Williamsbridge Center for Rehabilitation and Nursi

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Infection prevention and control practices were not maintained during medication administration. This was evident in 1 of 3 nurses observed for medication administration. 2.) Staff failed to assist residents with hand washing or hand hygiene before meals. This was evident in 2 of 2 units observed during meals. 3.) A resident's urinary drainage bag was observed touching the floor. This was evident in 1 (Resident #4) of 3 residents reviewed for Urinary Catheter out of 22 sampled residents.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, 1.) The walk-in refrigerator contained undated items. 2.) A unit refrigerator contained spilled liquids and undated fruit cups and open drinks items.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident in 2 of 22 sampled residents (Residents #35, #18). Specifically, 1.) Resident #35's care plan related to Smoking was not reviewed and revised quarterly after each assessment, and 2.) Resident #18's care plan was not reviewed and revised after a fall occurrence.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025 the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing Task.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident 1 (South Unit) of 2 resident units. Specifically, the make resident bathroom was observed to be dirty.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 06/13/2023 to 06/21/2023, the facility did not ensure that a safe food storage was practiced. This was evident during the Kitchen Observation. Specifically, expired water was observed in the kitchen's Emergency Food Storage Room (EMSR).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 6/13/23 to 6/21/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 2 (Resident #70 and #26) of 21 total sampled residents. Specifically, blood pressure (BP) cuffs were not cleaned and disinfected between use with Resident #70 and Resident #26.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 6/1/23 to 6/21/23, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident # 6) out of 5 residents reviewed for Accidents of 21 total sampled residents. Specifically, the facility did not report an unwitnessed incident resulting in bilateral eye ecchymosis and frontal hematoma to Resident #6.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 06/13/23 to 06/21/23, the facility did not ensure a person-centered Comprehensive Care Plans (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #24) of 21 total sampled residents. Specifically, a CCP related to Resident #24's behavior of emptying their urine and feces into the garbage bin in their room.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification from 6/13/23 to 6/21/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #27) of 2 residents reviewed for Edema out of 21 total sampled residents. Specifically, Resident #27 was observed on multiple occasions without Thrombo-Embolic Deterrent (TED)/compression stockings in place according to Medical Doctor Order (MDO).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and public. This was evident in stairwell of facility that is used by staff and visitors to access the basement. Specifically, the stairwell used to enter and exit the resident unit was soiled and dirty with debris.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 06/13/23 through 06/21/23, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for 1 (South Unit) of 2 resident units. Specifically, multiple gnats were observed room [ROOM NUMBER] and #20 on the South Unit.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident with chronic pain reported continued pain to the staff despite pain management. The nursing staff did not assess the resident's reported pain, complete pain assessments as ordered, or report the pain to the physician for follow-up. This was evident for 1 of 3 residents reviewed for pain management (Residents #273). The finding is: The facility policy, titled Pain Management dated 07/2019 documented the following: [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, conducted on 5/28/2021, 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. Specifically, 1) contracted vendors were not wearing the proper personal protective equipment (PPE) while working in the room of a resident on contact and droplet precautions; and 2) a resident's indwelling catheter drainage bag was on the floor on multiple occasions. This was evident for random observations of 2 residents (Resident #71 and Resident #222) on 1 of 2 units (1 South Unit).