The Grand Rehabilitation and Nursing at Batavia

Inspectors wroteBased on observation, record review, and interview conducted during an Abbreviated survey (Complaint #2651892) the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for one (1) (Resident #1) of three (3) residents reviewed for choices. Specifically, Resident #1 was not provided showers twice a week per their preference.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 2/20/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had issues with foods and beverages being either unlabeled or outdated in the refrigerators; kitchen had a grease laden hood with dusty, fuzzy debris, greasy black floor beneath the stove and oven, and thick greasy build up alongside the oven next to the stove/grill top; lack of [NAME] #1 wearing a facial hair covering in food preparation areas and during serving of food. Additionally, the pH (potential of hydrogen) test paper strips utilized to test the three-compartment sink were expired.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 2/20/25, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medication if clinically appropriate for one (1) (Resident #54) of one (1) resident reviewed. Specifically, Resident #54 was observed with medication in their room and had stated they self-administered the medication without being evaluated as to whether they could safely do so. In addition, the comprehensive care plan did not include the resident's ability to self-administer medications. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 2/20/25, the facility did not ensure the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision for one (Resident #54) of four residents reviewed. Specifically, the privacy curtain was not securely mounted to the ceiling track and the curtain fabric was lying directly on the floor. The finding is: The policy and procedure titled Falls Prevention Program, revised 1/2024, documented the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Identifying causes or fall risks included whether any environmental risk factors were involved (slippery floor, poor lighting, furniture, or objects in the way). [...]

Inspectors wroteBased on interviews and record review conducted during a Standard survey completed on 2/20/25, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #21) of five resident reviewed. Specifically, Resident #21 did not have a follow up Psychiatry consult as recommended and the facility was not aware the resident was not being provided with those Psychiatry services. The finding is: The policy and procedure titled Consultations with a revised date of 1/24, documented the facility is responsible to provide consultation services for any residents as needed. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 2/20/25, the facility did not ensure that the pharmacist reported irregularities to the Attending physician and the facility's Medical Director, and that these reports were acted upon for two (Residents #12 and #21) of five residents reviewed for drug regimen reviews. Specifically, irregularities identified by the Consultant Pharmacist were not sent to the Attending physician and Medical Director and they were not signed, addressed, or acted upon by a medical provider (Residents #12 and #21).

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 2/20/25, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances, and on-going preventative maintenance of carbon monoxide detectors. This affected two (Unit A and Unit B) of two resident units and the basement. The finding is: According to the 2020 Fire Code of New York State, patient rooms in nursing homes are defined as sleeping units. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaints #NY00320131 and #NY00322829) completed on 9/12/23, the facility did not protect the resident's right to be free from physical abuse by another resident for three (Residents #1, 2 and 4) of three residents reviewed for abuse. Specifically, on 7/16/23 Resident #5 pushed Resident #2 to the floor; on 7/23/23 there was a resident-to-resident altercation when Resident #5 utilized a rolling walker to strike Resident #1's bilateral lower extremities (BLE), and on 8/28/23 Resident #3 placed a towel over the head of Resident #4 and then intentionally hit Resident #4 multiple times in the head.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated survey (Complaint #NY00322829), completed on 09/12/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #3) of three reviewed for quality care. Specifically, there was a lack of an assessment when Resident #3 fell as a result of the resident-to-resident altercation. The finding is: The policy and procedure (P&P) titled Assessing Falls and Their Causes, revised 01/2023 documented after a fall, the nursing staff will record vital signs, and evaluate for possible injuries to the head, neck, spine, and extremities. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a compliant investigation (NY00298880) during the Standard survey completed on 4/12/23, the facility did not ensure that the residents' environment remained as free from accident hazards as possible and each resident receives adequate supervision and assistance devises to prevent accidents. Specifically, one (Unit A) of two resident units had issues with water temperatures exceeding 120 degrees Fahrenheit (°F). Additionally, one (Resident #50) of 4 residents reviewed for accidents, the facility did not ensure a cognitively impaired resident with known wandering behaviors had adequate superviosn to prevent elopement and was able to exit the facility undetected by staff.

Inspectors wroteBased on observation, interview, and record review, conducted during a Standard survey completed on 4/12/23, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for one (Resident #6) of one resident reviewed. Specifically, there was lack of documented evidence of ongoing monitoring of vital signs (VS) and the permacath (a flexible tube inserted into a vein at the neck or upper chest to use for short-term dialysis treatment) site for complications upon return to the facility after dialysis. The finding is: The policy and procedure (P&P) titled Central Venous Catheter Dressing Changes dated 1/2023, documented the following information should be recorded in the resident's medical record: location and objective description of insertion site and any complications, interventions that were done. 1. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/12/23, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #10) of five residents reviewed for psychotropic medication use. Specifically, there was a lack of a GDR for a resident receiving psychotropic medications; lack of supporting documentation for the continued use and adequate indication of the antipsychotic medication. Additionally, one (Resident #36) of five residents reviewed for psychotropic medication care plan development, lacked a comprehensive care plan for the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 4/12/23, the facility did not post, on a daily basis, the following information: 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. Specifically, the daily staffing levels were not in a prominent place readily accessible to residents and visitors and the actual hours worked were not updated to reflect changes. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 6/14/21, the facility did not ensure that the residents' environment remained as free from accident hazards as possible. Two (Unit A and Unit B) of two resident units had issues with water temperatures that exceeded 120 degrees Fahrenheit (°F), and this involved Residents #55 and 41. The finding is: Resident #55 had diagnoses including depression and end-stage kidney disease. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/24/21 revealed the resident was cognitively intact. Resident #41 had diagnoses including dementia and metabolic encephalopathy (abnormal levels of electrolytes and body chemicals that affect brain function). Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 6/14/21, the facility did not ensure resident's right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care that are significant to the resident. Specifically, one (Resident #47) of one resident reviewed for choices had an issue involving showers that were not provided in accordance with the resident's wishes. The finding is: The facility's policy and procedure (P&P) titled Quality of Life - Self Determination and Participation revision/ review date 1/2021 documented each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including daily routine, such as sleeping and waking, eating, exercise and bathing schedules. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 6/14/21, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene. Specifically, one (Resident #29) of four residents reviewed for activities of daily living (ADLS) had issues with dirty fingernails and not being get out of bed for meals as ordered. The finding is: The facility policy and procedure (P&P) titled Care of Fingernails/Toenails revision/ review date 1/2021 documented the purpose of this procedure are to clean the nail bed, to keep nails trimmed and prevent infections. Under general guidelines nail care includes daily cleaning. 1. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #45) of two residents observed for pressure ulcers. Specifically, the resident did not have a treatment in place for unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to bilateral (bil) heels for 17 days. Additionally, no pressure relieving measures were put into place upon the resident's readmission to the facility. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 6/14/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #29) of two residents reviewed. Specifically, oxygen tubing was not changed, and the oxygen concentrator filter was not cleaned per the physician's orders. Additionally, there were errors in the facilities documentation regarding oxygen equipment care. The finding is: The facility policy and procedure (P&P) titled Medication Orders dated 1/2021 documented a current list of orders must be maintained in the clinical record of each resident, and when recording treatment orders, specify the treatment, frequency and duration of the treatment. [...]