's discharge status was inaccurately documented in the Minimum Data Set assessment. 2.) Resident #311's diagnosis of Schizophrenia was not documented in the Resident's quarterly Minimum Data Set assessment. 3.) Resident #118's behavior symptoms was inaccurately documented in the Minimum Data Set assessment.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for Quarter 3 2024 (April 1 - June 30) in a timely manner.

Inspectors wroteBased on observations, staff interviews, and record review conducted during the Complaint Survey (NY00339166, NY00332772), the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the residents' choices. This was evident for 2 of 3 residents reviewed for medication administration. Specifically, 1.) On 04/02/2024, Resident #6, who had a diagnosis of Diabetes Mellitus, had not been given the prescribed Lantus Insulin (a long-acting insulin used in adults with type 2 diabetes) at 9:00 PM. 2.) On 10/24/2023, Resident #4 was admitted to the facility with hospital discharge orders for an antibiotic intravenous infusion for bacteremia (a medical condition characterized by bacteria in the bloodstream). [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 06/03/2024 to 06/11/2024, the facility did not ensure that a resident received foot care and treatment in accordance with professional standards of practice. This was evident for 1 (Resident #191) of 4 residents reviewed for pressure ulcer/injury. Specifically, Resident #191 did not receive the recommended wound treatment made by the Infectious Disease consultant and podiatrist for the care and treatment of diabetic foot ulcer.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey from 06/03/2024 to 06/11/2024, the facility failed to ensure that the physician reviewed the resident's total program of care. This was evident for 1 (Resident #191) of 4 residents reviewed for pressure ulcer/injury. Specifically, there was no documented evidence the treatment recommendations from the Infectious Disease consultant and podiatrist for Resident #191's diabetic ulcer on the left foot were reviewed by the attending physician. Additionally, there was no documented evidence that Resident #191's diabetic ulcer on the left foot was evaluated by the attending physician and/or the nurse practitioner.