Pathways Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing level of Certified Nurse Aides was not consistently met every day on 3 of 3 Nursing units from 12/07/2024 to 1/08/2025. This is evidenced by: Upon entrance to the facility on [DATE], there were 106 residents residing on 3 units. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) an opened medication had no open and/or expiration date; (b) 3 medications were passed expiration dates; (c.) medication requiring refrigeration were stored in the medication cart unrefrigerated, and (d.) shift change narcotic count signatures were missing on several dates, for 3 out of 3 medication carts reviewed. This is evidenced by: The Facility's Policy and Procedure titled, Medication Storage, revised 1/03/2017, documented, Medications listed in Schedules II, III, IV, and V would be stored under double locked conditions. The access key to the controlled medications was not the same key that allowed access to other medications. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for 2 (Resident #s 39 and 65) of 106 residents reviewed. This is evidenced by: The Policy and Procedure titled, Resident Rights and Dignity, revised 11/2018, documented it was the facility's policy to ensure that all residents' rights were ensured and respected. In addition, the facility would maintain strict adherence to state and federal guidelines with regards to granting residents' rights, maintaining resident dignity, and ensuring a pleasant and home-like environment for residents and their families. Resident #39: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 (Resident # ' s 30 and 64) of 24 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #30 and 64. This is evidenced by: The facility Policy titled, Assessment Prior to Admission, last revised September 2011 documented recipient was to be admitted without an assessment prior to admission of the need for the intended level of care using New York State mandated forms. The screen must be completed and signed by a qualified professional. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 (Resident #10) of 3 residents reviewed. Specifically, Resident #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The facility's Policy and Procedure titled, Activities, effective 9/30/2023, documented, the purpose was to provide structured and engaging activities that promoted the physical, mental, and emotional well-being of all participants, ensuring compliance with New York State Department of Health and Centers for Medicare & Medicaid Services regulations. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case # NY00269229), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (1) (Resident #1) of five (5) [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey on 04/13/2022 through 04/19/2022 and abbreviated survey (Case #NY00290615), the facility did not maintain medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 3 (Resident #'s 2, 32, and 89) of 21 residents reviewed. Specifically, the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care was complete and accurate. This was evidenced by: The Policy and Procedure titled Documentation and dated 05/2019 documented, the clinical team shall document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Documentation is relevant as evidence of clinical practice. Resident #2: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #12, 23, 26, 30, 86, and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, the facility did not ensure CCPs were individualized and included person-centered interventions for Resident #12's mood state and cognitive function; for Resident #'s 26 and #30's mood state; for Resident #91's communication, behavior, and mood state; for Resident #86's behavior and mood state; and for Resident #23, the facility did not ensure the CCP included Range of Motion (ROM) care needs. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (Resident #24) of one reviewed for activities. Specifically, facility did not ensure that the resident received ongoing and appropriate activities based on the resident's abilities. This is evidenced by: Resident #24: The resident was admitted with diagnoses of chromosomal anomalies, epilepsy, and reflux. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 (Resident #'s 41 & #76) of 3 residents reviewed. Specifically, for Resident #'s 41 and #76, the facility did not ensure the residents were provided with ROM with morning care. This was evidenced by: The Policy and Procedure (P&P) titled Range of Motion (undated) documented ROM should be performed at least two times per day; Once with AM care and once with PM care. Do each exercise/stretch 3-5 times or move the joint to the end range and hold for 10-15 seconds. Resident #41: The resident was admitted to the facility with the diagnoses of anoxic brain damage, respiratory failure and dysphagia. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates are not 5 percent or greater. Specifically, during a medication pass observation, the facility did not ensure that the medication rate was at or below 5%. This is evidenced by: A facility policy titled Metered Dose inhalers (MDI) and dry powder inhalers (DPI) last revised 2/15/18, documented that nursing staff will administer medications via MDI or DPI to maintain airway patency and improve respiratory function. When using a MDI, allow at least one minute for resident to rest between inhalations and for a DPI to allow at least one minute between inhalations and to repeat process until the total number of inhalations ordered is administered. Medical Doctor (MD) order dated 11/28/19, documented the following: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that 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 one (Resident #96) of three residents observed for dressing changes. Specifically, for Resident #96, the facility did not ensure infection control measures were maintained during a dressing change. This is evidenced by: Resident #96: The resident was admitted to the facility with diagnoses of dementia, cerebral infarction, and mood disorder. The Minimum Data Set (MDS - an assessment tool) dated 11/14/19 documented the resident had severely impaired cognition, could understand others and could make self understood. [...]