Mvhs Rehabilitation and Nursing Center

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure a process was in place for residents to have their grievances addressed appropriately for all190 of 190 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, 8 of 8 anonymous residents present at the resident group meeting did not know where to obtain grievances forms or their right to file anonymously and did not know who the facility grievance officer was.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure each resident received and the facility provided food that accommodated allergies, intolerances and preferences for 12 of 18 residents (Resident #3, #17, #47, #56, #67, #86, #110, #117, #146, #150, #158 and #187) reviewed. Specifically, Residents #3, #17, #47, #56, #67, #86, #110, #117, #146, #150, #158 and #187 were not provided hot beverages as specified on their meal ticket.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service for one (1) of three (3) walk-in coolers (the meat and dairy cooler) in the main kitchen. Specifically, the meat and dairy walk-in cooler did not maintain food temperatures below 41 degrees Fahrenheit as required.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure residents were screened for serious mental disorders, intellectual disabilities, and related conditions prior to admission to the facility for 1 of 35 residents (Resident #8) reviewed. Specifically, there was no documented evidence Resident #8 had a Preadmission Screening and Resident Review Level I completed by a qualified screener prior to admission to the facility to determine if the resident had a mental disorder, intellectual disability, or a related condition.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 7/16/2025 -7/22/2025 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 8 anonymous residents who expressed concerns regarding the lack of sufficient staffing and 2 of 2 residents (Residents #56 and #135) who experienced prolonged wait time for care. Specifically, during a confidential group meeting (resident council) 8 anonymous residents stated the facility was frequently short staffed and there were often only two certified nurse aides assigned to a unit; and Residents #56 and #135 had prolonged call bell response times.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not establish and 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 (1) of seven (7) residents (Resident #91) reviewed. Specifically, Resident #91 was on enteric pathogen precautions for active clostridium difficile (a contagious bacteria causing inflammation of the colon). Housekeeper #7 entered and cleaned the room without wearing required personal protective equipment, and Certified Nurse Aide #9 entered the room and delivered a meal tray without wearing required personal protective equipment.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00326875), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1: - did not have physician's orders implemented on admission for the care of their urinary catheter (tube that drains urine from the bladder), colostomy (artificial opening in the abdomen draining stool into a bag), and peripherally inserted central catheter (PICC, for intravenous medication) line. - Did not have a comprehensive care plan (CCP) developed and implemented on admission to direct staff in caring for the urinary catheter, colostomy, and PICC line. - Did not have a follow-up appointment scheduled with infectious diseases (ID) timely after order. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/24/21-5/28/21, the facility did not ensure food and drinks were palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meals (5/26/21 lunch, 5/27/21 lunch, and 5/28/21 lunch) reviewed. Specifically, food and drinks were not served at palatable temperatures including chef salad, lemon mousse, yogurt, turkey and cheese sandwich, tossed salad, fries, coleslaw and milk).

Inspectors wroteBased on observation and interview during the recertification survey conducted from 5/24/21-5/28/21, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in three isolated rooms (the main kitchen, the [NAME] nourishment room, the [NAME] North staff lounge, and the [NAME] North nourishment room). Specifically, in the main kitchen there were 4 whole pork roasts not cooled safely after being cooked, miscellaneous debris on the floors of the walk-in freezer and dairy cooler, outdated food in the cooler, an unclean slicer, and a section of the hood vent was missing; in the [NAME] unit nourishment room there was a broken refrigerator; and in the [NAME] North nourishment room there were loose miscellaneous sized cup lids and cups not protected from dust/debris.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 5/24/21-5/28/21, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 5 unit nourishment preparation rooms ([NAME] West, [NAME] East and [NAME] North) reviewed. Specifically, the [NAME] and the [NAME] North unit nourishment preparation room had electric steam tables turned on and the room was unlocked and accessible to residents. The [NAME] East unit nourishment preparation room had a steam table with a missing knob and staff were not aware if it was turned off or on.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00275797) conducted from 5/24/21-5/28/21 the facility did not implement corrective measures after an allegation of abuse was made for 1 of 2 residents (Resident #56) reviewed. Specifically, Resident #56 alleged rough treatment by certified nurse aide (CNA) #22. The facility's plan to prohibit CNA #22 from no longer caring for the resident was not documented and not implemented as planned as a corrective measure to prevent further allegations of abuse.

Inspectors wroteBased on observation, interview, and record review during a recertification survey conducted from 5/24/21-5/28/21, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Residents #12 and #95) reviewed. Specifically, Resident #12 rode the elevator to an unsupervised area of the facility where they fell out of their wheelchair. The resident was not re-assessed for wandering or elopement and the incident was not reported to the New York State Department of Health (NYS DOH) as required. Additionally, a plan was not implemented to prevent residents without wanderguards from going to the basement (a non-resident area). [...]