The Grand Rehabilitation and Nursing at Utica

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 5/27/2025 - 6/05/2025, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, following a wastewater back up from the grease trap and drains flooding the main kitchen on 5/27/2025, the facility failed to adequately address wastewater cleanup including monitoring, evaluating, and sanitizing as necessary, cooking equipment and appliances in the main kitchen. Additionally, there was no detectable level of sanitizer in the 3-bay sink and dishwasher to adequately sanitize dishware. This resulted in Immediate Jeopardy to resident health and safety for all 215 residents of the facility.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025 -6/5/2025 the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of one (1) main kitchen, and two (2) of seven (7) resident unit refrigerators (Units 3 and 6). Specifically, the main kitchen had multiple unclean surfaces, broken tiles and wall strips, food items were not labeled or dated, and the walk-in freezer had ice buildup; Units 3 and 6 refrigerators were outside acceptable temperatures for food safety; and the Unit 6 ice machine had white build up.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 5/27/2025-6/6/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of (2) two meals reviewed (Lunch meals on 6/3/2025 and 6/4/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 6/3/2025 and 6/4/2025. Additionally, six residents (Resident #64, #103, #138, #152, #161, and #173) stated the food did not taste good and was cold.

Inspectors wroteBased on observations, record review, and interviews during the recertification and extended surveys conducted 5/27/2025- 6/5/2025 the facility did not ensure it was 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 of each resident. Specifically, administration 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, F 812 Food and Nutrition Services. The facility failed to adequately address wastewater cleanup including monitoring, evaluating, and sanitizing cooking equipment and appliances in the main kitchen. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/28/2025-6/5/2025, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 2 of 2 residents (Residents #20 and #144) reviewed. Specifically, Resident #20 had medications left in their room and Resident #144 had an inhaler (used for breathing difficulty) at their bedside, without physician orders to self-administer medications or documented evidence they were assessed to determine their ability to safely self-administer medications.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure resident advance directives (instructions relating to the provision of health care when an individual is incapacitated) were accurately documented for 1 of 1 resident (Resident #55) reviewed. Specifically, Resident #55 did not have physician orders for advance directives and advance directives documented throughout the medical record did not reflect the resident's wishes to receive cardio-pulmonary resuscitation in the event of an emergency.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00358322) surveys conducted 5/27/2025-6/5/2025, the facility did not allow one (1) of three (3) residents (Resident #185) to return to the facility to their previous room or immediately upon the first availability of a bed. Specifically, Resident #185 was not accepted back to the facility in a timely manner once cleared by the hospital for discharge

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00370441) surveys conducted 5/27/2025 -6/5/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of five (5) residents (Residents #56 and #11) reviewed. Specifically, Resident #56 did not have a care plan for managing their peripherally inserted central catheter (intravenous line); and Resident #11's care plan did not reflect their current dialysis schedule or correct dialysis access site location.

Inspectors wroteBased on interview and record review during the recertification and abbreviated surveys (NY00352395) conducted 5/27/2025-6/5/2025, the facility did not ensure that each resident and/or resident representative participated in the development of the comprehensive care plan for one (1) of one (1) resident (Resident #214) reviewed. Specifically, there was no documented evidence Resident #214 participated in the development of their Comprehensive Care Plan or was invited to attend their initial comprehensive care plan meeting. The facility policy Care Planning-Interdisciplinary Team, revised 1/2025, documented the resident care plan was developed by the Care Planning/Interdisciplinary Team based on the resident's comprehensive assessment and the resident was encouraged to participate in development and revisions. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00370441) surveys conducted 5/27/2025-6/5/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) of six (6) residents (Resident #123) reviewed. Specifically, Resident #123 was not assisted with washing their hair or genital care as planned.

Inspectors wroteBased on record review, observations, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for 1 (one) of 3 (three) residents reviewed (Resident #96). Specifically, Resident #96 had pressure ulcers that were not monitored or have treatment/management interventions in place. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #91) reviewed. Specifically, Resident #91 who resided on the Dementia Care Unit had cough drops at their bedside not ordered by the medical provider.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure residents were evaluated for hydration care consistent with the resident's comprehensive assessment for 1 (one) of 3 (three) residents (Resident #144) reviewed. Specifically, Resident #144's hydration needs were not reassessed or reviewed for adequacy by clinical nutrition staff after they were diagnosed with urinary tract infections.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00372942) surveys conducted 5/27/2025-6/6/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #57) reviewed. Specifically, Resident #57 did not receive bilevel positive airway pressure (BiPAP/a device to assist with breathing) as ordered.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for one (1) of five (5) medication carts (4th floor cart) and one (1) of four (4) medication storage rooms (4th floor medication room). Specifically, the 4th floor medication cart and medication room had expired stock medications and biologicals.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure they established and maintained 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 three (3) residents (Resident #33, #118, and #211) reviewed. Specifically, Resident #118's urinary drainage bag was observed uncovered and lying directly on the floor; and Residents #33 and #211 were administered eye drops by Licensed Practical Nurse #49 who did not perform hand hygiene or don gloves. Additionally, the facility did not conduct legionella (a bacteria that causes Legionnaire's disease, a type of pneumonia) testing as required.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00343878), the facility failed to provide residents with treatment and care in accordance with professional standards of practice for 3 of 6 residents reviewed (Residents #1, #5, and #6). Specifically, - Resident #1 had an unwitnessed fall, the medical provider was not notified timely of the fall or outcome of the assessment, and there was no evidence neurological checks were implemented. Subsequently, the resident experienced a significant change in condition, the medical provider ordered the resident to be sent to the hospital, and Emergency Medical Services was not notified immediately for transportation. The resident was transferred to the hospital where they expired from asphyxiation (loss of oxygen) due to choking on their dentures. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated survey (NY00332276) conducted [DATE]-[DATE], the facility failed to ensure resident preferences and physician orders related to cardiopulmonary resuscitation (perform chest compressions in the event of a cardiac arrest), and other advance directive issues were communicated throughout the facility so that staff knew immediately what action to take or not to take when an emergency arose. Specifically, staff were unable to consistently identify resident code status indicators in the event of cardiac arrest. On [DATE], Resident #400 was found without a pulse in a non-residential area of the facility. Staff did not know the resident's code status and initiated cardiopulmonary resuscitation (chest compressions). [...]

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00299391, NY00325885, and NY00331016) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 18 isolated areas (resident rooms 263, 266, 270, and 273; second floor south hallway; second floor south dining room; second floor activities room kitchenette; second floor west shower room; second floor west lounge bathroom; second floor west soiled utility room; second floor south telephone room; second floor south closet near social workers office; resident rooms [ROOM NUMBERS]; third floor shower room; fifth floor hallway near resident room [ROOM NUMBER]; sixth floor hallways near elevator; and, resident room [ROOM NUMBER]). Specifically: - On multiple floors the halls, walls, and ceilings were in disrepair. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00328424) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles, and include the expiration date when applicable for 3 of 5 medication carts (4th floor, 6th floor and 7th floor) and 7 of 7 medication refrigerators (2 South, 2 West, 3rd floor, 4th floor, 5th floor, 6th floor and 7th floor) reviewed. Specifically, the 4th floor medication cart had eye drops for Resident #61 and Resident #136 without labeled open dates or discard dates; the 6th floor medication cart had eye drops for Resident #9 without labeled open or discard dates, and opened house stock cough syrup without labeled open date or discard date; [...]

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00323751) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (1/25/2024 breakfast and 1/26/2024 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/24/2024 - 2/1/2024 the facility did not ensure each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plans of care for 4 of 6 nursing floors (2 [NAME] and 2 South floors, 3rd floor, 5th floor, and 6th floor) observed. Specifically, resident meal trays were delivered to nursing floors up to 43 minutes after the scheduled mealtimes.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00325885) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure the facility stored, prepared, distributed, and served food in accordance with professional standards for food service safety for 1 of 1 kitchens (the main kitchen) reviewed. Specifically, multiple areas of the main kitchen were unclean; the steamer, a hand wash sink, and the high temperature were in disrepair; there was a an expired package of hot dog rolls and an expired jar of peanut butter; there was an unlabeled package of bread crumbs; there was an undated bag of chocolate mix and two opened containers of chicken paste with no opened date; there was a dented can of pears and a dented can of an unknown product; and there was three sections of sheet cake that were not covered.

Inspectors wroteBased record review and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure 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. Specifically, the required quarterly Legionella (type of bacteria that causes Legionnaire's disease) water testing was not completed after 30% of the annual water samples detected Legionella.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/24/2024-2/1/2024 the facility did not ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member for 2 of 6 units (Unit 2 and Unit 3) reviewed. Specifically, non-functioning call lights were observed on Unit 2 in resident rooms 266, 274, 269, 263, 261, 250, 248, 245, 241, the second floor south shower room, and the second floor dining room; and, on Unit 3 resident room [ROOM NUMBER].

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00300181, NY00323751, and NY00325885) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure the residents' rights to a private space for 2 of 13 residents (Residents #3 and #44) reviewed. Specifically, Residents #3 and #44 did not have keys to access a privately locked space.

Inspectors wroteBased on observation and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members and legal representatives of residents. Specifically, the most recent survey results and plan of correction were in a binder in a file bin on the wall, approximately 4-feet off the ground, around the corner from the main front lobby desk, and not easily accessible. There were no notices posted advising the residents, family members and legal representatives of the survey results location. Findings Include: During the Resident Council Meeting on 1/24/2024 at 1:53 PM, 10 anonymous residents stated they did not know where the binder of previous survey results was located. [...]

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00299391 and NY320041) surveys conducted 1/24/2023-2/1/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 4 residents (Resident #134 and 400) reviewed. Specifically, Resident #135 had injuries of unknown origin that were not thoroughly investigated, and Resident #400 was provided a regular consistency sandwich on a ground consistency diet and was later found unresponsive on the floor and the incident was not investigated.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00325885, NY00328424 and NY00331016) conducted 1/24/2024-2/1/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 7 residents (Residents #38, #64, #80) reviewed. Specifically, - Resident #38 received rapid-acting insulin (starts to lower glucose levels 15 minutes after injection) greater than one hour before meals. - Resident #64 was observed with a vacuum assisted wound closure device (a type of therapy used for wound healing) that was not functioning. - Resident #80 was found on the floor, was not assessed by a qualified professional timely, did not receive a physician ordered X-ray immediately as ordered, and was diagnosed with a right hip fracture.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00322708 and NY00325885) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #24) reviewed. Specifically, Resident #24 was observed in their bed with their air mattress (a specialty mattress that provides air flow to relieve pressure) not functioning.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00299391, NY00322708, and NY00331016) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure each resident received adequate supervision to prevent accidents and the environment remained free of accident hazards for 2 of 10 residents (Residents #128 and #400) reviewed. Specifically, Resident #400 was given food not consistent with their physician ordered diet, and Resident #128 had an unidentified medication on the floor of their room.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00299391 and NY00322708) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #184) reviewed. Specifically, Resident #184 had a significant weight loss, their nutritional interventions were not reassessed, and the resident had additional weight loss. Additionally, there was no documented evidence medical was made aware of the resident's significant weight loss.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure that a resident being fed by enteral means (tube placed in the stomach for feedings) received the appropriate treatment and services to prevent complications for 3 of 3 residents (Residents #2, #24, and #134) reviewed. Specifically, Residents #2, #24, and #134 did not have their tube feeding formula labeled with a date and time.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, or obtain informed consent prior to the installation of bedrails for 3 of 3 residents (Residents #88, #160 and #192) reviewed. Specifically, for Residents #88, #160 and #192, there was no documented evidence there were bed rail assessments prior to bed rail installation, the risks and benefits of bed rails were explained to the residents or their representatives, or that consents were obtained prior to bed rail installation.

Inspectors wroteBased on record review and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure nursing staff had 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with facility assessment for 3 of 8 staff personnel records (Licensed practical nurse #67, licensed practical nurse #68, and registered nurse #69) reviewed. [...]

Inspectors wroteBased on observation, interview, and record review during recertification and abbreviated (NY00323751) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure menus were followed for 1 of 3 residents (Resident #64) reviewed. Specifically, Resident #64 had missing menu items from their meal trays and did not receive double entrees as care planned.

Inspectors wroteBased on observations and interview during the recertification and abbreviated surveys post survey revisit conducted 4/4/2024-4/9/2024, the facility did not ensure it was administered in a manner that enabled it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the call bell system for Unit 2 was not functioning properly (see F 919); foods were not maintained at palatable and safe temperatures (see F 804); medication refrigerator temperatures were not consistently logged to ensure maintenance of safe temperatures for medications and education regarding medication refrigerator temperatures and logbooks was not completed as planned (see F 761); and resident areas had fruit flies and floors in disrepair (see F 584).

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure facility equipment was maintained in proper operating condition for 1 of 7 resident floors (5th floor). Specifically, the fifth floor ice machine was not functional.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted on 12/13/21-12/21/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety affecting the entire facility. Specifically, the facility failed to maintain a walk-in cooler in operating condition and was found to have an ambient air temperature above 45 degrees Fahrenheit (F). Milk from that walk-in cooler was found to be at 59.5 degrees F and was to be served to residents (required temperature: 45 F or less per New York State, NYS, code and 41 F or less per Food and Drug Administration, FDA, food code). Additional food product in a stand-up cooler that came from the improperly functioning walk-in cooler contained cottage cheese which was measured at 52 degrees F. The milk from the line was pulled at 12:45 PM. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00269688 and NY00273974) surveys conducted on 12/13-12/21/21, the facility failed to ensure 2 of 13 residents (Residents #184, and 224) reviewed received adequate supervision and assistance devices to prevent accidents and/or their environments remained as free of accident hazards as possible. Specifically, - Resident #184 exited the secure unit (2S) undetected and made it to a non-resident area, and the incident was not thoroughly investigated, nor was a plan implemented to prevent further unsafe wandering. Resident #184 subsequently eloped from the facility and was found walking in the roadway by the local police after certified nurse aide (CNA) #24 did not appropriately respond when the wander guard system (to alert staff of resident wandering) alarmed. [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 12/13/21-12/21/21, the facility failed to ensure 1 of 2 residents (Resident #31) reviewed was free from physical restraints. Specifically, Resident #31's restraint was not released at least every 2 hours and at meals as care planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00281850, NY00270904, NY00269162 and NY00281169) conducted on 12/13/21-12/21/21, the facility failed to ensure 1 of 7 residents (Resident #2) reviewed received the necessary services to maintain good nutrition. Specifically, Resident #2 was not assisted with meals timely.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted on 12/13-12/21/21, the facility failed to ensure 1 of 4 residents reviewed (Resident #145) maintained acceptable parameters of nutritional status. Specifically, Resident #145 had a significant weight loss which was not reassessed timely by clinical nutrition staff.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted on 12/13/21- 12/21/21, the facility failed to ensure the menu was prepared in advance, followed, and reflect, based on reasonable efforts, input from the residents for 4 of 35 residents reviewed (Residents #28, 91, 111, and 215). Specifically, Residents #28, 91, and 111 received a substitution of peas instead of spinach at the 12/13/21 lunch without documented rationale for the substitution. Resident #28 received incorrect items at 2 meals and Resident #215's meal preferences were not honored, and they received foods they did not like.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted on 12/13/21 through 12/21/21, the facility failed to provide food and drink that is palatable and at a safe and appetizing temperature for 1 of 2 test trays reviewed. Specifically, a breakfast tray was served at unpalatable temperatures to Resident #2 and Residents #6, 28, #103, 111, and 133 reported receiving food at unpalatable temperatures.

Inspectors wroteBased on observation and interview during the recertification survey conducted on 12/13/21-12/21/21, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes affecting 1 of 7 units (Unit 2S) reviewed. Specifically, the Unit 2S dining room's heat was not working, residents were displaced to their rooms and hallways for meals, and the facility did not report the heat outage to the New York State Department of Health (NYS DOH) as required.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 12/13/21-12/21/21, the facility failed to furnish services by a person or agency outside the facility if the facility does not employ a qualified professional to furnish a specific service for 2 of 3 residents (Residents #6 and 175) reviewed. Specifically, Resident #6 missed a virtual medical appointment; and Resident #175's outpatient nephrology appointment was canceled, the cancellation was not communicated, and the resident went to the canceled appointment with a family member.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00272513) conducted 12/13/21-12/21/21, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #83) reviewed. Specifically, registered nurse (RN) #30 did not change gloves after removing an old dressing and cleansing a wound and did not perform hand hygiene between glove changes during wound care for Resident #83.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted on 12/13/21-12/21/21, the facility failed to conduct testing based on parameters set forth by the Secretary for 3 of 4 residents (Residents #76, 132, and 156) reviewed. Specifically, Residents #76, 132 and 156 were identified as having a close contact with a COVID-19 positive staff member (certified nurse aide, CNA, #54) and were not tested per the outbreak testing guidelines on Day 2.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00273974) conducted from12/13/21-12/21/21, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 7 resident units (2S Unit). Specifically, the 2S Unit (secured dementia unit) elevator was not disabled by the presence of a wander alert bracelet (used to alert staff of resident wandering). Subsequently, Resident #184 was able to take the elevator to the first floor, unsupervised, while wearing a wander alert bracelet.