The Hurlbut

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure each resident with pressure ulcers (ulcers on the skin due to prolonged pressure) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for two (2) (Residents #43 and #95) of three (3) residents reviewed. Specifically, for Resident #43, staff did not follow physician's orders when completing a pressure ulcer treatment. For Resident #95, there was a lack of consistent weekly pressure ulcer assessments (including staging, measurements, or a description of the wound) and ongoing monitoring of a left medial ankle pressure ulcer. [...]

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure pharmacist reported irregularities were reviewed by the attending physician and acted upon timely for two (2) (Residents #69 and #77) of five (5) residents reviewed. Specifically, the facility could not provide documentation supporting the consultant pharmacist's monthly recommendations were acted upon by the facility's Medical Director, attending physicians, or designees. For Resident #77 the facility could not provide evidence the Director of Nursing or an attending physician had reviewed the consultant pharmacist's recommendations for ten (10) of twelve (12) months reviewed, and for nine (9) of twelve (12) months reviewed for Resident #66.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, for one (1) (Resident #52) of two (2) residents reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of a bottle of pills labeled as zinc (a supplement that helps the immune system and metabolic function) left at Resident #52's bedside and there were no medical orders in place for the medication or to self-administer (the practice of an individual taking their own prescribed or over-the-counter medications independently, without direct assistance or supervision) the medication. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, raw shell eggs were stored above ready to eat foods, there was bare-hand contact with ready to eat food, and there was a missing section of floor tile that was dirty.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, 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 two (2) (Residents #43 and #95) of three (3) residents reviewed for pressure ulcers. Specifically, Resident #43 was on enhanced barrier precautions (techniques used to prevent transmission of infectious disease utilizing gloves and gowns with all high-contact care) and staff were observed providing wound care without the appropriate personal protective equipment (gown). [...]

Inspectors wroteBased on record review and interview conducted during the Standard Recertification Survey, it was determined that for three (Employees #1, #2, and #5) of six recently hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening of prospective employees. Specifically, a nurse aide registry abuse screening was not completed for recently hired employees prior to starting work.

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who much be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide evidence that the Infection Preventionist attended the Quality Assurance Improvement Performance meetings on a regular basis. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement meetings last three Sign-In Sheets dated 8/8/23, 10/17/23 and 1/23/24 did not include the presence of the Infection Preventionist. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey it was determined that for one (Residents #67) of five residents reviewed for immunizations, the facility was unable to provide documentation that the resident who was eligible had been offered, declined, and/or educated on the pneumococcal immunization or had received it prior to admission. This is evidenced by the following. The facility policy, Resident Influenza and Pneumococcal Vaccine, dated November 2023, included that each resident (upon admission) will be offered the pneumococcal vaccine and the influenza vaccine. Before offering the vaccines each resident/resident representative will receive education and information regarding the benefits and potential side effects of the immunizations. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey it was determined that the facility did not consistently post the daily nurse staffing information to include the daily resident census, the total number and actual hours worked by the licensed and certified nurses and must post the data on a daily basis at the beginning of each shift and be readily accessible to residents and visitors. Specifically, the nursing staff information was not updated to reflect any staffing changes throughout the day per the regulations. This is evidenced by the following: In an observation on 2/12/24 at 12:59 PM, the printed daily nurse staffing posting dated 2/12/24 listed the resident census as 100. There was no documentation to reflect updated staffing changes if applicable. [...]

Inspectors wroteBased on observations and interviews, and conducted during the Recertification Survey completed on 5/13/22, it was determined that for one of one main kitchen, the facility did not store, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a storage unit containing potentially hazardous foods was not maintained in good repair, a refrigeration unit had a damaged seal, a handwash sink was not accessible, and a ceiling fan and tiles were dirty. This is evidenced by the following: 1. During the initial brief tour of the main kitchen on 5/9/22 from 8:45 a.m. to approximately 9:15 a.m., observations and interviews included the following: a. A 'curtain cooler' (portable one door refrigeration unit) used for production beverages was inoperable with regard to refrigeration, and the door did not latch closed. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey conducted 5/9/22 to 5/13/22, 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 disease and infections. Specifically, three Certified Nursing Assistants (CNAs) did not apply the appropriate personal protective equipment (PPE) prior to entering and exiting resident's rooms that were on transmission-based precautions (TBP or quarantine) due to COVID-19 infections and/or exposures. This was evidenced by the following: [...]

Inspectors wroteBased on observation, interviews and record review conducted during a Recertification Survey completed 5/9/22 to 5/13/22 the facility did not ensure that all staff, except for those staff who have been granted exemptions to the vaccination requirements or staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control and Prevention (CDC) have received, at a minimum, one dose of a single-dose vaccine or all doses of a multiple vaccine series prior to providing care/treatment/services for the facility and/or its residents. This resulted in a 94.1% COVID-19 staff vaccination rate. In addition, the facility had 13 residents who were currently positive for COVID-19 and had observations of noncompliant infection control practices by staff. This was evidenced by the following: [...]