Inspection Reports for
Pathways Nursing and Rehabilitation Center
1805 Providence Avenue, Niskayuna, NY, 12309
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with staffing requirements and overall resident care standards at Pathways Nursing and Rehabilitation Center.
Findings
The facility was found to have insufficient nursing staff, particularly Certified Nurse Aides, on multiple units and shifts over a period from December 7, 2024 to January 8, 2025. Staffing shortages impacted resident care and safety, with multiple residents and family members reporting delays and inadequate assistance. The facility experienced significant staff turnover and reliance on agency staff during this period.
Deficiencies (1)
F 0725: The facility failed to provide enough nursing staff every day to meet the needs of every resident and did not have a licensed nurse in charge on each shift. Certified Nurse Aide staffing levels were not consistently met on 3 of 3 nursing units from 12/07/2024 to 1/08/2025.
Report Facts
Resident census: 106
Average daily census: 109
Certified Nurse Aide staffing shortages: 1
Resident dependency counts: 95
Resident dependency counts: 90
Resident dependency counts: 69
Resident dependency counts: 102
Resident dependency counts: 99
Resident census by unit: 39
Resident census by unit: 33
Resident census by unit: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator #1 | Certified Nurse Aide and Staffing Coordinator | Provided detailed information about staffing shortages, agency staff usage, and facility staffing challenges during interviews. |
| Administrator #1 | Administrator | Discussed staff turnover, recruitment challenges, and staffing issues during interview on 1/10/2025. |
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 5
Date: Jan 10, 2025
Visit Reason
The inspection was a recertification survey to assess compliance with state and federal regulations for nursing home licensure and certification.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, incomplete preadmission screening, insufficient activities programming, inadequate nursing staffing levels, and improper medication storage and labeling practices.
Deficiencies (5)
F 0550: The facility did not ensure residents were treated with respect and dignity, with reports of residents left in wet briefs for hours and staff being rude or unresponsive.
F 0645: The facility failed to complete required PASARR screening for mental disorders or intellectual disabilities prior to admission for 2 of 24 residents reviewed.
F 0679: The facility did not ensure ongoing provision of meaningful activities to meet residents' needs, with one resident not consistently attending activities to maintain quality of life.
F 0725: The facility did not provide sufficient nursing staff consistently on 3 nursing units from 12/07/2024 to 1/08/2025, resulting in frequent shortages of Certified Nurse Aides.
F 0761: The facility failed to ensure drugs and biologicals were properly labeled and stored, with expired medications, unrefrigerated medications requiring refrigeration, and missing narcotic count signatures observed.
Report Facts
Residents present: 106
Resident census on units: 39
Resident census on units: 33
Resident census on units: 36
Staffing shortages: 1
Staffing shortages: 2
Staffing shortages: 3
Expired medication: 1
Missing narcotic count signatures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #39 | Reported being left in wet briefs for 5-6 hours and staff rudeness | |
| Resident #65 | Reported being left in wet bed for hours and rude staff behavior | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding staffing and complaint follow-up |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about resident care and activity attendance |
| Director of Activities #1 | Director of Activities | Interviewed about resident activities and staffing |
| Director of Respiratory Therapy #1 | Director of Respiratory Therapy | Interviewed about ventilator-dependent residents attending activities |
| Administrator #1 | Administrator | Interviewed about staffing challenges and facility operations |
| Staffing Coordinator #1 | Staffing Coordinator | Interviewed about staffing shortages and agency staff |
| Registered Nurse #1 | Registered Nurse | Observed medication storage and expiration issues |
| Registered Nurse #2 | Registered Nurse | Observed medication storage and expiration issues |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed expired medications and storage practices |
| Nurse Educator #1 | Nurse Educator | Interviewed about medication training and narcotic count procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jan 10, 2025
Visit Reason
Multiple standard health and life safety code citations including deficiencies in activities, drug labeling, PASARR screening, resident rights, nursing staff sufficiency, and electrical systems. All deficiencies corrected by early 2025.
Findings
Multiple standard health and life safety code citations including deficiencies in activities, drug labeling, PASARR screening, resident rights, nursing staff sufficiency, and electrical systems. All deficiencies corrected by early 2025.
Deficiencies (9)
Activities meet interest/needs each resident
Label/store drugs and biologicals
Pasarr screening for md & id
Resident rights/exercise of rights
Sufficient nursing staff
Electrical systems - essential electric syste
Ep training program
Illumination of means of egress
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
Abuse reporting documentation deficiency noted.
Findings
Abuse reporting documentation deficiency noted.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
The abbreviated survey was conducted to review the facility's compliance with timely reporting requirements for suspected abuse, neglect, or theft and the reporting of investigation results to proper authorities.
Findings
The facility failed to ensure that injuries of unknown origin observed on 12/22/2020 for Resident #1 were reported to the State Survey Agency within the required timeframe. The injury was reported six days late, on 12/28/2020, violating state reporting requirements.
Deficiencies (1)
F 0609: The facility did not report injuries of unknown origin for Resident #1 within the required timeframe to the State Survey Agency. The injury observed on 12/22/2020 was reported six days later on 12/28/2020.
Report Facts
Residents sampled: 5
Residents affected: 1
Days late reporting injury: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Abuse Coordinator | Interviewed regarding reporting responsibilities and timelines |
| Director of Nursing | Interviewed regarding reporting procedures for injuries of unknown source | |
| Former Nursing Home Administrator | Interviewed regarding typical reporting timelines and incident details |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
One standard health citation for reporting of alleged violations, isolated and corrected by November 2023.
Findings
One standard health citation for reporting of alleged violations, isolated and corrected by November 2023.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 19, 2022
Visit Reason
The inspection was conducted as a recertification survey and abbreviated survey to assess compliance with professional standards for medical record documentation and care provision.
Findings
The facility failed to maintain complete and accurate medical records for 3 of 21 residents reviewed, specifically lacking Certified Nurse Aide documentation of Activities of Daily Living care across multiple shifts and dates.
Deficiencies (1)
F 0842: The facility did not maintain medical records in accordance with accepted professional standards for 3 residents. Certified Nurse Aide documentation of Activities of Daily Living care was incomplete and inaccurate across multiple shifts and dates.
Report Facts
Residents reviewed: 21
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Interviewed regarding documentation practices and workload |
| Registered Nurse Manager #2 | Registered Nurse Manager | Interviewed about CNA documentation responsibilities and oversight |
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Interviewed about CNA documentation and supervisory roles |
| Director of Nursing | Director of Nursing | Interviewed about efforts to improve CNA documentation and care priorities |
| MDS Coordinator | MDS Coordinator | Interviewed about CNA documentation and assistance with care documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 19, 2022
Visit Reason
Two standard health citations for infection control and resident records identifiable information, both isolated or pattern scope and corrected by June 2022.
Findings
Two standard health citations for infection control and resident records identifiable information, both isolated or pattern scope and corrected by June 2022.
Deficiencies (2)
Infection control
Resident records - identifiable information
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 26, 2021
Visit Reason
One standard health citation for free from abuse and neglect with actual harm, isolated and corrected by January 2022.
Findings
One standard health citation for free from abuse and neglect with actual harm, isolated and corrected by January 2022.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not corrected as of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 10, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Pathways Nursing and Rehabilitation Center.
Findings
The facility was found deficient in developing and implementing comprehensive, person-centered care plans, providing appropriate activities, ensuring residents received proper range of motion care, maintaining medication error rates below 5%, and implementing effective infection prevention and control measures.
Deficiencies (5)
F 0656: The facility did not ensure comprehensive person-centered care plans with measurable objectives and individualized interventions for 6 of 22 residents reviewed.
F 0679: The facility did not provide ongoing and appropriate activities based on the resident's abilities for one resident reviewed.
F 0688: The facility did not ensure residents with limited range of motion received appropriate ROM care during morning care for 2 of 3 residents reviewed.
F 0759: The facility did not ensure medication error rates were below 5%, evidenced by improper intervals between inhalations during medication administration.
F 0880: The facility did not maintain infection control during a dressing change by using the same gauze for wound and peri wound cleansing for one resident.
Report Facts
Residents reviewed for comprehensive care plans: 22
Residents with deficient care plans: 6
Residents reviewed for activities: 1
Residents reviewed for ROM care: 3
Residents with deficient ROM care: 2
Medication error rate threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed regarding care plan personalization and mood state care plans. |
| Director of Social Work | Director of Social Work | Interviewed about mood state care plans and care plan tailoring. |
| Licensed Practical Nurse Manager #3 | Licensed Practical Nurse Manager | Interviewed about interdisciplinary team meetings and care plan improvements. |
| MDS Coordinator | MDS Coordinator | Interviewed about care plan editing and review. |
| Director of Nursing | Director of Nursing | Interviewed about care plan meetings, expectations for activities, ROM care, and medication administration. |
| Activities Director | Activities Director | Interviewed about resident activities and activity attendance records. |
| Activity Aide #8 | Activity Aide | Interviewed about one-to-one activities and activity attendance. |
| Rehabilitation Director | Rehabilitation Director | Interviewed about ROM care frequency and responsibilities. |
| Certified Nurse Aide #6 | Certified Nurse Aide | Observed providing morning care without proper ROM. |
| Licensed Practical Nurse Manager | Licensed Practical Nurse Manager | Interviewed about ROM care monitoring. |
| Registered Nurse Educator | Registered Nurse Educator | Interviewed about ROM training and CNA compliance. |
| Registered Nurse #4 | Registered Nurse | Interviewed about medication administration errors and wound care. |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed about infection control breach during dressing change. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
No citations found in 4 inspections during the reporting period.
Findings
No citations found in 4 inspections during the reporting period.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
No citations found in 4 inspections during the reporting period.
Findings
No citations found in 4 inspections during the reporting period.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
No citations found in 4 inspections during the reporting period.
Findings
No citations found in 4 inspections during the reporting period.
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