Dunkirk Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Dunkirk Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 11, 2022

  Based on record review and interviews conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had Full Code status for one (Resident #86) of three residents reviewed. Specifically, on [DATE] Resident #86 was found unresponsive by Certified Nurse Aide (CNA #1) at approximately 4:30 AM. At that time, CNA #1 notified Licensed Practical Nurse (LPN #1). LPN #1 observed Resident #86, who was unresponsive without a pulse, respirations, or blood pressure and had bubbling excretions from their mouth. […]

• Actual harm, isolatedF689Sep 9, 2021

  Based on record review and interview conducted during a Complaint Investigation (Complaint #NY 172) completed during the Abbreviated survey on 9/9/21, the facility did not ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed. Specifically, Resident #1 sustained a 42 centimeter (cm) by 7 cm second degree burn (partial thickness) to their left lower leg from an electric baseboard heater located in the resident's room. Resident #1 developed necrotic tissue in the affected area and was subsequently admitted to the hospital burn unit for debridment. This resulted in actual harm that is not immediate jeopardy. […]

• No harm, potential for more than minimal, widespreadF727Mar 11, 2022

  Based on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Specifically, reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on multiple dates December 4, 2021 through March 6, 2022, and an RN was not designated as DON from 12/30/21 through 3/7/22. […]

• No harm, potential for more than minimal, widespreadF835Mar 11, 2022

  Based on interview and record review conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure a Registered Nurse (RN) was scheduled eight consecutive hours per 24-hour period as required and did not designate a full time Director of Nursing (DON) when the DON was off for an extended period. In addition, the Administrator did not ensure there was an effective system in place when there was no RN coverage in the building to respond to an emergency in accordance with facility policy and protocols. […]

• No harm, potential for more than minimal, isolatedF689Apr 18, 2025

  Based on observations, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for one (1) (Resident #9) of two (2) residents reviewed for accidents. Specifically, Resident #9's wheelchair left pedal was in disrepair and missing the leg rest, exposing a sharp edge at the hinge point. The sharp edge was noted at times pressing against the residents left lower leg. The finding is: The policy titled Assistive Devices and Equipment dated 2/2025 documented the facility maintained and supervised the use of assistive devices and equipment for residents. […]