Inspection Reports for
Pathways Nursing and Rehabilitation Center
1805 Providence Avenue, Niskayuna, NY, 12309
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Inspection Report — Jan 10, 2025
Annual Inspection CMS
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.
Citations (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
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 — Jan 10, 2025
Complaint Investigation State
Date: Jan 10, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 36 complaints about this facility; 6 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 5 inspections, 3 had no citations while 2 inspections resulted in 10 citations total, including 6 standard health and 4 life safety code violations. The facility had 36 complaints with 6 on-site inspections and 1 enforcement action recorded.
Citations (10)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: Failed to properly label and store drugs and biologicals.
Standard Health Citation — quality of care: PASARR screening for MD and ID was inadequate.
Standard Health Citation — quality of care: Resident rights were not fully exercised or protected.
Standard Health Citation — quality of care: Nursing staff levels were insufficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies noted.
Life Safety Code Citation — NFPA requirements: Emergency power training program was deficient.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress was inadequate.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were insufficient.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Report Facts
Inspections on page: 5
Total violations/citations: 10
Inspections with violations: 2
Inspections without violations: 3
Total complaints: 36
On-site complaint inspections: 6
Citations from complaints: 2
Enforcement actions: 1
Total fines: 2000
Inspection Report — Sep 13, 2023
Abbreviated Survey CMS
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.
Citations (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 — Apr 19, 2022
Annual Inspection CMS
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.
Citations (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 — Dec 10, 2019
Annual Inspection CMS
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.
Citations (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. |
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