Grandell Rehabilitation and Nu

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, and mistreatment. This was identified for one (1) (Resident #256) of eight (8) residents reviewed for Accidents. Specifically, Resident #256 with impaired cognition was found on the floor on 06/24/2025. The incident was reported to the facility staff by the resident's roommate. The facility did not thoroughly investigate the incident and did not include a statement from the resident's roommate to identify the root cause of the incident. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #7) of six (6) residents reviewed for Nutrition. Specifically, Dietitian #1 recommended Resident #7 receive a liquid nutritional supplement of Glucerna Shake 240 milliliters twice daily for additional calories and protein; however, the supplement was never ordered. The finding is:The facility's policy titled, Nutritional Status and Recommendations, last reviewed/revised in December 2024, documented the Registered Dietitian will document in a progress note and communicate nutritional recommendations to the Primary Medical Doctor (PMD). [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure the Facility Assessment was updated to reflect the actual staffing levels. Specifically, the Facility assessment dated [DATE] inaccurately reflected the number of Registered Nurse Supervisors needed during the 11:00 PM-7:00 AM shifts and the number of Registered Nurses needed on the first floor during the 7:00 AM-3:00 PM shifts. The finding is:The facility policy, titled Facility Assessment, dated 01/15/2024, documented the interdisciplinary team members will conduct a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The interdisciplinary team will review and update the assessment as necessary and at least annually. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #142) of three (3) residents reviewed for Transmission Based Precautions and for one (1) (Resident #7) of six (6) residents reviewed for Nutrition. Specifically, 1) Resident #142's Interim Payment Assessment (IPA), dated 07/25/2025, did not correctly reflect Resident #142's Isolation or Quarantine status for an active infectious disease. 2) Resident #7 had a significant weight loss, which was not identified in the significant change Minimum Data Set assessment dated [DATE].

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that all investigations were thoroughly investigated to rule out abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #206) of eight residents reviewed for Accidents. Specifically, Resident #206 was noted with swelling and ecchymosis (bruise) of unknown source to the left shoulder and chest on 1/5/2024. The facility did not have documented evidence that an investigation was conducted to rule out abuse, neglect, or mistreatment. The finding is: The facility policy titled, Accident Incident Reporting dated 12/4/2023 documented that if a staff member discovers an abrasion, bruise, or skin tear on a resident an accident/incident report should be completed. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024, the facility did not ensure that a comprehensive person-centered care plan (CCP) was implemented to meet the resident's medical and nursing needs to include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #156) of six residents observed during the medication administration task Specifically, Resident #156 had a physician's order to administer Timolol Maleate Ophthalmic solution eye drops to both eyes every day for Glaucoma. The comprehensive care plan initiated on 7/6/2020 for the visual function was not updated to reflect the administration of the Timolol Maleate Ophthalmic solution eye drops until 3/5/2024. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for one (Resident #192) of three residents reviewed for skin conditions. Specifically, Resident #192, with a chronic large salivary gland mass with a history of intermittent oozing from the mass, was observed on 3/4/2024 with a dressing to the right side of the jaw/neck area. The Electronic Medical Record lacked documented evidence of a physician's order for the dressing or treatment to the affected site. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident #233) of six residents reviewed for Respiratory Care. Specifically, Resident #233 had a physician's order to receive oxygen at 3-10 Liters per minute via a nasal cannula. There were no physician's orders or parameters established to guide the facility staff on when and how much oxygen to administer to the resident (3-10 liters per minute) based on the resident's clinical condition. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024 the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #156) of six residents observed during medication administration task. Specifically, the label on Resident #156's eye drop medication bottle, Timolol (administered for Glaucoma), did not match the physician's order. The finding is: The facility's policy titled Administration of Ophthalmics, dated 5/2/2023, documented for the nurses to check medication labels against medication administration records three times to ensure the correct resident, drug, dose, and time of administration. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey and Abbreviated survey (NY 00286986) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that all accidents and incidents are thoroughly investigated to rule out Abuse, Neglect, or Mistreatment. This was identified for 1 (Resident #65) of 7 residents reviewed for Accidents. Specifically, Resident #65 exited an alarmed stair door and was found in the stairwell on 11/22/2021. The facility did not determine a timeline of preceding events that led up to the fall and if the resident was adequately supervised by staff. Additionally, an assessment of the events including the mobility device used by the resident, the position of the resident upon discovery of the falls, and the extent of the resident's injuries were not documented on the facility's investigation report. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00292844) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not develop a Comprehensive Care Plan (CCP) for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #319) of two residents reviewed for Infection Control. Specifically, Resident #319 was diagnosed with Pneumonia on 3/13/2022 and treated with intravenous (IV) antibiotics, however, there was no CCP developed to address the resident's Pneumonia diagnosis and use of the IV antibiotics. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00292844) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that services provided or arranged by the facility met professional standards of quality. This was identified for one (Resident #319) of two residents reviewed for Infection Control. Specifically, 1)Resident #319 was diagnosed with Pneumonia on 3/13/2022 and treated with intravenous (IV) antibiotics, however, there was no documented evidence in the resident's Electronic Medical Record (EMR) that indicated when the IV line was placed, where the IV line was placed (the access site), and the type of catheter used for the IV line. 2) There was no documented evidence that the IV line was flushed before and after the administration of the IV antibiotics. The finding is: [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY00286986) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that each resident received adequate supervision to prevent an avoidable accident. This was identified for 1 (Resident #65) of 7 residents reviewed for accident hazards. Specifically, Resident #65, with a history of multiple falls was assessed as high risk for falls and required 30-minute monitoring as per the Comprehensive Care Plan. On 11/22/2021, Resident #65 breached an alarmed door without the staff knowledge and fell down a flight of stairs with their wheelchair. Additionally, the facility did not have documented evidence that the resident was monitored every 30 minutes as per their Comprehensive Care Plan. The finding is: [...]

Inspectors wroteBased on record review and staff interview during the Recertification Survey initiated on 4/26/2022 and completed on 5/3/2022 the facility did not ensure that the ordering Physician was notified promptly of laboratory results that fall outside of clinical reference ranges. This was identified for 1 (Resident #97) of 4 residents reviewed for tube feeding. Specifically, Resident #97 had an elevated Blood Urea Nitrogen (BUN) and Creatinine level (blood levels used to determine kidney function). There was no documented evidence that the laboratory results were reviewed by the nursing staff and that the ordering Physician was notified of the abnormal levels. The finding is: The facility Laboratory Test Orders and Review Policy and Procedure last updated 11/12/2021 documented the Primary Medical Doctor (PMD) will be notified of all abnormal lab results during the 7 AM-3PM shift. [...]

Inspectors wroteBased on observation, interview and record review during the Recertification and Abbreviated survey (Complaint #NY00285890) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #269) of 3 residents reviewed for Activities of Daily Living. Specifically, Resident #269 was administered the first Mantoux Purified Protein Derivative (PPD) on 9/27/2021, however, the facility staff did not document the site of administration and did not read the results as per the facility policy. The finding is: [...]