New Lebanon Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, staff interview and policy review, the facility failed to prepare, store, and distribute food in a safe manner. This had the potential to affect all 96 residents who received food from the facility. The facility census was 96Findings include:1. Observation on 09/22/25 at 8:23 A.M. revealed during the initial tour with the DM #155 revealed a swarm of flying gnats throughout the kitchen areas. Interview on 09/22/25 at 8:25 A.M. confirmed the facility has an ongoing issue with fruit flies and gnats. DM #155 stated she will check to ensure she does not have overripe bananas as she peered over a box of bananas and confirmed that is not the issue to cause the active gnats. DM #155 stated the facility has an ongoing issue with active gnats in the kitchen.2. Observation on 09/23/25 at 3:01 P.M. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide medical records to a resident upon his or her request. This affected one (#37) out of one residents reviewed for medical record request. The facility census was 96.

Inspectors wroteBased on record review, resident, family and staff interviews, review of the grievance log, and policy review, the facility failed to complete thorough investigations for complaints of missing items. This affected one (#76) of two residents sampled for missing items. The facility census was 96.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to develop comprehensive person-centered care plans. This affected two (#49 and #76) residents out of 23 residents reviewed for comprehensive person-centered care plans. The facility census was 96.

Inspectors wroteBased on review of the medical record, observations, resident and staff interviews, and policy review, the facility failed to ensure residents received showers. This affected three (#76, #37, and #92) of ten residents sampled for bathing assistance. The facility census was 96.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to provide activities designed to meet resident needs. This affected one (#29) resident of one resident reviewed for activities. The facility census was 96.

Inspectors wroteBased on medical record review, staff interviews, and review of facility timeline documentation, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#70) resident out of three residents reviewed for accidents. The facility census was 96.

Inspectors wroteBased on review of the medical record. staff interview and review of guidelines from the National Institute of Health, the facility failed to ensure non-rebreather masks were used according to professional standards. This affected one (#108) of one residents sampled for respiratory services. The facility census was 96.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to administer medications as ordered. This affected one (#70) out of four residents reviewed for medication administration. The facility census was 96.

Inspectors wroteBased on record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were stored appropriately. This affected two (#15 and #97) of five residents reviewed for medication storage. The facility census was 96.

Inspectors wroteBased on medical record reviews, observations, and resident and staff interviews, the facility failed to maintain a pest free environment. This affected three (#49, #61, and #96) residents out of six residents reviewed for pest control. The facility census was 96.

Inspectors wroteBased on record review, observations, staff interviews and review of facility policy the facility failed to ensure smoking items were properly stored according to policy. This affected two (#49 and #16) of four residents reviewed for smoking. The facility census was 96.

Inspectors wroteBased on record review, staff interview, review of the directive from Centers for Medicare and Medicaid Services (CMS), and facility policy review, the facility failed to notify the local health department of a COVID-19 facility outbreak that began on 11/16/24 and ended on 12/24/24. This had the potential to affect all residents in the facility. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, review of hospital documentation, review of Omnicell (automatic medication dispensing cabinet) documentation, and policy review, the facility failed to administer medication as ordered. This affected one (#97) out of three residents reviewed for medication administration. The facility census was 96.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#09) out of the two residents observed for medication administration. The facility census was 96.

Inspectors wroteBased on medical record reviews, staff interviews, observations, and pest control invoices, the facility failed to ensure resident rooms were free from flies and gnats. This affected two (#11 and #13) out of the three reviewed for environment. The facility census was 96.

Inspectors wroteBased on record review, interview, observation, nursing staff schedule review, facility assessment review, and policy review, the facility failed to maintain sufficient levels of state tested nursing staff and licensed nursing staff to meet the total care needs of all facility residents. This resulted in Immediate Jeopardy when on 08/26/24 at 7:00 A.M., there were three licensed practical nurses (LPN) and two state tested nurse aides (STNA) on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 105 residents residing in the facility. [...]

Inspectors wroteBased on record review, observation, interview, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to provide adequate care and services to prevent and timely identify pressure ulcers and injuries for Residents #37, #86, and #4. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or negative health outcomes, when Resident #37 developed six facility acquired deep tissue pressure injuries and was hospitalized for osteomyelitis. Additionally, Resident #86 developed facility acquired unstageable (the base of the wound is covered by dead tissue) pressure ulcers to the coccyx, left heel, and left lateral ankle, and was hospitalized for osteomyelitis. [...]

Inspectors wroteBased on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, and staff interview, the facility failed to be administered in a manner to ensure proper care and services for residents. This had the potential to affect all 105 residents residing in the facility. The census was 105.

Inspectors wroteBased on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, staff interview, and policy review, the facility failed to have an effective governing body to oversee the functions of the facility. This had the potential to affect all 105 residents in the facility. The census was 105.

Inspectors wroteBased on facility assessment review and staff interview, the facility failed to include staffing needs for each resident unit within the facility and time frames for adjustments as necessary with changes in the resident population. This has the potential to affect all residents in the facility. The facility census was 105.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure appropriate and adequate oversight by the Medical Director. This had the potential to affect all 105 residents residing in the facility. The census was 105.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to make good faith attempts to correct identified concerns with appropriate oversight from leadership as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 105 residents residing in the facility. The census was 105.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff followed infection control precautions related to handling soiled linens, providing care for residents on enhanced barrier precautions, and providing meals and eating assistance with proper hand hygiene. This had the potential to affected all 105 residents residing in the facility. The facility census was 105.

Inspectors wroteBased on record review, review of facility Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to thoroughly investigate resident-to-resident altercations. This affected six (Residents #69, #72, #74, #79, #91, and #152) of six residents reviewed for abuse. The facility census was 105.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received care and services in a timely manner. This affected four (Residents #4, #6, #41 and #50) of four residents reviewed for care and services. The facility census was 105.

Inspectors wroteBased on observation, record review, interview and policy review, the facility to ensure residents did not have their smoking equipment in their rooms. This affected three (Residents #51, #68 and #77) residents. The facility identified 47 residents who used tobacco products. The facility census was 105.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure resident privacy. This affected one (Resident #5) of two residents reviewed for dignity and respect. The facility census was 105.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure call lights were within reach. This affected one (Resident #15) of four residents reviewed for accommodations of needs. The facility census was 105.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to notify a resident representative of a change in condition. This affected one (Resident #87) one resident reviewed for notification. The facility census was 105.

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to remain in the facility and not transfer or discharge a resident from the facility without the proper documentation. This affected one (Resident #100) of three residents reviewed for transfer or discharge. The facility census was 105.

Inspectors wroteBased on interview and record review, the facility failed to provide notification to a resident of the transfer or discharge and the reasons for the move to a resident that was discharged to a homeless shelter. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105.

Inspectors wroteBased on interview and record review, the facility failed sufficiently prepare and orient a resident to ensure a safe and orderly discharge from the facility. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately. This affected three (Residents #41, #62, and #77) of twelve residents reviewed for MDS accuracy. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for residents with a change in their mental health or physical condition. This affected two (Residents #04 and #79) of five resident reviewed for PASARR. The facility census was 105.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to develop comprehensive care plans for residents. This affected three (Residents #04, #62, #77) of twelve residents reviewed for care plans. The facility census was 105.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to revise the plans of care timely and failed to conduct care conferences as required. This affected three (Residents #46, #77, and #92) of three residents reviewed for care planning. The facility census was 105.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure a resident had an order for a dressing change and failed to change the dressing as ordered; failed to ensure transportation was provided to appointments; and failed to timely address a change in condition. This affected three (Residents #86, #87 and #303) residents. Seven residents were reviewed for wound care, and two residents were reviewed for transportation and changes in condition. The facility census was 105.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure catheter care was provided appropriately. This affected one (Resident #46) of two residents reviewed for urinary concerns. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician approved admission to the facility in writing. This affected three (Residents #58, #85, and #92) out of five residents reviewed for physician services. The facility census was 105.

Inspectors wroteBased on interview and record review, the facility failed ensure medically related social services was provided to a resident discharging from the facility. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure laboratory tests were obtained per physician orders. This affected two (Residents #16 and #77) of five reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to schedule an oral surgeon appointment timely for one (Resident #62) of one resident reviewed for dental concerns. The facility census was 105.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure residents received drinks of their preference and request in a timely manner. This affected one (Resident #13) of 25 residents residing in the memory care unit. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident medical records were complete and accurately documented. This affected one (Resident #87) one resident reviewed for notification. The facility census was 105.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents received pneumococcal vaccinations as ordered. This affected two (Residents #38 and #71) of five residents reviewed for immunizations. The facility census was 105.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to maintain a safe environment. This affected one (Resident #76) out of one resident reviewed for environment. The facility census was 105.

Inspectors wroteBased on observation, medical record review, staff interview, review of pest control visit documentation, and review of a facility policy, the facility failed to maintain an environment which was free from pests. This affected two (Residents #4 and #5) of two reviewed for environment. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were seen by the physician upon admission. This affected three (Resident #58, #87 and #92) of three reviewed for physician visits. The facility census was 105.

Inspectors wroteBased on observation, interview and policy review the facility failed to post nurse staffing information in a clear visible place. This had the potential to affect all residents residing in the facility. The facility census is 105.

Inspectors wroteBased on medical record review and staff, resident and resident representative interviews, the facility failed to provide adequate supervision to ensure a resident, that had an order for supervised Leave of Absence (LOA), did not leave the facility unsupervised. This affected one (#06) out of three reviewed for elopement. The facility census was 96.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure staff implemented assistance and/or supervision with meals in accordance with a resident's care plan. This affected one (#20) out of three residents reviewed for assistance with feeding. The facility census was 94.

Inspectors wroteBased on record review, observations, staff and resident interviews, the facility failed to ensure resident beds were working properly. This affected three (#14, #15 and #16) of four residents reviewed for the physical environment. The facility census was 91.

Inspectors wroteBased on medical record review, observations, staff interview, and policy review, the facility failed to ensure wound dressings were changed in a clean and sanitary manner. This affected two (#56 and #36) of three residents reviewed for wound care. The census was 86.

Inspectors wrote3. Review of the medical record for Resident #10 revealed an admission date of 11/06/21. Diagnoses included end stage renal disease, venous insufficiency, morbid obesity, chronic venous hypertension with inflammation of bilateral lower extremity, acute respiratory failure with hypercapnia, protein-calorie malnutrition, hypotension, cardiomegaly, secondary hyperparathyroidism of renal origin, heart failure, hypothyroidism, and type two diabetes mellitus with diabetic nephropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This resident was assessed to require limited assistance for transfer and toileting as well as supervision for bed mobility, dressing, and eating. [...]

Inspectors wroteBased on medical record review, staff and resident interviews and review of the facility policy, the facility failed to ensure baseline plan of care was completed within 48 hours of admission and failed to provide the baseline plan of care to a resident. This affected four (#225, #28, #285, #10) out of four residents reviewed for baseline plan of care. The facility census was 84.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to secure the maintenance room which contained multiple hazardous items. This had the potential to affect 23 (#18, #15, #11, #286, #42, #279, #3, #20, #38, #26, #25, #44, #65, #27, #34, #9, #50, #276, #12, #4, #63, #64 and #44) residents the facility identified as confused and independently mobile that could access the unlocked/unsecured area. The facility census was 84.

Inspectors wroteBased on observations, staff interviews and review of a daily cleaning list, the facility failed to ensure the kitchen equipment was kept sanitary. This had the potential to affect all resident receiving food from the facility kitchen, except four residents (#19, #229, #278, #14) that did not receive food prepared in the facility kitchen. The facility census was 84.

Inspectors wroteBased on medical record review, staff and resident interviews, and review of facility policy, the facility failed to issue bed hold notices to residents. This affected three (#21, #50, and #73) of six residents reviewed for hospitalization. Facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's preadmission screening and resident review (PASARR) was accurate. This affected one (#73) of two reviewed for PASARR. The census was 84.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure residents were properly groomed. This affected two (#19 and #50) of four residents reviewed for activities of daily living (ADL's) in the sample. The census was 84.

Inspectors wroteBased on medical record review, observations, and staff and resident interviews, the facility failed to ensure resident had privacy curtains. This affect two (#21, #22) out of two residents reviewed for privacy. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure all residents had a functioning call light. This affected one (#72) out of eight residents reviewed for call lights. The facility census was 84.