The Grand Rehabilitation and Nursing at Mohawk

Inspectors wroteBased on observations, record review, and interviews during the abbreviated (IQIES 2600078) survey, the facility failed to ensure a resident received adequate supervision and assistance devices for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 required supervision at meals due to hyperphagia (insatiable hunger) and dysphagia (difficulty swallowing) and was on aspiration precautions (inhaling food into the lungs). Specifically, the resident was left unattended in the dining room on 08/23/2025 with access to inappropriate food consistency and the Resident began choking, showed signs of distress, and staff did not intervene to assist the resident. The resident was discovered unresponsive approximately 90 minutes later and was pronounced deceased after cardiopulmonary resuscitation was attempted. [...]

Inspectors wroteBased on observations, record review, and interviews during the abbreviated (IQIES 2600078) survey, the facility did not ensure provision of emergency basic life support immediately when needed, for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was found in the dining room unresponsive and without a pulse and staff did not initiate cardiopulmonary resuscitation (chest compressions and rescue breathing) immediately and moved the resident to their room to start cardiopulmonary resuscitation.

Inspectors wroteBased on observations, record review, and interviews during the abbreviated (IQIES #2600078) survey the facility did not implement a comprehensive person-centered to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was left in the dining room after the lunch meal ended, and staff did not assist with toileting as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00340946 and NY00374215) surveys conducted 6/23/2025-6/30/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for five (5) of eight (8) residents (Residents #7, #23, #55, #57, and #75) reviewed. Specifically, Residents #23 was not provided with shaving and showers as planned; Resident #75 did not receive assistance at meals as planned; Residents #57 and #7 had unclean fingernails; and Resident #55 was not offered a lunch meal.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted from 6/23/2025-6/30/2025, the facility did not establish and 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 and infections for three (3) of seven (7) residents (Residents #24, #32 and #51) reviewed. Specifically, Licensed Practical Nurse #6 administered medications through Resident #51's gastrostomy tube (a tube placed into the stomach to provide nutrition) without wearing required personal protective equipment; Resident #32 had a gastrostomy tube and staff did not utilize required personal protective equipment while providing a shower; [...]

Inspectors wroteBased on record review and interviews during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for two (2) of three (3) residents (Residents #89 and #271) reviewed. Specifically, Resident #89 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required; and Resident #89 had a planned discharge from the facility and was not provided with a timely Notice of Medicare Non-Coverage.

Inspectors wroteBased on record review and interview during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility failed to ensure each resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument for one (1) of two (2) residents (Resident #55) reviewed. Specifically, a Significant Change Minimum Data Set assessment was not completed as required for Resident #55 following enrollment in a hospice program. Additionally, the resident did not have an individualized care plan including the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not provide ongoing programs to support each resident in their choice of activities for one (1) of one (1) resident (Resident #37) reviewed. Specifically, Resident #37 was not offered meaningful activities that included their interests and preferences.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, 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 one (1) of one (1) resident (Resident #24) reviewed. Specifically, Resident #24 required dialysis (used to filter waste products from the blood) at a community based dialysis center, did not have orders for on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and their comprehensive care plan did not reflect the resident received dialysis. Additionally, the resident did not have a rolled washcloth in their hand as planned and their nails were long with a dark substance underneath.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for one (1) of three (3) residents (Residents #35) reviewed. Specifically, Licensed Practical Nurse #12 did not adhere to the physician orders for Resident #35's pressure ulcer treatment and applied a different dressing than what was ordered. Additionally, Resident #35's pressure relieving devices for their heels were not consistently implemented as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of three (3) resident floors (Floor 4) reviewed. Specifically, Floor 4, a locked dementia care unit had an unlocked treatment cart accessible to residents, containing medicated creams and other potentially hazardous items.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for two (2) of two (2) residents (Resident #106 and #102) reviewed. Specifically, there was no documented evidence informed consent was obtained for the use of the side rails for Resident #106 and the informed consent for Resident #102 was not done timely.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025 the facility did not ensure licensed nurses had specific competencies and skills sets necessary to care for residents' needs for two (2) of two (2) licensed staff (Registered Nurse Manager #7 and Licensed Practical Nurse #6) reviewed. Specifically, Resident #51 had a tracheostomy (an opening in the neck into the windpipe to provide an airway) and Registered Nurse Manager #7 and Licensed Practical Nurse #6 had insufficient training and knowledge of emergency procedures for accidental decannulation (tracheostomy tube removed in error). Additionally, the Minimum Data Set did not accurately reflect the resident's respiratory status.

Inspectors wroteBased on record review, observation, and interview during the abbreviated survey (NY00341788), the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (second, third, and fourth floors). Specifically, the second and third floors had hot water that was not maintained at acceptable temperatures and the second, third, and fourth floors had clean linen supplies that were stained.

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00326912) surveys conducted 10/30/2023-11/7/2023, 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 and infections. Specifically, the facility's water Legionella (a type of bacteria usually found in water causing Legionnaires' disease) quarterly testing had positive Legionella results for the second quarter of 2023 and the facility water was not resampled. Also, Legionella testing had not been completed for the third quarter of 2023.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00316983, NY00323441, NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Units 2, 3, and 4), and the main kitchen. Specifically, the Unit 2 dining room had unclean curtains; Unit 3 had a strong urine odor, unclean fall mats, shower nozzles, shower chair, and floors and walls near the elevator in the kitchenette; Unit 4 had unclean walls and floors in the kitchenette, and a strong urine odor; the main kitchen had unclean walls and equipment; and Units 2, 3, and 4 had hot water that was not maintained between 90 degrees Fahrenheit (F) and 120 degrees F.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00322422 and NY00315912) surveys conducted 10/30/2023-11/7/2023 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 9 of 9 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) residents stated their call bell may be answered but there were not always staff available to assist with activities of daily living (ADLs) such as going to the bathroom. Additionally, deficiencies related to staffing levels were identified in the areas of ADL Care Provided for Dependent Residents (Residents #51, #53, #74, and #90).

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00323441, NY00322422, and NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, and at an appetizing temperature for 2 of 2 meals reviewed (10/30/2023 and 10/31/2023 lunch meals). Specifically, food was not served at palatable and appetizing temperatures.

Inspectors wroteBased on observation and interview during the recertification survey conducted 10/30/2023-11/7/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (Units 3 and 4) and the main kitchen. Specifically, Unit 3, Unit 4, and the main kitchen had house flies and fruit flies.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00315912 and NY00323441) surveys conducted 10/30/2023-11/7/2023 the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 2 residents (Residents #26) reviewed. Specifically, Resident #26 received an item they ordered online, the facility did allow the resident to use the item and did not give the resident sufficient time to return the item within the required vendor time frame.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00315912 and NY00323441) surveys conducted 10/31/2023-11/07/2023, the facility did not make prompt efforts to resolve grievances the resident may have for 1 of 1 resident (Resident #53) reviewed. Specifically, grievances regarding Resident #53's eyeglasses and missing wheelchair were not addressed timely by the facility and the resident/representative were not updated timely on the outcome of the grievances.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated (NY00315912, NY00316983, NY00323441, and NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming, and personal and oral hygiene for 4 of 8 residents (Residents #51, #53, #74, and #90) reviewed. Specifically, Resident #90 was not assisted with toenail care; Residents #51 and #53 were observed with their call bells out of reach; Resident #53 was not bathed/showered as planned; and Resident #74 was not provided oral hygiene and was not assisted out of bed to a chair daily as planned.

Inspectors wroteBased on observation, interview, and record review for the recertification and abbreviated (NY00315912, NY00322422, and NY00323441) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #90) reviewed. Specifically, Resident #90 had a skin condition on admission that was not re-evaluated by the medical provider, and the resident did not receive the prescribed treatment for the skin condition. Additionally, the resident had not received a shower in one month. The facility policy Administering Topical medications revised 1/2023 documented the guidelines for the safe administration of topical medications. The steps included: [...]

Inspectors wroteBased on observations, record review and interview during the recertification and abbreviated (NY00304868 and NY00322422) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #98) reviewed. Specifically, Resident #98 had a history of falls with injury and the facility did not update the resident's environment or comprehensive care plan to incorporate planned safety measures.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 10/30/2023-11/7/2023, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Residents #5 and #74) reviewed. Specifically, Residents #5 and #74 received oxygen (O2) at flow rates that were not consistent with physician orders, and Resident #5's oxygen nasal cannula was observed on the floor.

Inspectors wroteBased on record review and interview during the recertification survey conducted 10/30/2023-11/7/2023, the facility did not ensure that a resident who required dialysis received such services consistent with professional standards of practice for 1 of 1 resident (Resident #56) reviewed. Specifically, Resident #56 received hemodialysis (a process of purifying the blood when the kidneys do not work properly) treatments at a community based dialysis center and did not have ongoing monitoring before/after the dialysis treatments, and there was no evidence of ongoing communication, service coordination, or collaboration between the facility and the dialysis staff.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00323441) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure facility equipment was maintained in proper operating condition for 2 of 3 units (Units 3 and 4) and the main kitchen. Specifically, the dispensing ice machines were not functional on Unit 3 and Unit 4, Unit 4's kitchenette had a convection toaster with a damaged plug, and the main kitchen's three bay sink had a leak.

Inspectors wroteBased on observation, record review, and interview during the recertification and extended survey conducted from 8/24/21- 9/1/21, the facility failed to ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 2 residents (Residents #92 and 320) reviewed. Specifically, the facility failed to have emergency equipment available for two residents with tracheostomies and staff were unaware of the location of emergency equipment, and their role in performing routine and emergency tracheostomy care. [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00258153, NY00271122, NY00275226 and NY00273295) conducted from 8/24/21-9/1/21, the facility to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #108 and #92) reviewed. Specifically, Residents #108 and 92 were not provided with showers and shampoos and were not dressed in their regular clothing.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 8/24/21-9/1/21, the facility failed to ensure that residents who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; and receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 6 residents (Resident #25) reviewed. Specifically, Resident #25 received an antipsychotic medication without an appropriate diagnosis and there was no documented evidence the resident received a gradual dose reduction (GDR) while receiving the medication.

Inspectors wroteBased on observation and interview during the recertification survey conducted 8/24/21-9/1/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 nursing unit medication carts and medication rooms (Unit 3) reviewed. Specifically, the facility had expired stock medications and biologicals in the 3rd floor medication cart, medication room, and medication storage refrigerator.

Inspectors wroteBased on observation, interview and record review during the recertification and extended survey conducted from 8/24/21-9/1/21, the facility failed to 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 and infections for 1 of 2 residents (Resident #90) reviewed. Specifically, Resident #90's urinary catheter collection bag and catheter tubing were observed laying directly on the floor and the bag did not have a non-permeable covering (dignity bag).