Northwoods Rehab and Nursing Center at Moravia

Inspectors wroteBased on record review and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure there were services of a Registered Nurse for at least eight consecutive hours, seven days a week. Specifically, the facility did not provide eight (8) consecutive hours of Registered Nurse coverage on 9/6/2025, 9/14/2025, 9/15/2025-9/18/2025, and 9/21/2025 as required, and did not have a waiver.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of two (2) medication carts (Sides 1 and 2 medication carts), one (1) of one (1) medication room, and one (1) of one (1) treatment cart reviewed. Specifically, the Side 1 medication cart contained medications that were not dated when opened, and expired medications; the Side 1 and Side 2 medication carts and treatment cart were unlocked and unattended; and the medication room refrigerator was unclean and had a large buildup of ice on the back.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (IQIES 676829) surveys conducted 9/22/2025-9/25/2025, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (2) of four (4) residents (Residents #32 and #45) reviewed. Specifically, the facility did not complete a thorough investigation after neglect related to medication errors and did not report the incidents to the New York State Department of Health as required.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure the activities program was directed by a qualified person responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. Specifically, Director of Activities #9 was not qualified to direct the provision of activities to the residents.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 had wound treatment order changes that were not implemented, did not have weekly wound follow-up as recommended, and the wounds to the right foot were not included in the comprehensive care plan.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/22/2025-9/25/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of one (1) Resident (Resident #31) reviewed. Specifically, Resident #31 had significant weight loss and did not receive their planned nutritional supplement or a comparable substitution.

Inspectors wroteBased on record review and interviews during the recertification survey and abbreviated (NY00361275) surveys the facility did not ensure residents were free of significant medications errors for two (2) of two (2) residents (Residents #32 and #45) reviewed. Specifically, Registered Nurse #16 falsely documented administering clonazepam (antianxiety medication) to Resident #32 and failed to administer multiple doses of an intravenous antibiotic to Resident #45.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/10/2024 through 6/13/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 12 residents (Residents # 6, #9 and # 13) reviewed. Specifically, Resident #6 was not care planned for contractures; and Resident # 9 and Resident #13 were not cared planned for anticoagulant (drug used to prevent blood clots from forming or traveling to vital organs) therapy. Findings Include: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00312820) surveys conducted 6/10/2024-6/13/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 4 residents (Resident #22) reviewed. Specifically, Resident #22 was not assisted with shaving unwanted facial hair.

Inspectors wroteBased on record review and interview during the recertification survey conducted from 6/10/2024-6/13/2/24, the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Side 2) reviewed. Specifically, Side 2 medication cart had three medicated eye drops that were opened and not dated.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated (NY00312820) surveys conducted 6/10/2024 - 6/13/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test trays reviewed (6/11/2024 lunch meal). Specifically, the lunch tray included foods that were not palatable or served at safe and appetizing temperatures.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 6/10/2024 -6/13/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the floors under the dish machine and the walk-in cooler were unclean with food debris and there was brown liquid spilled on the walk-in cooler floor.

Inspectors wroteBased on observation and interviews during the recertification survey conducted 6/10/2024-6/13/2024, the facility did not post the following required information on a daily basis: the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 4 of 4 days reviewed. Specifically, the facility did not post the resident census and nurse staffing information daily, as required.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 5/23-5/25/22, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent for 4 of 12 residents (Residents #4, 9, 24 and 35) reviewed. Specifically, - for Residents 4, 9, 24, and 35 there was no documentation bed rail assessments were completed, no documentation the risks/benefits of bed rails was explained to the resident/representative prior to their implementation, no physician orders for bed rails, and the care instructions and comprehensive care plans (CCP) did not document a plan for bed rail use. - Residents #4 and 35 did not have consent for bed rail use provided by their designated representative.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00282267 and NY00292425) conducted 5/23/22-5/25/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 4 residents (Resident #2). Specifically, Resident #2 was not assisted with shaving as frequently as they preferred.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/23/22-5/25/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #35) reviewed. Specifically, Resident #35 had a significant weight loss and a recommendation by the registered dietitian (RD) to increase a nutritional supplement was not implemented.

Inspectors wroteBased on observation and interview during the recertification survey conducted 5/23/22-5/25/22, the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test trays reviewed (5/25/22 lunch meal). Specifically, the lunch tray included foods that were not palatable or served at safe and appetizing temperatures.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 5/23/22-5/25/22, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen. Specifically, the floors under the dishwasher and the walk-in cooler in the main kitchen were unclean and black with food debris; the exhaust hood over the stove was dust laden and unclean with grease build up; and there was a bag of frozen raw chicken stored above fully cooked rib and sausage patties.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 5/23/22-5/25/22, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 1 of 10 resident beds (Resident #24). Specifically, when Resident #24's bed rails were checked for possible zones of entrapment using the Bionex bed entrapment device, the rails failed for zones 1 (within the bedrail) and 2 (top of compressed mattress to bottom of bedrail, between bedrail and supports).

Inspectors wroteBased on record review and interview during the recertification survey conducted 5/23-5/25/22, the facility failed to inform each resident and/or their designated representatives of changes to services covered by Medicare and potential financial liability for services provided during a non-covered stay for 2 of 3 residents (Residents #15 and 36) reviewed. Specifically, Residents #15 and 36 had facility-initiated discharges from Medicare Part A services when benefit days were not exhausted, remained in the facility, and were not provided with the SNF (Skilled Nursing Facility) ABN (Advanced Beneficiary Notice), Form CMS (Centers for Medicaid and Medicare Services)-10055 as required.