Gurwin Jewish Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews 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 #11) of three (3) residents reviewed for Physical Restraints. Specifically, Resident #11's Minimum Data Set assessments dated 10/31/2025 and 11/11/2025 inaccurately documented that Resident #11 used physical restraint in a chair or out of bed daily. The finding is: The facility's policy titled Minimum Data Set Accuracy last revised on 09/2025, documented the Minimum Data Set Assessor will ensure the Minimum Data Set is coded accurately to reflect the resident's status. All Minimum Data Set assessments must be completed accurately and within the required timeframes. Minimum Data Set coding must be supported by clinical documentation in the medical record. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This was identified for one (1) (Resident #30) of three (3) residents reviewed for Activity of Daily Living. Specifically, Resident #30 had limited range of motion for both hands and required assistance with hand hygiene. The resident was observed with accumulation of moisture and brown sticky substance with a strong odor in the resident's hands. The assigned Certified Nursing Assistant #8 acknowledged not providing hand hygiene to the resident due to not being able to open the resident's hands. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review (Complaint #2698214), the facility did not ensure each resident environment remained as free of accident hazards as possible. This was identified for one (1) (Resident #473) of five (5) residents reviewed for Accidents. Specifically, Resident #473 required two (2) person assistance for transfers as per their plan of care. On 12/19/2025, the assigned Certified Nursing Assistant #5 transferred Resident #473 alone from the wheelchair to a shower chair, resulting in the resident sustaining multiple skin tears to the right hand, left hand, and left shin. The finding is:A facility policy titled Activities of Daily Living last revised 09/2022 documented Certified Nursing Assistants must review the Certified Nursing Assistant Taks List and Kardex to ensure adherence to the resident's plan of care. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure the irregularities identified by the Pharmacist during the drug regimen review was documented on a separate, written report and the attending Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address the recommendations. This was identified for one (1) (Resident #358) of five (5) residents reviewed for Unnecessary Medications. Specifically, Pharmacist #1 documented a medication regimen review recommendation in Resident #358's medical record on 12/2/2025 to review duplicate use of sleeping agents Melatonin (a sleep medication) and Ramelteon (a prescription sleep medication for adults with sleeping difficulty-a melatonin receptor). [...]

Inspectors wroteBased on observation, record review, and interviews the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (1) (Resident #432) of nine (9) residents reviewed for Infection Control. Specifically, Resident #432 had a physician's order for contact isolation precautions for a diagnosis of shingles (blistering skin rash caused by the reactivation of the varicella-zoster virus). Certified Nursing Assistant #1 was observed in Resident #432's room making the resident's bed without wearing appropriate personal protective equipment. The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that a person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's needs was developed timely and implemented accurately. This was identified for one (Resident #210) of five residents reviewed for Respiratory Care. Specifically, Resident #210 had a physician's order for oxygen therapy at one liter per minute via nasal cannula. During three seperate observations, Resident #210 was observed receiving oxygen at three liters per minute. Additionally, there was no documented evidence that a comprehensive care plan for the resident's Respiratory Status was developed in a timely manner. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00321973) initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. This was identified for one (Resident #90) of two residents reviewed for abuse. Specifically, Resident #90 was involved in a resident-to-resident altercation on 8/11/2023 and sustained a 4-centimeter by 4-centimeter Hematoma (bruise) to their left forearm. The comprehensive care plan for Resident #90 was not reviewed or revised to reflect the altercation. The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that each resident who needs respiratory care is provided such care consistent in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #210) of five residents reviewed for Respiratory Care. Specifically, Resident #210 had a Physician's order for oxygen to be administered at one liter per minute via nasal cannula. On three separate occasions, the resident was observed receiving oxygen at three liters per minute. The finding is: The facility's oxygen policy and procedure dated 7/2023 documented to check the physician's order for the rate of flow and type of mask used. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that the facility's medication error rate was not five percent or greater. This was identified for three of the 27 medications observed during the medication pass observation, resulting in an 11.11% medication error rate. Specifically, during a medication pass observation Resident #155 did not receive three of their 8:00 AM physician-ordered medications until 11:46 AM on 5/15/2024. The finding is: The Facility's Policy for Administering Medications revised on 1/12/2024 documented that medications should be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Resident #155 was admitted with diagnoses that include Dementia and Hypertension. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024 the facility did not ensure that all drugs were labeled and stored in accordance with professional standards including the expiration dates. This was identified for 1) one (medication cart on Unit 2) of thirteen medication carts observed during the medication storage task, and 2) one (Unit 4 medication room) of seven medication rooms reviewed for the medication storage task. Specifically, 1) On 5/22/2024, Unit 2's medication cart was observed with an expired Fluticasone inhaler. The label on the inhaler had Resident #371's name with an expiration date of 5/15/2024. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/15/24-5/23/24, the facility did not ensure each resident was provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This was identified for one (Resident #36) of five residents reviewed for Nutrition. Specifically, Resident #36 verbalized disliking the food served to them and requested a burger as a preferred meal. The facility did not honor the resident's preference and only provided a burger meal once in three weeks.

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY 00282941 and NY 00277891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. This was identified for 2 (Resident #394 and Resident #35) of 7 residents reviewed for Accidents . Specifically, 1) Resident #394 required bilateral Ankle-Foot Orthoses (AFO) and Darco shoes (special orthopedic shoes) and two-person assistance for transfers from one surface to another. On 9/8/2021 Certified Nursing Assistant (CNA) #3 transferred Resident #394 without using the AFO and the Darco shoes and without the assistance of a qualified staff member to transfer the resident from the wheelchair to the bed. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification survey and Abbreviated Survey (NY 00286250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for one (Resident #489) of two residents reviewed for dignity. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower. Resident #489's right to refuse the shower was not honored; and the staff administered the shower even though the resident refused to be showered. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00286250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. This was identified for one (Resident #489) of one resident reviewed for choices. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower and the staff administered the shower even though the resident refused to be showered. The finding is: The facility Bathing/Personal Care Policy dated 10/2008 documented if the resident refuses the bath/shower, the nurse is to be notified. This is to be noted by the nurse in a quick note in the electronic medical record (EMR). [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00277891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not report an alleged violation related to an injury that resulted from not following the resident's plan of care to the New York State Department of Health (NYSDOH) within the required 24 hours. This was identified for one (Resident #35) of six residents reviewed for Accidents. Specifically, Resident #35 fell from their bed on 6/8/2021 which resulted in an injury, however the facility did not report the injury to the NYSDOH until 6/15/2021. The finding is: The facility's policy and procedure entitled Free From Abuse and Neglect dated 9/2017 documented: One element is needed for an incident of neglect to be reported to DOH: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure residents who need respiratory care, including tracheostomy care, are provided such care consistent with professional standards of practice and the Comprehensive Person-Centered Care Plan. This was evident for one (Resident #88) of five residents reviewed for respiratory care. Specifically, Resident #88 had a Physician's order to change the tracheostomy inner cannula once a day. During an observation of the tracheostomy care on 8/17/2022, Resident #88 was observed without a disposable inner cannula in place. The finding is: The facility Policy and Procedure dated 8/1996, and last updated on 8/17/2022 for Tracheostomy care documented: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Post Survey Revisit (PSR) conducted on 10/21/2022, the facility did not maintain 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 one (Resident #1) of three residents reviewed for tracheostomy care. Specifically, during observation of tracheostomy care for Resident #1, who was on Contact and Droplet precautions due to Carbapenem-resistant Enterobacterales (CRE) in sputum and Extended Spectrum Beta-Lactamase (ESBL) infection in the urine, Respiratory Therapist (RT) # 1 did not utilize appropriate Personal Protective Equipment (PPE); did not follow infection control protocols while changing the tracheostomy inner cannula; [...]