The Grand Rehabilitation and Nursing at Rome

Inspectors wroteBased on record review and interviews (iQIES Intake 2740528), the facility failed to ensure alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of four (4) residents (Residents #11, #21, and #37) reviewed. Specifically, it was reported Certified Nurse Aide #31 was heard calling Resident #21 a liar and there was no documented evidence the facility investigated the allegation to rule out abuse; Resident #11 reported to several staff members that Licensed Practical Nurse #36 intentionally did not provide them with their pain medication and the allegation was not reported to administration to ensure an investigation was completed to rule out neglect or mistreatment; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #3 and #16) reviewed. Specifically, Residents #3 and #16 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments and there was no documented evidence the resident's Tesio catheter (access site for dialysis treatment) was routinely assessed.

Inspectors wroteBased on observations and interviews (iQIES intake 2620687), the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for three (3) of four (4) medication carts (Wing Three front and back and Wing Four back medication carts) reviewed. Specifically, Wing Three front medication cart was unlocked and unattended with two (2) medicine cups containing pre-poured medications; Wing Three back medication cart had an undated, unlabeled, open vile of lidocaine (anesthetic), an opened and undated inhaler, one (1) expired insulin pen and one (1) expired insulin vial, and one (1) insulin pen and one (1) insulin vial that were opened and undated; and Wing Four had two (2) opened undated eyes drops, and five (5) opened undated inhalers.

Inspectors wroteBased on observations and interviews (iQIES Intake 2620687), the facility failed to store food in accordance with professional standards for food service safety in one (1) of one (1) main kitchen and 1 (one) of 4 (four) unit pantries (Unit 2 pantry). Specifically, a black substance was observed on the main kitchen cold production reach in cooler door gasket; in the main kitchen walk-in milk cooler along the rim of the ceiling; and on the Unit 2 snack refrigerator door gasket; the cold production reach in cooler did not maintain a safe temperature, the food inside tested at unsafe temperatures; and Food Service Worker #19 attempted to serve Resident #108 a meal tray removed from a food cart with dirty trays.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intakes 2626225, 2712590, and 2740528), the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (2) of seven (7) residents (Residents #1 and #2) reviewed. Specifically, Resident #2 was not toileted as planned; and Resident #1 was not provided with oral care as planned.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were provided with nutritional and hydration care services consistent with the resident's comprehensive assessment for one (1) of four (4) residents (Resident #3) reviewed. Specifically, Resident #3 was on a renal diet (specialized diet for kidney failure that limits specific minerals) and a fluid restriction. Resident #3's actual fluid intake was not monitored and the resident received extra fluids beyond the allotted restrictions at meals; and was provided with extra food which was limited on their prescribed renal diet.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of one (1) resident (Resident #47) reviewed. Specifically, there was no documented evidence Resident #47 had an individualized care plan with interventions in place that included person-centered approaches or steps to assist in guiding staff in managing the resident's care.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2620687) the facility failed to ensure a system of records and accounts of all controlled drugs was maintained for one (1) of five (5) residents (Residents #28, #40, #57, #99, and #106) reviewed. Specifically, on Unit 1 a controlled substance reconciliation (a system of recordkeeping that ensures an accurate inventory of controlled medications) was not performed between the oncoming and outgoing nurse, narcotic keys were not transferred between nurses in a secured manner, a narcotic medication was signed out as administered, but was not, and a poured controlled substance was insecurely stored in the medication cart; Resident #28's, Resident #40's, Resident #57's, and Resident #99's controlled substance records did not accurately reflect the level of medications on hand; [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure that residents were free of any significant medication errors for one (1) of one (1) resident (Resident #14) reviewed. Specifically, Resident #14 received Ativan (a medication for anxiety) twice a day and the medication was not administered within the prescribed time frame causing discomfort to the resident.

Inspectors wroteBased on observations and interviews the facility failed to ensure garbage and refuse was disposed of properly for one (1) of one (1) dumpster area located near the loading dock. Specifically, there were several used gloves, empty food containers, and vegetable scraps on the ground around the dumpster.

Inspectors wroteBased on observations, record review, and interviews the facility failed to 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 two (2) of three (3) residents (Residents #61 and #146) reviewed. Specifically, staff did not wear the required personal protection equipment while caring for Residents #61 and #146 who were on contact precautions.

Inspectors wroteBased on record review and interviews during the abbreviated survey (Complaint ID# 2613592), the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was discharged on 05/19/2025 to the Department of Social Services via family transportation without consulting the Department of Social Services to ensure the plan met the resident's health and safety needs, and preferences. The resident had no identification, and no supportive services in place, and was discharged without proper education and supplies to manage their diabetes and diabetic wounds. This resulted in the likelihood of serious harm, serious injury, serious impairment or death that was Immediate Jeopardy to Resident #2.

Inspectors wroteBased on observation, record review, and interview during the abbreviated (NY00339441) survey the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 5 residents (Resident #293) reviewed. Specifically, Resident #293 developed a Stage 2 (partial-thickness skin loss) facility-acquired pressure ulcer when incontinence care was not provided routinely or as planned and treatments to the area were not consistently administered. Subsequently, the pressure injury progressed to an unstageable pressure ulcer (full thickness tissue loss in which the base of the wound is covered with dead tissue).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure a safe, clean, comfortable, and home-like environment for 4 of 4 Units (Units 100, 200, 300, and 400) reviewed. Specifically, floors, walls, ceilings, and resident chairs were damaged or unclean on Units 100, 200, 300, and 400; drain flies were observed in the Unit 200 shower room; and there was no negative air pressure in Units 200, 300, and 400 soiled utility rooms (negative pressure rooms have a lower air pressure, created by ventilation, to reduce the flow of potentially contaminated air or odors from leaking into the surrounding areas).

Inspectors wroteBased on observation, record review and interviews during the recertification and abbreviated (NY00340701, NY00330066, NY00333069, and NY00328237) surveys conducted 6/24/2024 - 6/28/2024, 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 4 of 11 residents (Residents #56, #80, #90, and #127) reviewed. Specifically, Resident #127 had untrimmed fingernails and was not wearing their glasses; and Residents #56, #80, and #90 had unclean and untrimmed fingernails.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00340613, NY00328237, and NY0330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (6/26/2024 breakfast meal and 6/26/2024 lunch meal) reviewed. Specifically, the breakfast and lunch meals were not served at safe and appetizing temperatures.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00330066 and NY00331744) surveys conducted 6/24/2024-6/28/2024, the facility did not provide one or more rooms designated for resident dining and activities that were adequately furnished and had sufficient space to accommodate all activities for 2 of 4 dining rooms (Units 100 and 400). Specifically, Units 100's and 400's dining rooms had tables that did not accommodate residents' social and physical needs with inadequate space for dining or activities, and residents were lined up in the hallways during meals.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure residents had the right to a dignified existence for 2 of 18 residents (Resident #28 and #44) reviewed. Specifically, Residents #28 and #44 were referred to with undignified labels (feeders); and Resident #44 was assisted with eating while staff stood over them.

Inspectors wroteBased on interview and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions were referred for a Level II Pre-admission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care and a Level II PASARR identifies the specialized services required by the resident) for 1 of 2 residents (Resident #101) reviewed. Specifically, there was no documentation Resident #101 was referred for a Level II Preadmission Screening and Resident Review when the resident was newly diagnosed with a serious mental health disorder.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6242024-6/28/2024, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 7 residents (Resident #111) reviewed. Specifically, Resident #111 had a physician order for a chopped consistency diet and was served a whole sandwich.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #59) reviewed. Specifically, Resident #59 did not receive ordered fluids on their meal tray and was not offered a substitution when they requested a sandwich.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well-being of each resident. Specifically, the facility received a letter from Centers for Medicare and Medicaid Services dated 2/09/2024, prohibiting the provision of a Nurse Aide Training and Competency Evaluation Program, conducting onsite nurse aide competency exams, or utilizing onsite clinical training by an off-site nurse aide training program, effective through 10/2025, and the facility was observed conducting an off-site nurse aide training program.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00304388), the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a history of aspiration (inhalation of foods/fluids into the lungs) risk, was on an altered consistency diet (chopped solids) and required supervision and assistance with eating. On 4/26/2023, the resident was provided a sandwich and was not supervised while eating. Subsequently, approximately 30 minutes later, the resident was found without signs of life (no pulse or respirations), with food in their mouth, and was pronounced deceased . The resident had an autopsy that concluded their airway was completely obstructed by a food bolus (soft mass of chewed food). [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00304388), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated; did not ensure residents were protected while the investigation was in process; did not implement plans to prevent reoccurrence; and did not ensure incidents were reported to the New York State Department of Health (NYS DOH) when required for 2 of 3 residents reviewed (Residents #1 and 2). Specifically, - Resident #1, whose cognition was severely impaired, had a sexual encounter with a cognitively intact resident (Resident #2) and a plan was not implemented to protect Resident #1 from further potential abuse. Additionally, recommendations from the psychiatric nurse practitioner (NP) for 15-minute checks were not implemented. [...]

Inspectors wroteBased on record review, and interview during the abbreviated survey (NY00304388), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed (Resident #1). Specifically, facility Administration, including the Director of Nursing (DON) did not ensure residents received adequate supervision to prevent accidents (choking), did not complete a thorough investigation into resident choking, and did not report neglect as required to the New York State Department of Health (NYS DOH).

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00271335, NY00276204, NY00290644, NY00293364, and NY00297551) conducted 8/8/22-8/15/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4) reviewed. Specifically, there were sticky/unclean floors, scrapped/damaged walls, exposed electrical wires, water dripping from a ceiling vent, resident clothing left on the ground in a clean utility closet, a loose/unsecured toilet bowl, and a loose/unsecured resident room doorknob. Additionally, Resident #48's room was not personalized and/or homelike.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 23 of 39 residents (Residents #2, 4, 13, 19, 32, 34, 36, 37, 39, 43, 44, 57, 66, 81, 82, 87, 89, 100, 102, 104, 111, 146, and 155) reviewed. Specifically, during a medication storage review of the Unit 1 medication cart, 23 residents had pre-poured medications in cups, stored in the top drawer of the Unit 1 medication cart.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 2 of 7 medication carts (Units 1and 4) and 3 of 4 medication storage rooms (Units 1, 3, and 4) observed. Specifically, Units 1 and 4 had expired stock medications in the medication rooms and medication carts and the Unit 3 medication storage room refrigerator had an expired biological multi-dose vial.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00271335) surveys conducted 8/8/22-8/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's main kitchen and emergency food supply room. Specifically in the main kitchen: - the hand-washing sink, near the dishwasher area, had a faucet that was leaking water. - The metal vent system, over the dishwasher, was rusty and soiled. - The metal support pieces for the ceiling tiles in the dishwasher area were unclean/rusty. - The wall behind the dishwasher was soiled with food and unclean. - The floor behind the 3 bay sink area was unclean with debris on it. - A section of floor between the 3 bay sink and a food heating oven had standing water and was unclean. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to 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, recognizing each resident's individuality for 1 of 1 resident (Resident #55) reviewed. Specifically, the facility did not provide Resident #55, whose primary language was not English, with a plan for communication of needs and preferences.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22 the facility failed to determine the clinical appropriateness of self-administration of medications for 1 of 8 residents (Resident #124) reviewed. Specifically, Resident #124 had a physician order documenting the resident was not capable of self-administering medications and multiple creams and Melatonin (a hormone that promotes sleep) were observed in the resident's locked bedside table.

Inspectors wroteBased on interview and record review during the recertification survey conducted 8/8/22 to 8/15/22, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in process for 1 of 3 residents (Resident #99) reviewed. Specifically, certified nurse aide (CNA) #10 was not removed from having contact with residents immediately following an alleged incident of abuse, neglect, or mistreatment involving Resident #99.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00276204, NY00294053, NY00297551, NY00264591, NY00293364, NY00300052, and NY00290644) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 10 residents (Residents #17, 37 and 48) reviewed. Specifically, Resident #17's hair was unclean, Resident #37 was not dressed daily, and Resident #48's nails were unclean, and their clothing was not changed daily.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated (NY00300052 and NY00264591) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents 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 1 of 1 resident (Resident #73) reviewed. Specifically, Resident #73 did not have Prevalon boots (a boot that floats the heels to reduce pressure) applied to their bilateral heels while in bed or in their wheelchair as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00268090) conducted on 8/8/22-8/15/22, the facility failed to ensure the resident environment remained free of accident hazards as possible and residents received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #108) reviewed. Specifically, Resident #108 had smoking materials in their room which were not secured per facility policy and the resident's plan of care and other care planned interventions to promote smoking safety were to implemented as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to assist residents in obtaining routine dental care for 1 of 3 (Resident #96) residents reviewed. Specifically, the facility did not obtain the services of a dentist for Resident #96 when their lower dentures were missing and not recovered.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure the menus reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population for 1 of 1 resident reviewed (Resident #48). Specifically, Resident #48 had limited intake due to cultural and ethnic food preferences and there was no documented evidence the facility attempted to obtain foods that would meet the resident's preferences.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00294053) surveys conducted 8/8/22-8/15/22, 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 2 certified nurse aides (CNAs #20 and 45) and activity aide #51 observed for appropriate mask wearing. Specifically, CNAs #20 and 45 and activity aide #51 were observed not wearing face masks appropriately in resident care areas.