The Grand Rehabilitation and Nrsg at River Valley

Inspectors wroteBased on observations and interviews during the abbreviated survey (2725858) the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. Specifically,1) on 3/3/2026 at 10:20am observed on unit 3 East a treatment cart left unlocked and unattended with Nystatin cream left on top of the cart. This cart was under the responsibility of Licensed Practical Nurse # 1. 2) On unit at 5 East at 11:00 am observed medication cart on the unit left unlocked and unattended; while Licensed Practical Nurse # 2 was passing medication to the resident in room [ROOM NUMBER].

Inspectors wroteBased on observation, interviews and record review conducted during an abbreviated survey (2725858), the facility did not ensure infection prevention and control standards were maintained. Specifically, 1) on 3/2/2026 observed Certified Nurse Aide #1 not applying personal protective equipment to go into Resident # 2's room who had a contact precaution sign on the door. 2) On 3/3/2026 Observed Certified Nurse Aide #2 going into Resident # 3's room on droplet precaution with appropriate personal protective equipment, Certified Nurse Aide #2 exited the room wearing the mask in the hallway.

Inspectors wroteBased on interview and record review the facility did not ensure individual financial records were available to residents through quarterly statements. This was evident for (6) six residents (Residents #18, #103, #127, #140, #157, and #160) reviewed for personal funds. Specifically, there was no documented evidence Residents #18, #103, #127, #140, #157, and #160 were provided with quarterly statements for personal need accounts managed by the facility.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 01/20/2026 to 01/28/2026 the facility did not ensure residents were provided food and drink that was palatable, and at a safe and appetizing temperature. Specifically, due to food temperature complaints from residents at the resident council meeting on 01/21/2026 at 11:11AM a test tray temperature was taken of egg salad that had a holding temperature of 70 degrees Fahrenheit, and during the observation of a lunch meal service in the kitchen, the egg salad and yogurt temperatures were held at 58 degrees Fahrenheit.

Inspectors wroteBased on observation and interview, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unlabeled foods were stored in the kitchen walk in refrigerator, freezer, and cooks prep counter 2) expired foods were stored in the walk-in refrigerator, emergency food supply, and Resident #5's personal refrigerator and 3) staff were observed not wearing beard nets while in the kitchen.

Inspectors wroteBased on observation, record review and interview the facility did not ensure proper disposal of garbage and refuse. Specifically, three (3) garbage/recycle dumpsters were left open and there were cardboard boxes spilling over the top of the dumpsters and litter on the ground around the dumpsters.

Inspectors wroteBased on interview and record review the facility did not ensure residents were informed of items and services the resident may be charged for and the amount charged for those items and services for (2) two of (3) three residents (Residents #13 and #157) reviewed for Beneficiary Notification. Specifically, there was no documented evidence the facility provided Resident #13 and Resident #157's representative with a Skilled Nursing Facility Advanced Beneficiary Notification informing them of the cost to continue receiving skilled services once their Medicare Part A coverage ended.

Inspectors wroteBased on record review and interview the facility did not ensure the accuracy of the preadmission screening for 1 (one) of thirty-eight residents reviewed for preadmission screening. Specifically, on the preadmission screen for Resident #81, number 23 was marked yes indicating that Resident #81 had a serious mental illness. However, the categorical determinations, numbers 27 to 30, were not completed as instructed to determine if a level two screen was indicated.

Inspectors wroteBased on record review and interview the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for (2) two (5) five residents (Resident #18, Resident # 157) reviewed for care planning. Specifically, 1) there was no documented evidence that Resident #18's comprehensive care plan was reviewed and/or revised with the quarterly Minimum Data Set completed on 8/25/2025 and 11/18/2025 and 2) there was no documented evidence that a care plan meeting was conducted between 09/2025 and 01/2026 for Resident #157.

Inspectors wroteBased on interview, observation and record review the facility did not ensure the resident environment remains as free of accident hazards as is possible for one (1) of seven (7) residents (Resident # 54) reviewed for Accidents. Specifically, there was no documented evidence that hazards and risks were evaluated and analyzed and that care plan interventions were monitored for effectiveness and/or modified when necessary for Resident #54 who was observed in their room on 01/28/2026 with a lighter in their possession. Additionally, the 06/15/2025 Annual Minimum Data Set Assessment documented Resident #54 did not use tobacco.

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 1/20/2026 to 1/28/2026, the facility did not ensure specialized care needs for the provision of respiratory care in accordance with professional standards of practice for one (1) of one (1) residents (Resident #34) reviewed for respiratory care. Specifically, Resident #34 was administered oxygen without a medical order from 01/06/2026 to 01/22/2026.

Inspectors wroteBased on observation interview and record review during Recertification and Abbreviated Surveys (#723126) the facility did not ensure that the Minimum Data Set accurately reflected the resident status for two (2) of six (6) residents (Resident #162, and Resident #157) reviewed for general skin issues. Specifically, 1) the 09/29/2024 Minimum Data Set Assessment did not reflect documented refusal of care/s for Resident #162 and 2) Resident #157 had a chronic ulcer to the scalp, that was not reflected in the 11/28/2025 and 01/02/2026 Minimum Sata Set Assessments.

Inspectors wroteBased on staff interviews and review of facility documentation conducted during the abbreviated (NY00371494, NY00364683) surveys, it was determined that the facility did not ensure that a performance review of every certified nurse aide was completed at least once every 12 months, and that each certified nurse aide received no less than twelve hours of in-service education per year. This was evident for 2 of 3 Certified Nurse Aides (#3, #5) reviewed for completion of performance evaluations and in-service education. Specifically, the facility did not ensure that Certified Nurse Aide #3 and #5 had a performance evaluation completed at least once every 12 months and received no less than twelve hours of in-service education per year.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00364683), the facility did not ensure the resident's representative was informed of a significant change in the resident's physical status or a need to alter treatment significantly for 1 of 3 residents (Resident #2) reviewed for abuse. Specifically, Resident #2 was a victim of sexual abuse on 12/13/24 by Resident #3, and there was no documented evidence that Resident #2's representative was notified of the incident until 12/16/24.

Inspectors wroteBased on interviews and review of facility documentation conducted during the abbreviated (NY00371494, NY00364683) surveys the facility did not ensure that residents were free from abuse. This was evident for 2 (Residents #1, #2) of 3 residents reviewed for abuse. Specifically, 1) Registered Nurse Supervisor observed Certified Nurse Aide #3 pushing Resident #1's arm, and 2) Resident #3 was observed by a Certified Nurse Aide touching Resident #2's breast.

Inspectors wroteBased on interviews and review of facility documentation conducted during the abbreviated (NY00364683) survey, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to either the State Survey Agency or local law enforcement in accordance with State law through established procedures. This was evident for 2 of 3 residents (Residents #2, #3) reviewed for abuse. Specifically, Certified Nurse Aide # 2 observed Resident #3 touching Resident #2's breast on 12/13/24 at 8:48PM and the facility did not report the incident to the State Survey Agency until 12/14/24 at 3:59 PM, the facility also never notified law enforcement, although the facility could not rule out abuse. The Finding is: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00364683), the facility did not ensure the comprehensive care plan was reviewed and revised in a timely manner for 1 of 3 residents (Resident #2) reviewed for abuse. Specifically, Resident #2 was a victim of witnessed sexual abuse on 12/13/24, and there was no documented evidence of the care plan having been revised to reflect the abuse incident or any new intervention.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey 9/27/2023 - 10/3/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Specifically, 1) A dietary aide did not handle cleaned and sanitized dishware in a sanitary manner; 2) Equipment used for food service preparation, storage, and service was not maintained in a sanitary condition; 3) A cook did not properly sanitize a thermometer being used to check meal time food temperatures; 4) One dry storage room was being used to store dry foods and large quantities of multiple chemicals; 5) Cold foods temperatures were not maintained at 41 degrees Fahrenheit (F) or less.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 9/27/2023 to 10/3/2023, the facility did not ensure that all alleged violations involving abuse were reported timely for one (Residents #4) of two residents reviewed for abuse. Specifically, Resident #4 was observed in another resident's room inappropriately touching the other resident and the facility did not report the incident to the New York State Department of Health (NYSDOH).

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated surveys (NY00325065) from 9/27/2023-10/03/2023. The facility failed to ensure the safe and secure storage of medications, in accordance with currently accepted professional standards. Specifically, the registered nurse (RN) Supervisor #1 accepted and signed for thirty Oxycodone tablets (a narcotic pain medication) and placed the medication in the supervisor's office with one lock on the door and not a locked cabinet for narcotics. As a result, the medication went missing and was not found. Resident #59 had diagnoses including low back pain, Bipolar disorder and hypertension. The annual Minimum Data Set (MDS, an assessment tool) dated 8/23/2023 documented the resident had intact cognition and received pain medication daily. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team. This was identified for 1 of 6 residents (Resident # 59) reviewed for accidents. Specifically, Resident # 59 had a fall on 2/4/23 and a fall with injury on 2/28/23 and the Fall Care Plan was not revised.

Inspectors wroteBased on observation, interview and record review conducted during the most recent recertification survey and an abbreviated survey (Complaint #NY00237514), the facility did not ensure that the plan of care for each resident included the necessary person-centered interventions to address, when indicated, their needs related to respiratory care, activities of daily living, and the prevention of the development of pressure sores. This was evident for 1 of 2 resident (Resident #18) reviewed for respiratory care; 1 of 4 residents (Resident #121) reviewed for bowel and bladder incontinence and 1 of 5 residents (Resident #70) reviewed for pressure ulcer. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that the comprehensive care plan was revised for one resident (#39) reviewed for diabetes management. It was determined that the care plan was not updated to address the recent change of insulin administration from periodic insulin pen injections and fingersticks to an external continuous insulin pump with continuous blood glucose monitoring.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that 1 of 4 residents reviewed for bowel and bladder incontinence was provided the necessary care to address bowel regularity. Specifically, the nursing staff did not implement the physician's orders to address the absence of bowel movements in at least three days. (Resident #4).

Inspectors wroteBased on observations, interview and record review conducted during the recertification survey, the facility did not ensure that care and treatment were provided to prevent the development of pressure ulcers for 1 of 5 residents (Resident #70) reviewed for pressure ulcers. Specifically, there were no pressure relieving measures including off loading and the use of heel booties for a resident at risk for the development of pressure ulcers.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure that staff demonstrated competency in providing necessary care to meet the needs of one resident reviewed for diabetes management. Specifically, staff were not provided education and competency review for the use of an insulin pump for 1 resident ( Resident #39 ).

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that the medication error rate did not exceed five percent for a total of 29 opportunities for error. This resulted in an error rate of 6.9%.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, it was determined that the facility did not ensure that residents received menu items listed on their meal tickets. Specifically, food and drink items were not provided according to each resident's personal preference. (Residents #7, #64 and #99).