The Grand Rehabilitation and Nrsg at Guilderland

Inspectors wroteBased on observations, record review, and interviews during a recertification and abbreviated survey (Case #'s NY00363829, NY00364424, and NY00347964), the facility failed to ensure residents were free of any significant medication errors for five (5) (Resident #s 12, 23, 47, 77, and 327) of 10 residents reviewed for medication administration. Specifically, (a.) Resident #47 was not administered 12 days-worth of psychiatric medication from 11/25/2024 to 12/06/2024. Over the 12 days, the resident decompensated psychiatrically, and on 11/29/2024 at 9:00 AM, the resident requested to be sent to the hospital. (b.) Resident #12 was not administered their antibiotics (medication to treat active infections) 10 of 20 times as prescribed. (c.) Resident #23 was not administered antibiotics as prescribed, receiving only four (4) of eight (8) doses prescribed. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification and abbreviated survey (Case #NY00347964), 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 levels were not met each day from 2/22/2025 through 3/06/2025 per facility assessment and New York State Nursing Home Minimum Staffing and Direct Resident Care. This is evidenced by: Upon entrance to the facility on 2/22/2025 there were 123 residents residing on 3 units. Nursing Homes are required by New York State Public Health Law and Regulations to meet minimum staffing standards. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for two (2) (Resident #s 39 and 61) of 32 residents reviewed. Specifically, Resident #s 39 and 61 were not cared for in a manner that promoted maintenance or enhancement of quality of life by staff providing care. This is evidenced by: The Policy and Procedure titled, Resident Rights, reviewed 1/2025, documented employees would treat all residents with kindness, respect and dignity. Federal and state laws guaranteed certain basic rights to all residents in the facility. These rights included the resident's right to a dignified existence and be treated with respect, kindness, and dignity. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case # NY00347964), the facility did not provide effective housekeeping and maintenance services on 3 (A, B, and C) of 3 resident units. Specifically, floors, walls, window blinds, ceilings, and dining tables were not clean or maintained and obnoxious odors were detected. This is evidenced by: During observations on 2/23/2025 at 1:52 PM, a urine and fecal odor was detected on the B-Wing corridor, an unwashed body odor was detected by room B13, and trash was found on the floor in room B19. During observations on 02/24/2025 from 9:45 AM through 11:39 AM: • Strong urine odors were detected in the corridor outside rooms A01 through A05 and rooms B14 through B19. • The ventilation grid by the emergency exit on the B-Wing was soiled with a heavy dust build-up. [...]

Inspectors wroteBased on record review and interviews during the recertification and abbreviated survey (Case #NY00363829), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for eight (8) (Residents #12, 20, 23, 37, 47, 53, 110, and #231) of 32 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #12, there was no care plan developed and implemented for urinary tract infection with antibiotic treatment, diagnosed on [DATE]. (b.) for Resident #20, there was no comprehensive care plan in place to address podiatry issues; (c.) for Resident #23, there was no care plan for the use of Lotrisone Cream for fungal skin rash; [...]

Inspectors wroteBased on record reviews and interviews during a recertification and abbreviated survey (Case #NY00363829) , the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for eight (8) (Resident #'s 20, 23, 28, 47, 51, 84, 114, and 328) of 31 residents reviewed for comprehensive care plans. Specifically, for Resident #20, the care plan was revised to remove a medication that the resident was prescribed. Additionally, Resident #23's care plan for bladder incontinence with an intervention to monitor for signs and symptoms of urinary tract infection was not revised to include an infection diagnosed on [DATE]; Resident #28, the discharge planning care plan was not revised to reflect the resident's current status and goals; [...]

Inspectors wroteBased on record review, observations, and interviews during the recertification survey and an abbreviated survey (Case #s NY00369042 and NY00363829), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for five (5) (Resident #s 6, 14, 20, 23, and 77) of 32 residents reviewed. Specifically, [a.] Resident #6 who was newly admitted on [DATE] with diagnoses of diabetes, was to have blood sugar checks 3 times a day, per discharge paperwork. The facility did not check the resident's blood sugar until 1/11/2025 at 4:55 PM; [b.] Resident #14's clothes and bedding were not changed effectively; [c.] Resident #20 did not receive proper footcare; and [d.] for Resident #s 23 and 77, vital signs ordered daily and for changes in condition were not obtained, and did not monitor the resident's condition. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification and abbreviated survey (Case # NY00363829), the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for 2 (Resident #s 23 and 77) of 3 residents reviewed. Specifically, Resident #23 was ordered a topical medication for fungal infection that did not indicate where the medication was to be applied and/or the duration of use. For Resident #77, the provider did not evaluate a high potassium level on 12/17/2024, when the result was reported, and on 12/18/2024, when the provider saw the resident. This is evidenced by: Cross-referenced to F554: Resident Self-Administer Medications - Clinically Appropriate Cross-referenced to F760: Residents are Free of Significant Medication Errors Cross-referenced to F773: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (Case #s NY00343930, NY00347964, NY00354057, NY00363829, NY00364424, NY00364701, and NY00369042) , it was determined the facility and governing body failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F760: Residents are Free of Significant Medication Errors and F684 Quality of Care. Specifically, the facility's governing body did not ensure established policies regarding the management and operation of the facility were implemented. Subsequently, resident care was compromised. This is evidenced by: Facility was cited F760: Residents are Free of Significant Medication Errors Cross-referenced to F684: [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure medical records were kept in accordance with accepted professional standards. Medical records were not complete and accurate for three of three units and two (2 ) (Resident #'s 23 and 53) of 31 residents. Specifically, (a.) narcotic count record books for 3 of 3 units were incomplete; (b.) Resident #23's documentation of vital signs was either incomplete or duplicated; and (c.) for Resident #53, wound care documentation was inaccurate. This is evidenced by: A review of the narcotic count record book for Unit A, there were no documented evidence of Nurses signatures for the following: [...]

Inspectors wroteBased on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections for three (3) (Residents #s 110, 115, and 231) of 31 residents reviewed for infection control. Specifically for Residents #s 110, 115, and 231, the facility did not implement and maintain enhanced barrier precautions for residents with indwelling medical devices. This is evidenced by: The policy and procedure titled Barrier Enhanced Precautions reviewed 1/2025 documented nursing home resident with wounds and indwelling medical devices were at especially high risk for multi drug resistant organisms and the use of gown and gloves for high contact resident care activities was indicated. [...]

Inspectors wroteBased on observation, record review, and interview, during the recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for 1 (Resident #23) of 1 resident reviewed. Specifically, Resident #23 was observed with topical steroid cream in their room and there was no assessment in the medical record and/or physician order for the resident to self-administer the medication. This is evidenced by: Cross-referenced to F656: Develop/Implement Comprehensive Care Plan Cross-referenced to F711: [...]

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure residents were aware of the grievance process. Specifically, (1.) grievance forms were not readily available to residents; (2.) residents did not have the option to file a grievance anonymously; and (3.) 12 of 12 residents present at the Resident Council meeting reported they did not know the process by which to file a grievance. This is evidenced by: The facility policy, Filing A Grievance/Complaint dated 11/2016, documented any resident or resident representative may file a grievances and/or complaint regarding care, treatment, staff members etc. without fear of retaliation. Grievances could be made orally or in writing. The facility had a designated Grievance Officer who investigated grievances and/or complaints. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for 2 (Residents #68 and #113) for 6 reviewed for abuse. Specifically, an allegation of a resident-to-resident altercation was reported by Resident #113 on 12/13/2024. The incident was not reported to the New York State Department of Health. This is evidenced by: The policy and procedure titled, Abuse Prevention Program/Abuse and Neglect - Clinical Protocol/Abuse Investigation and Reporting reviewed 1/2023 documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and .federal agencies (as defined by current regulations). [...]

Inspectors wroteBased on interviews and record review during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and to the Office of State Long-Term Care Ombudsman of the resident's transfer or discharge for 2 (Residents #112 and 123) of 2 residents reviewed for hospitalization. Specifically, (a.) for Resident #112, written notification of transfer to the hospital was not provided to the Ombudsman for 3 out of 4 hospital admissions; (b.) for Resident #123, written notification of transfer was not provided to the resident, the resident's representative, or the Ombudsman when the resident was admitted to the hospital from the facility on 12/27/2024 . This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or representative upon transfer to the hospital for 2 (Residents #112 and 123) of 2 residents reviewed for hospitalizations. Specifically, a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon discharge to the hospital. This is evidenced by: The facility policy titled, Bed-Holds and Returns, dated 1/2022, documented residents or resident representatives would be informed in writing of the bed hold and return policy prior to transfers and therapeutic leave. [...]

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 1 (Resident #47) of 32 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) did not identify Resident #47 as having a serious mental illness when indicated, and a Level II referral was not made. This is evidenced by: The Policy and Procedure titled, Preadmission Screening and Resident Review (PASARR), dated 9/2021, documented the admissions coordinator would obtain a Preadmission Screening and Resident Review for all new residents admitted to the facility and a Level II Screen when required. [...]

Inspectors wroteBased on record reviews and interviews during the recertification survey , the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident #115) of three (3) residents reviewed. Specifically, for Resident #115, the wound care treatment ordered by provider not was followed. Specifically, on 2/11/2025, when the resident was assessed with a pressure on their left heel and on 2/18/2025, when the resident was seen by the wound care provider for further assessment of the wound. Additionally, the facility failed to ensure a care plan was developed timely and implemented to promote healing of the wound and to prevent infection. A care plan was not developed until 2/27/2025. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preference for three (3) (Resident #'s 23, 51 and 231) of 5 residents reviewed for oxygen administration. Specifically, (a.) for Resident #s 23 and 231 who were ordered to have medications via nebulizer, the facility did not ensure documentation of nebulizer maintenance; and (b.) for Resident #51, supplemental oxygen was not provided as ordered by the physician. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification and abbreviated survey (Case # NY00347964), the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, for two (2) (Resident #s 11, and 110) of 3 residents reviewed for dialysis. Specifically, (a) the facility did not ensure nursing consistently completed, reviewed, and logged dialysis communication sheets for Resident #110 on between 2/18/2025 and 2/26/2025; (b) for Resident #11, there was no ongoing communication and collaboration with the dialysis facility and ongoing assessments in January 2025 and February 2025. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure licensed nurses and Certified Nurse Aides had the specific competencies and skills necessary to care for resident's need. Specifically, based on the facility assessment of required education, (a.) education records reviewed for Certified Nurse Aides #3 and #4 were incomplete; (b.) Licensed Practical Nurses #s 11 and 12 education were incomplete; (c.) Registered Nurse #4's education record was incomplete, and (d.) Registered Nurse #2 did not possess the knowledge needed to complete the tasks being assigned to their position. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for two (2) (Resident #s 47, and 67) of 11 residents observed during a medication pass for a total of 30 observations. This resulted in a medication error rate of 6.87 percent. This is evidenced by: The Facility's Policy and Procedure titled, Administering Medication, effective date: 10/1997 and revised 1/2025, documented medications shall be administered in a safe and timely manner, and as prescribed. Additionally, it documented medications must be administered in accordance with the orders, including any required time frame; [...]

Inspectors wroteBased on observation, record review, and interviews, conducted during the recertification survey, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 3 (Unit A cart 2, Unit B cart 2, and Unit C cart 1) of 6 carts reviewed and 5 of 6 narcotic logbooks. Specifically, (1) medication cart on Unit A cart 2 contained multiple stock medications that were not dated, 2 bottles of resident specific eye drops that were not dated, a bottle of insulin with no label indicating resident ownership or date opened, and a bottle of mediation which required a biohazard bag that was open loose in the cart; (2) the medication cart on Unit B cart 2 contained a stock medication that was not dated; (3) the medication cart on Unit C cart 1, contained an insulin pen for a resident that should have been in Unit C cart 2; [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure residents were provided a therapeutic diet as prescribed by a physician for one (1) (Resident #103) of 2 reviewed for diet consistencies. Specifically, Resident 103 did not receive the correct diet consistency per the physician order for meat during a lunch observation. The Policy and Procedure, Food Consistencies and Definitions, revised 3/2022, documented all diet modifications would print on the meal tickets. A regular diet was unrestricted. A chopped diet was foods that were nearly regular' textures, not including hard or crunchy foods. A chopped diet texture required the ability to chew and have tongue control. Foods should be softer and easy to break into pieces with a fork. Foods should be chopped, including tender vegetables such as broccoli and cauliflower. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food was not cooled properly, the automatic dishwashing machine was not functioning, a test kit for checking sanitizing solution was not available, and food temperature thermometer were not in calibration. This is evidenced by: During observations of the main kitchen on 02/23/2025 at 12:48 PM: • Purred vegetables stored in the walk-in refrigerator were 52 degrees Fahrenheit. During an interview on 2/23/2025 at 1:25 PM, cook #1 stated that they had prepared the purred vegetables yesterday (2/22/2025). [...]

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, dumpsters were not kept closed to prevent the harborage and feeding of pests. This is evidenced by: During observations on 2/23/2025 at 1:58 PM, the lid to the garbage dumpster was propped open with a broom handle; kitchen and housekeeping waste was found inside the dumpster. During an interview on 2/24/2025 at 11:13 AM, Administrator #1 stated that the dumpster should be kept closed and that they would review keeping the dumpster closed with their staff. 10 New York Codes, Rules, and Regulations 415.14(h)

Inspectors wroteBased on record review and interview during the recertification survey and abbreviated survey (Case # NY00363829), the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents for two (2) (Resident #s 47 and 77) of 5 residents reviewed. Specifically, [a.] for Resident #47 with diagnoses of schizophrenia, the facility did not ensure Clozapine (atypical antipsychotic) was available to administer on 11/25/2024 to 12/26/2024 and, [b.] for Resident #47, the facility did not ensure Lokelma was available on 12/21/2024, when ordered for a high potassium level. The resident did not receive the medication until 12/25/2024. This is evidenced by: Cross-referenced to F760: [...]

Inspectors wroteBased on record review and interview during the recertification and abbreviated survey (Case #NY00363829), the facility did not ensure laboratory services were provided timely to meet the needs of the resident for 1 (Resident #77) of 3 residents reviewed. Specifically, Resident #77 [a.] provider ordered to have laboratory tests completed on 11/27/2024. The tests were not completed, and the provider was not notified; [b.] provider reordered the tests again on 12/03/2024. The tests were not completed, and the provider was not notified; and [c.] provider reordered the tests again on 12/06/2024 and the specimen was collected and resulted on 12/09/2024. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not promptly notify the ordering nurse practitioner of laboratory results that fall outside of clinical reference ranges for 1 (Resident #77) of 3 residents reviewed. Specifically, the facility did not promptly notify Nurse Practitioner #2 or the on-call provider of an abnormal laboratory result for Resident #77 on 12/17/2024 at 3:05 AM. This is evidenced by: Cross-referenced to F711: Physician Visits - Review Care/Notes/Order Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease, cerebral infarction (stroke), and chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms). [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, there was not sufficient staff to meet the needs of residents at any given time. This is evidenced by: The Facility Assessment, dated 7/27/2023, documented the facility capacity was 127 and the average daily census was 123-125. [...]

Inspectors wroteBased on observation during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not dispose of garbage and refuse properly. Specifically, the facility did not ensure 2 of 3 trash bins were pest and rodent-proof by not fully closing trash bin lids and having damaged/broken lids, and garbage receptacles were not covered when being removed from the kitchen area to the dumpster by staff. This is evidenced by: During an observation on 1/25/2024 at 10:35 AM, the trash collection area was inspected. One of the trash bins, used for cardboard, had a damaged, broken lid and could not be closed entirely. One of the two trash bins used for refuse and garbage was left open, and the lid was flipped open to the back of the dumpster. At the time of observation, kitchen staff were removing a garbage receptacle from the kitchen to the dumpster. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure the Quality Assurance Performance Improvement Program developed and implemented appropriate plans of action to correct identified quality deficiencies, or regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not ensure that previously approved Plans of Correction for F-725, F-812, and F-880 cited during Recertification Surveys completed on 2/22/2018, 8/27/2019, and 8/23/2021 were implemented as indicated by the same deficiencies being issued on the current survey. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey from 01/22/2024 to 01/30/2024, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, (1.) a Certified Nursing Assistant and Licensed Practical Nurse did not perform hand hygiene between assisting residents with care; (2.) a Resident Assistant did not put on personal protective equipment when entering a transmission-based precaution room; (3.) soiled laundry was not removed and kept separate from clean laundry. Additionally, a resident's urinal was not emptied and soiled laundry was not removed from resident room. This is evidenced by: [...]

Inspectors wroteBased on observation and interview during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure that (1) the results of the most recent survey report and plan of correction of the facility was posted in a place readily accessible to residents, family members, and legal representatives of residents; and (2) did not ensure to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, the facility did not ensure that the residents and staff knew what the survey reports were and where they were located. This is evidenced by: During an observation on 1/22/2024 at 9:14 AM upon entrance to conference room, the survey team noted the Survey Results Binder on the conference room table. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure that each resident received the necessary respiratory care and services that are in accordance with professional standards of practice, the resident's care plan and the resident's choice, for 1 (Resident #63) of 3 residents reviewed for oxygen administration. Specifically, for Resident #63, the facility did not ensure supplemental Oxygen was provided as ordered by the physician on 01/23/2024, 1/24/2023, 1/25/2023, and 1/29/2024. This is evidenced by: Resident #63 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and anemia. [...]

Inspectors wroteBased on interviews and record review during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure that residents requiring dental care were promptly referred for dental evaluation and care for 1 (Resident #65) of 3 residents reviewed for dental services. Specifically, for Resident #65, the facility did not assist the resident to make an appointment for emergency dental services as requested. This is evidenced by: A facility policy and procedure for Dental Services, with a revision date of 1/2024, documented that routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social services representatives would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. [...]

Inspectors wroteBased on observation and interviews during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety for the main kitchen. Specifically, infection control procedures were not followed in which facility staff did not wear hair restraints in the kitchen, no hairnets were available at the entrance to the kitchen, and three (3) of 3 refrigerators were not properly cleaned with dirt around the top seal of the appliance. This is evidenced by: During an observation on 1/22/2024 at 10:33 AM upon entrance to the main kitchen area, Food Service Manager #1 was not wearing any hair restraints. When the surveyor requested a hairnet, they stated that they needed to return to their office and retrieve some because there were no hairnets at the kitchen entrance. [...]

Inspectors wroteBased on record review and interview during the recertification and abbreviated survey (Case #NY00329958) from 1/22/2024 to 01/30/2024, the facility did not ensure a copy of discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident # 52) of 1 resident reviewed. Specifically, Resident #52 received a 30-day discharge termination notice on 11/7/2023, and a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman was not sent until 12/4/2023. This is evidenced by: Resident #52 was admitted on [DATE] with diagnoses of diabetes mellitus type 2, depression, and bladder cancer. The Minimum Data Set (an assessment tool), dated 11/2023, documented that the resident was able to understand, be understood by others, and was cognitively intact. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on 3 of 3 resident units and the core area, walls, ceilings, and floors were clean and/or in good repair. This is evidenced as follows. The A-Unit, B-Unit, C-Unit, and facility core area were inspected on 08/16/2021 at 8:22 AM, 08/19/2021 at 2:00 PM and 3:20 PM, and on 08/20/2021 at 12:21 PM. The corridor floor next to walls and next to door frames were soiled with dirt or old wax on the A-Unit, B-Unit, and C-Unit. The floors next to walls were soiled with dirt, dust, or old wax in 18 resident rooms (A2, A6, A10, A14, B6, B8, B11, B12, B16, B20, B21, C5, C6, C11, C13, C14, C16, and C18). The following rooms were soiled throughout with dirt or dust: [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated survey (Case #'s NY00280730, NY00277981, NY00277350, NY00280475) the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 12 (Resident #'s 7, 20, 39, 43, 44, 57, 71, 72, 94, 95, 101 and #121) of 29 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #7, the facility did not ensure a CCP was developed to address the resident's behavior of picking at their arms causing multiple bruises and breaks in the skin; [...]

Inspectors wroteBased on observations, interviews and record review during the recertification survey and abbreviated survey (Case #NY00273603 and #NY00277350), the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services 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 did not ensure there was sufficient staff to meet the needs of residents at any given time and did not ensure the resident dignity was maintained; did not ensure residents on the B Unit, who were unable to carry out activities of daily living, received weekly showers and incontinence care to maintain good hygiene and consistently received assistance with eating; [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the Monthly Medication Regimen Review (MRR) that included timeframes for the different steps in the process. Specifically, the facility did not ensure there were timeframes were established and documented in the policy for steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity was identified. This is evidenced by: The Policy and Procedure titled Medication Therapy/Drug Regimen Review dated 1/2021, documented a drug regime review includes medication reconciliation, a review of all medications a resident is currently using and a review of the drug regimen to identify, and if possible, prevent potential clinically significant medication adverse consequences. [...]

Inspectors wroteBased on observation and interview during the recertification survey the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards and include the appropriate accessory and cautionary instructions on 3 (Unit A, Unit B, Unit C) of 3 nursing units inspected. Specifically, the facility did not ensure that medications designed for multiple administrations (insulins, inhalers and eye drops) located in three (Unit A Medication Cart #2, Unit B Medication Cart #2 and Unit C Medication Cart #2) of three medication carts, were labeled with the date they were opened. This is evidenced by: Unit C Medication Cart #2: On 8/19/2021 at 7:35 AM, the inspection of Unit C Medication Cart #2 revealed the following medications that were opened and were not labeled with the date they were opened: [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean and in good repair, toxic materials are to be stored to preclude food contamination, and a test kit is to be provided to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, food contact equipment in the main kitchen and 3 of 3 resident unit nourishment stations were not clean and in good repair, toxic materials were not stored properly, and an accurate test kit was not provided. This is evidenced as follows. The main kitchen and the nourishment stations were inspected on 08/16/2021 at 7:23 AM. [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not ensure foods brought to residents is in accordance with adopted regulations. Specifically, the facility did not adhere to its established policy on food brought to residents and did not provide information for family and other visitors on safe food handling practices of food that they bring to residents. This is evidenced is as follows. The nursing unit nourishment station refrigerators were inspected on 08/16/2021 at 7:23 AM. On the B-Unit, cold cuts and cheese brought to Resident #95 were dated 08/07/2021. On the C-Unit, two food items brought to Resident #86 were not dated, and one food item brought to Resident #65 was not dated. [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey completed on 8/16/21, 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, infections, and COVID-19 upon entry to, and within the facility. Specifically, a Licensed Practical Nurse and two Dietary Aides did not wear facemasks in accordance with Centers of Disease Control guidance, and a Certified Nurse Aide and a Licensed Practical Nurse wore their face masks in a manner that did not cover their nose and mouth. This was evidenced by: The CDC guidance updated 2/23/2021, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, documented: [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility did not maintain an adequate pest control program as evidenced by multiple sightings of rodent droppings. This is evidenced as follows. Observations on 08/16/2021 at 10:24 AM and at 10:57 AM, revealed rodent droppings in a cabinet where plastic silverware was stored in the A-Unit nourishment station, next to the floor below the main kitchen dishwashing machine, and the Minimum Data Set Co-ordinator's office. Additionally, the floor below the kitchen dishwashing machine was soiled with food particles. Record review of the pest-control service reports on 08/16/2021, revealed that the facility was treated at least monthly for rodents from February 2021 through August 2021. [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not ensure 2 (Resident #'s 67 and #117) of 2 residents were treated in a dignified manner. Specifically, for Resident #67, the facility did not ensure to the resident's dignity was maintained when incontinence care was not provided in a timely manner and for Resident #117, did not ensure staff responded to the resident's call bell and the resident's request for assistance to use the bathroom in a timely manner resulting with the resident lying in bed in a soiled brief. This is evidenced by: The Policy and Procedure (P&P) titled Quality of Life-Dignity dated 1/2021, documented each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Demeaning practices and standards of care that compromised dignity were prohibited. [...]

Inspectors wroteBased on record review, and interviews during a recertification survey 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 (Resident #71) of twenty-four residents reviewed. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure that resident assessments accurately reflected the resident's status for 4 (Resident #'s 11, 39, 95 and #101) of 29 resident assessments reviewed. Specifically, for Resident #11, the facility did not ensure the accuracy of the Minimum Data Set (MDS) when the MDS documented the resident received an anticoagulant (blood thinner) medication when an anticoagulant had not been prescribed for the resident; for Resident #'s 39 and #95, the facility did not ensure the MDSs accurately reflected that the residents received oxygen therapy; and for Resident #101, the facility did not ensure the MDS accurately reflected that the resident's teeth had caries (decay and crumbling of teeth). This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated survey (Case #NY00277981), the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 (Resident #'s 20, 71, 94, and #95) of 4 residents reviewed for ADL's. Specifically, for Resident #71, the facility did not ensure the resident received weekly showers, did not receive incontinence care for over 6 hours and did not receive consistent assistance with eating; for Resident #'s 20, 94 and #95, did not ensure the residents, who were unable to carry out activities of daily living, received weekly showers to maintain good personal hygiene; and for Resident #95, did not ensure nail care was provided. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during a recertification survey on 8/16/2021, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #124) of 1 resident reviewed for death. Specifically, the facility did not ensure Resident #124, who experienced an acute onset of gastrointestinal (GI) symptoms, including vomiting, diarrhea, abdominal pain with distention on the afternoon on 5/21/2021, was provided with treatment and care in accordance with professional standards. The resident expired in the facility on 5/22/2021 with a time of death at 8:20 AM. This was evidenced by: Resident #124: Resident #124 was admitted to the facility with the diagnoses of urinary tract infection, depression, and anxiety. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #39 and #95) of 2 residents reviewed for respiratory care. Specifically, for Resident #39 and Resident #95, the facility did not did not ensure physician orders for the oxygen flow rate and oxygen (O2) tubing changes were followed. This is evidenced by: The Policy and Procedure (P&P) titled Oxygen Administration dated 1/2021, documented the purpose of the procedure was to provide guidelines for safe oxygen administration. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, which was any drug used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences which indicated the dose should be reduced or discontinued for 1 (Resident #57) of 5 resident reviewed for unnecessary medications. Specifically, the facility did not ensure a physician order for Lovenox injections (anticoagulant medication) was re-evaluated to include an intended stop date after the resident was seen by orthopedics and could weight bear as tolerated. This is evidenced by: Resident #57: Resident #57 was admitted to the facility with the diagnoses of pelvic fracture, pneumonia, and anxiety. [...]

Inspectors wroteBased on record review and interviews during a recertification survey and an abbreviated survey (Case # NY00279431) the facility did not ensure the residents were free from significant medication errors for 1 (Resident #427) of 1 resident. Specifically the facility did not ensure Resident #427 received prescribed medications. This was evidenced by: Resident #427 Resident #427 was admitted to the facility with diagnoses of human immunodeficiency virus disease, chronic respiratory failure with hypoxia, and schizoaffective disorder bipolar type. The Minimum Data Set (MDS - an assessment tool) dated 6/25/2021 documented the resident could understand and make self understood. The resident was cognitively intact. Resident # 427 was discharged from facility prior to the recertification survey. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and abbreviated survey (Case #NY00280929), the facility did not maintain medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 6 (Resident #'s 67, 71, 95, 101, 109, and #117) of 29 residents. Specifically, Resident #'s 67, 71, 95, and #117, the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care was complete and accurate; for Resident #95, did not ensure that documentation on the Treatment Administration Record (TAR) was accurate for physician ordered oxygen tubing changes; for Resident #101, did not ensure physician documentation was clear and legible; [...]