Inspection Reports for
Ghent Rehabilitation & Nursing Center
1 Whittier Way, Ghent, NY, 12075
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
116% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 1, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 08/28/2023 through 09/01/2023 to assess compliance with regulatory standards for nursing home operations.
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 rates, serving food at unsafe temperatures, unsanitary kitchen conditions, and improper labeling and storage of visitor-provided food.
Deficiencies (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 and neglect involving serious bodily injury for two residents, missing required notifications to the NYSDOH within 2 hours.
F 0695: The facility did not ensure a resident received oxygen at the prescribed flow rate of 2 liters per minute and failed to routinely monitor oxygen flow as ordered.
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, bland, or unappetizing food items.
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.
F 0813: The facility did not ensure foods brought to residents by family and visitors were properly labeled and discarded timely, with outdated and unlabeled food found in a 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 | Named in failure to report abuse/neglect findings and interview regarding reporting. |
| Director of Nursing | DON | Named in failure to report abuse/neglect findings and interview regarding reporting. |
| Licensed Practical Nurse Unit Manager | LPNUM | Interviewed regarding Resident #69 fall and reporting. |
| Registered Nurse Supervisor | RNS | Interviewed regarding oxygen therapy procedures. |
| Licensed Practical Nurse | LPN | Observed adjusting oxygen flow rate for Resident #33. |
| Certified Nursing Assistant | CNA | Interviewed regarding oxygen flow rate and food complaints. |
| Food Service Director | FSD | Interviewed regarding food service quality and kitchen cleanliness. |
| Director of Environmental Services | Interviewed regarding housekeeping and food storage responsibilities. | |
| Administrator | Interviewed regarding housekeeping, food service, and reporting deficiencies. |
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 9
Date: Sep 1, 2023
Visit Reason
Multiple standard health and life safety code citations including food procurement, nutritive value, personal food policy, reporting violations, respiratory care, environment, cooking facilities, electrical equipment, and fire alarm system; all corrected by October 2023.
Findings
Multiple standard health and life safety code citations including food procurement, nutritive value, personal food policy, reporting violations, respiratory care, environment, cooking facilities, electrical equipment, and fire alarm system; all corrected by October 2023.
Deficiencies (9)
Food procurement,store/prepare/serve-sanitary
Nutritive value/appear, palatable/prefer temp
Personal food policy
Reporting of alleged violations
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Cooking facilities
Electrical equipment - testing and maintenanc
Fire alarm system - installation
Inspection Report
Annual Inspection
Deficiencies: 6
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.
Deficiencies (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
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Dec 19, 2022
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 8
Date: Oct 27, 2022
Visit Reason
Multiple standard health citations including labeling drugs, laboratory services, nutrition/hydration, quality of care, resident records, medication errors, environment, and pressure ulcer treatment; all corrected by December 2022.
Findings
Multiple standard health citations including labeling drugs, laboratory services, nutrition/hydration, quality of care, resident records, medication errors, environment, and pressure ulcer treatment; all corrected by December 2022.
Deficiencies (8)
Label/store drugs and biologicals
Laboratory services
Nutrition/hydration status maintenance
Quality of care
Resident records - identifiable information
Residents are free of significant med errors
Safe/clean/comfortable/homelike environment
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Covid-19 Survey
Capacity: 60
Deficiencies: 1
Date: Jan 24, 2022
Visit Reason
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Findings
One standard health citation for reporting to national health safety network; no actual harm but minor discomfort and potential for more than minimal harm.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Survey
Capacity: 60
Deficiencies: 1
Date: Dec 23, 2021
Visit Reason
One standard health citation for quality of care; no actual harm but minor discomfort and potential for more than minimal harm; corrected by February 2022.
Findings
One standard health citation for quality of care; no actual harm but minor discomfort and potential for more than minimal harm; corrected by February 2022.
Deficiencies (1)
Quality of care
Inspection Report
Annual Inspection
Deficiencies: 5
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.
Deficiencies (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
Annual Inspection
Deficiencies: 14
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.
Deficiencies (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
Residents on Wing 1 census: 36
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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