Lockport Rehab & Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a survey, the facility did make prompt efforts to resolve grievances for two (2) (Residents #5 and #6) of two (2) residents reviewed for missing property. Specifically, there was lack of follow-through and resolution for Resident #5 and Resident #6's reports of missing property. The findings are: The policy titled Resident Personal Property and Inventory, last reviewed on 08/04/2025 and approved by the Administrator 1/26 documented the facility shall maintain a system to inventory, label, and safeguard resident property to minimize the risk of loss, theft, or damage. In the event of lost property, a grievance form must be completed; the Administrator or designee will investigate the loss; if the facility is found to be responsible, the facility will replace the item or reimburse the resident for the fair market value. The policy titled Reporting and Investigation of Personal Property Lost or Damaged revised 01/26, documented the purpose was to assure that all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review conducted during a survey, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, risks and benefits of bed rails were reviewed with the resident or resident representative, and informed consent was obtained prior to the installation of bed rails for one (1) (Resident #87) of three (3) residents reviewed. Specifically, Resident #87's bed rail was loose and not secure to the bedframe and the resident was not assessed for risk of entrapment from the bed rails. Additionally, the risks and benefits of bed rail use were not reviewed with the resident or their representative and consent was not obtained prior to bed rail use. The finding is: The policy and procedure titled Bed Assist Devices revised 11/2024 documented bed assist devices are mobility devices used to aid in resident independence with bed mobility and/or to improve resident participation in bed mobility during care. Occupational Therapy and Physical Therapy will assess resident's bed mobility skills and their ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the survey, the facility did not store food in accordance with professional standards for food service safety. Specifically, one (1) (West Wing Unit) of two (2) unit nourishment refrigerators contained unlabeled, out of date food and drink items, and personal food was stored with residents' food. The finding is: The policy titled Dietary Sanitation revised 02/26, documented its purpose was to prevent the incidence of food borne illness through safe food handling procedures. Stored foods to be held or leftovers should not exceed a 72-hour period in refrigeration. Leftovers should be covered, labeled and dated, put in the freezer right away or if put in refrigerator, use within 72 hours (3 days) or discard. Juices, iced tea should be used within seven (7) days. All food items must be dated once they are opened. The policy and procedure titled Dietary Services revised 01/26, documented the facility stores, prepares, distributes and serves food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review conducted during a survey, the facility did not ensure regular inspections of all bed frames, mattresses, and rails were conducted as part of a regular maintenance program to identify areas of possible entrapment (when a person is trapped in a hospital bed's rails, mattress or frame, preventing them from moving) for two (2) (Residents #1 and #71) of three (3) residents reviewed for side rail use. Specifically, Residents #1 and #71's bed rails were checked for possible zones of entrapment using a bed system measurement device that lacked a measurement component per the manufacturer's specifications. Additionally, the facility did not ensure Residents #1 and #71's bed rails, which were used and purchased separately from the bed frames, were compatible. The findings are:The policy titled Bed Assist Devices, revised 11/2024, documented the Maintenance Department, OT (Occupational Therapy) Department or Housekeeping will be involved in the placement and removal of the bed assist devices. Along with performing an Entrapment Gap Tool Test…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the Standard survey completed on 6/4/24 the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for one (Resident #9) of two residents reviewed for choices. Specifically, Resident #9 was provided with a shower once a week in the evening instead of twice a week during the day as care planned and preferred. The finding is: The policy and procedure titled Resident Rights reviewed 5/24 documented each resident was ensured the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy and procedure titled Quality of Life dated 4/92 documented the resident has the right to choose activities, schedules, and health care consistent with their interests, assessments and plans of care and the right to make choices about aspects of their life in the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review conducted during a Standard survey completed on 6/4/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #29) of three residents reviewed. Specifically, Resident #29 had long thick jagged fingernails with dark brown debris underneath on their left contracted (loss of joint mobility) hand, and long jagged fingernails with chipped polish and dark brown debris underneath on their right hand. The finding is: The policy and procedure titled Nail Care dated 2/23, documented the facility will provide appropriate nail care to all residents. Nails would be observed daily by staff providing direct AM care, would be trimmed weekly on bath day, and residents with special needs (diabetic and residents on blood thinners) will have nails trimmed by the nurse weekly. 1. Resident #29 had diagnoses including vascular dementia, obstructive hydrocephalus (excessive accumulation of cerebral spinal fluid on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a Complaint investigation (Complaint #NY00323467) during the Standard survey completed on 6/4/24, the facility did not ensure that a resident who was fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for one (Resident #127) of one resident reviewed for feeding tubes. Specifically, the facility did not provide the tube feed formula as per the hospital discharge summary. The finding is: The policy and procedure titled Enteral Feeding/Gastrostomy (a tube that passes through the abdominal wall into the stomach) - Jtube (jejunostomy tube- a tube placed through the abdominal wall into the small intestine)- Nasogastric Tube (tube inserted through the nose into the stomach) - Duodenal Feeding Tube (a tube inserted into the small intestine) reviewed 05/23 documented the purpose was to provide adequate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review completed during a Standard survey conducted from 6/22/22 through 6/28/22, the facility did not inform the resident's representative of a need to alter treatment significantly for one (Resident #55) of one resident reviewed for notification of change. Specifically, Resident #55 was placed on an antipsychotic medication (Zyprexa) for aggression related to dementia and the responsible party was not notified prior to initiation of the medication. The finding is: The policy and procedure (P/P) titled Notification of Change in Resident Condition/ Status revised date 3/22 documented the facility will assure that communication with Resident's responsible family member and physician is made in the event of a change in condition and/or status. The Resident's responsible family member will be notified if the resident's physical, communicative, psychosocial and/or functional status changes unexpectedly or substantially. The resident's plan of care must be altered significantly. 1. Resident #55 had diagnoses including dementia without behavioral disturbance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review completed during a Standard survey started 6/22/22 and completed 6/28/22, the facility did not ensure the resident's rights to be free from abuse for one (Resident #55) of two residents reviewed for abuse. Specifically, Resident #55 was bitten on the left (L) hand sustaining a skin tear measuring 3 x 3.5 by Resident #75 who has a history (hx) of physical aggression towards other residents and staff. The findings are: The policy and procedure (P/P) titled Abuse Prevention with revision date 8/21 documented it is the policy of the facility to implement and maintain an abuse prevention program. Physical abuse defined as striking, pinching, kicking, shoving, bumping or unwanted sexual attention. The purpose is to prevent incidents of abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. The P/P titled Resident to Resident dated 3/22 documented the staff will identify potentially harmful situations and create a plan of care which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review completed during a Standard survey started 6/22/22 and completed 6/28/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency). Specifically, two (Residents #55 and 75) of two residents reviewed for abuse were involved in a resident-to-resident altercation which was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure (P/P) titled Abuse Prevention with revision date 8/21 documented it is the policy of the facility to implement and maintain an abuse prevention program. Physical abuse defined as striking, pinching, kicking, shoving, bumping or unwanted sexual attention. The purpose is to prevent incidents of abuse, neglect, involuntary seclusion, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview during the standard Survey started 6/22/22 and completed 6/28/22, the facility did not ensure a resident with an indwelling catheter received the necessary services and treatment for catheter use for one (Resident #44) of one resident reviewed. Specifically, Resident #44's indwelling urinary catheter (tube inserted into the bladder to drain urine) was not anchored to prevent excessive tension on the catheter. Additionally, the facility's policy and procedure (P&P) did not address anchoring of the catheter. The finding is: Review of the facility P&P titled Urinary Catheterization dated 10/18, revealed there was no documentation that a resident's urinary catheter was to be anchored to prevent tension on the catheter. 1. Resident #44 had diagnoses including multiple sclerosis (chronic disease affecting the brain and spinal cord) and neurogenic bladder (bladder with diminished sensation). The Minimum Data Set (MDS-a resident assessment tool) dated 4/23/22 documented Resident #44 was cognitively intact and had an indwelling urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.