Inspection Reports for
Ghent Rehabilitation & Nursing Center
1 Whittier Way, Ghent, NY, 12075
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Inspection Report — Oct 30, 2023
State
Date: Oct 30, 2023
Visit Reason
State-compiled facility profile showing 12 inspections from June 2022 to May 2026 with citation and complaint history, enforcement actions, and detailed inspection findings.
Complaint Details
The state logged 147 complaints about this facility; 9 led to on-site inspections. The facility received 133.1 complaints per 100 beds versus a statewide rate of 57.4, resulting in 14 citations from complaints.
Findings
Across 12 inspections, 6 had no citations and 6 resulted in 21 total citations, mostly related to standard health and life safety code issues. The facility had 147 complaints with 9 on-site inspections and 2 enforcement actions totaling $30,000 in fines.
Citations (18)
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficiencies noted in multiple COVID19 surveys with widespread and isolated issues.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary found deficient with pattern scope.
Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp found deficient with pattern scope.
Standard Health Citation — quality of care: Personal Food Policy deficient with pattern scope.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficient with isolated scope.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning deficient with isolated scope.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation deficient with isolated scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficient with pattern scope.
Standard Health Citation — quality of care: Laboratory Services deficient with isolated scope.
Standard Health Citation — quality of care: Nutrition/hydration Status Maintenance deficient with isolated scope.
Standard Health Citation — quality of care: Quality Of Care deficient with pattern scope.
Standard Health Citation — quality of care: Resident Records - Identifiable Information deficient with pattern scope.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors deficient with isolated scope.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer deficient with isolated scope.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment deficient with pattern scope.
Report Facts
Inspections on page: 12
Total violations/deficiencies cited: 21
Inspections with violations: 6
Inspections without violations: 6
Total complaints: 147
On-site complaint inspections: 9
Citations issued from complaints: 14
Enforcement actions: 2
Total fines: 30000
Inspection Report — Sep 1, 2023
Annual Inspection CMS
Date: Sep 1, 2023
Visit Reason
The inspection was a recertification survey conducted from 08/28/2023 through 09/01/2023 to assess compliance with regulatory standards for the nursing home.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, timely reporting of suspected abuse and neglect, respiratory care, food service quality and safety, and food brought in by visitors. Deficiencies included soiled floors and walls, failure to report serious injuries within required timeframes, improper oxygen flow rate management, serving food at unsafe temperatures and poor palatability, unsanitary kitchen and kitchenette conditions, and unlabeled or outdated food stored in resident refrigerators.
Citations (6)
F 0584: The facility did not provide effective housekeeping and maintenance services for three resident units and the core area, including soiled floors, walls, windows, and peeling wallpaper.
F 0609: The facility failed to timely report suspected abuse or neglect involving serious bodily injury to the New York State Department of Health for two residents with unwitnessed falls resulting in serious injuries.
F 0695: The facility did not ensure a resident requiring oxygen at 2 liters/minute via nasal cannula was provided the correct flow rate and did not routinely monitor the prescribed oxygen flow rate.
F 0804: The facility did not provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures, with multiple observations of cold, lukewarm, or unpalatable food items across units.
F 0812: The facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards, with soiled kitchen equipment, floors, and pantry restroom fixtures observed.
F 0813: The facility did not have an effective policy implementation for use and storage of foods brought to residents by family and visitors, with unlabeled and outdated food items found in a resident kitchenette refrigerator.
Report Facts
Residents reviewed for accidents: 6
Residents reviewed for respiratory care: 1
Test trays evaluated: 4
Packages of deli-sliced cold cuts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding failure to report abuse allegations and fall incidents. |
| Director of Nursing | DON | Interviewed regarding failure to report abuse allegations and fall incidents. |
| Licensed Practical Nurse Unit Manager | LPNUM | Interviewed about Resident #69 fall and reporting guidelines. |
| Registered Nurse Supervisor | RNS | Interviewed about oxygen therapy orders and monitoring. |
| Licensed Practical Nurse | LPN | Observed adjusting oxygen flow rate for Resident #33. |
| Certified Nursing Assistant | CNA | Interviewed about oxygen flow rate adjustments and food complaints. |
| Food Service Director | FSD | Interviewed about food service quality, kitchen cleanliness, and food storage. |
| Director of Environmental Services | Interviewed about housekeeping and food storage responsibilities. | |
| Administrator | Interviewed about facility awareness and corrective actions for deficiencies. |
Inspection Report — Jun 9, 2021
Annual Inspection CMS
Date: Jun 9, 2021
Visit Reason
The inspection was conducted as a recertification survey and abbreviated survey to assess compliance with regulatory requirements for Ghent Rehabilitation & Nursing Center.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, comprehensive care planning, medication regimen review policies, food service safety, and staff education on abuse and neglect. Several residents lacked appropriate care plans, food safety equipment was not properly maintained, and new employee orientation was not consistently provided.
Citations (5)
F 0584: The facility did not provide effective housekeeping and maintenance services; floors and tables were not clean and resident room walls were not maintained on 3 of 3 resident units.
F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 of 24 residents reviewed, missing care plans for seizures, hypothyroidism, and discharge planning.
F 0756: The facility policy for monthly Medication Regimen Review did not include documentation of specific time frames for the steps in the process.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; thermometers were not calibrated, plumbing fixtures were in disrepair, and equipment and floors required cleaning.
F 0943: The facility did not provide new employee orientation on abuse, neglect, exploitation, and reporting procedures to 5 employees prior to their start of work.
Report Facts
Residents reviewed for Comprehensive Care Plans: 24
Residents affected by care plan deficiencies: 3
Food thermometers tested: 5
Food thermometers not calibrated: 2
Employees without abuse orientation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Interviewed regarding missing care plans for seizures, hypothyroidism, and discharge planning |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding responsibilities for care plans and employee orientation |
| Regional Director of Quality Assurance #5 | Regional Director of Quality Assurance | Interviewed regarding Medication Regimen Review policy |
| Food Service Director | Food Service Director | Interviewed regarding food service deficiencies and corrective actions |
| Certified Nursing Aide (CNA) #1 | Certified Nursing Aide | Interviewed regarding lack of abuse orientation |
| Laundry Employee #1 | Laundry Employee | Interviewed regarding lack of abuse orientation |
| Maintenance Employee #1 | Maintenance Employee | Interviewed regarding lack of abuse orientation |
| Dietary Employee #1 | Dietary Employee | Interviewed regarding lack of abuse orientation |
| LPN Staff Educator (SE) | Licensed Practical Nurse Staff Educator | Interviewed regarding suspension and resumption of new employee orientation |
| Human Resource Staff Person (HR) | Human Resource Staff Person | Interviewed regarding new employee hiring and orientation process |
| Administrator (Adm) | Administrator | Interviewed regarding staff orientation and education practices |
Inspection Report — May 22, 2019
Annual Inspection CMS
Date: May 22, 2019
Visit Reason
The survey was a recertification annual inspection to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, management of personal funds, use of physical restraints, transfer and discharge notifications, comprehensive care planning, staffing adequacy for feeding assistance, drug regimen review, medication management, food service quality and safety, feeding assistant program appropriateness, and medical record maintenance.
Citations (14)
F 0550: The facility did not ensure residents were treated with dignity; residents' pants were pulled down exposing briefs and thighs in public areas.
F 0567: The facility did not ensure residents had access to personal funds on weekends and holidays as required by policy.
F 0604: The facility did not ensure residents were free from physical restraints not required for medical treatment, including use of tray tables and locked chairs without assessments.
F 0623: The facility did not provide written notification of transfer/discharge to resident, representative, or ombudsman for a hospitalized resident.
F 0625: The facility did not notify resident or representative in writing of bed hold policy upon hospital transfer.
F 0656: The facility failed to develop and implement comprehensive care plans for pressure ulcers, dehydration, and respiratory diagnoses including oxygen and BIPAP therapy.
F 0725: The facility did not ensure sufficient nursing staff to meet resident needs, resulting in delayed or incomplete feeding assistance on a dementia care unit.
F 0756: The facility did not ensure drug regimen review recommendations were acted upon timely for residents with medication irregularities.
F 0757: The facility did not ensure residents' drug regimens were free from unnecessary drugs; pain levels were not consistently monitored before and after PRN pain medication administration.
F 0804: The facility did not ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; cold drinks were served warm and bread was stale.
F 0811: The facility did not ensure residents fed by feeding assistants were assessed for appropriateness; a resident with swallowing difficulties and aspiration risk was fed by a feeding assistant without documented assessment.
F 0812: The facility did not ensure food was stored and prepared in accordance with professional standards; germicidal wipes were stored with dry food and freezer food was unlabeled.
F 0813: The facility did not have a policy to educate family and visitors on safe food handling practices for foods brought in for residents.
F 0842: The facility failed to maintain complete, accurate, and accessible medical records; resident fluid intake and output documentation was incomplete and inconsistent.
Report Facts
Residents requiring feeding assistance: 14
Medication administrations without post pain scale: 15
Medication administrations without post pain scale: 5
Medication administrations without post pain scale: 5
Medication administrations without pre pain scale: 2
Medication administrations without pre pain scale: 1
Medication administrations without pre pain scale: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pharmacist #1 | Pharmacist | Named in drug regimen review finding for Resident #7 |
| Registered Nurse Unit Manager #5 | RNUM | Named in pain medication monitoring and feeding assistance staffing findings |
| Director of Nursing | DON | Named in multiple findings including drug regimen review, care planning, staffing, and intake documentation |
| Registered Dietitian #11 | Registered Dietitian | Named in food temperature and feeding assistant appropriateness findings |
| Food Service Director #26 | Food Service Director | Named in food quality and storage findings |
| Licensed Practical Nurse #1 | LPN | Named in staffing and feeding assistance findings |
| Personal Care Assistant #23 | PCA | Named in feeding assistant program finding |
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