The Grand Rehabilitation and Nursing at Barnwell

In the surveyor’s words

From the most serious findings on record at The Grand Rehabilitation and Nursing at Barnwell, in the surveyor’s own words.

• Immediate jeopardy, widespreadF700May 19, 2026

  Based on observations, record review, and interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails (side rails, safety rails, grab bars, assist bars, enabler bars) to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for four of four residents (Residents #3, #10, #12, #101, and #112) reviewed. Specifically, Resident #10's bed rail failed the entrapment zone test in Zone 3 (space between the mattress and the bed rail); Resident #101's bed rail failed the entrapment zone test in Zone 1 (space within the bed rail itself); and Residents #3, #10, #12, #101, and #112 did not have routine inspections of their mattress and/or bed rails for areas of possible entrapment. […]

• Immediate jeopardy, isolatedF600Apr 8, 2024

  Based on record review and interviews during an abbreviated survey (Case # NY00331916), the facility failed to protect residents' rights to be free from abuse for 2 (Resident #s 1 and 2) of 3 residents reviewed for abuse. Specifically, the facility failed to ensure the residents' safety and provide adequate supervision to prevent abuse on 1/21/2024, when Certified Nurse Aide #1 observed Residents #s 1 and 2, both of whom had severe cognitive impairment, sitting next to each other on Resident #1's bed. Resident #2 was not redirected out of the room and Certified Nurse Aide #1 left the room, with the residents unsupervised. Subsequently, Certified Nurse Aide #1 returned to the room [ROOM NUMBER] to 8 minutes later and observed Resident #s 1 and 2 engaging in inappropriate sexual behavior. […]

• Actual harm, isolatedF600Jun 30, 2026

  Based on interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property and exploitation for one out of three residents reviewed for abuse. Specifically, the Facility Incident Report documented on 05/26/2026, Resident #1 became combative during the provision of care and Resident #1 struck Certified Nurse Aide #1 in the face. Certified Nurse Aide #2 reported that Certified Nurse Aide #1 then struck Resident #1 in the face in response. Care continued to be provided to the resident, and it was documented the resident had a bloody nose. The resident was not reapproached or redirected after striking Certified Nurse Aide #1. […]

• Actual harm, isolatedF689Jun 28, 2024

  Based on observation, record review, and interview during the recertification survey, the facility did not ensure a resident received adequate supervision and assistive device to prevent accidents for 1 (Resident #64) of 6 residents reviewed for accidents. Specifically, Resident #64, who was identified as high risk for falls on admission, had a witnessed fall on 7/01/2023 while ambulating without a walker. There were no interventions initiated or implemented following the fall to prevent further accidents. Subsequently, on 9/26/2023 Resident #64 fell and sustained a cervical 1 vertebrae fracture (broken neck). This resulted in actual harm for Resident #64 that is not immediate jeopardy. […]

• Actual harm, isolatedF689Aug 30, 2022

  Based on observation, record review, and interviews during an abbreviated survey (Case #NY 510), the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically for Resident #1, the facility did not ensure they provided adequate supervision to maintain the safety of the resident who had a recent history of self-harm and hospitalization s for mental health issues. Resident #1 made suicide attempts on 7/5/2022 and 8/11/2022. This resulted in actual harm to Resident #1 that was not immediate jeopardy. This was evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of non-suicidal self-harm, [CONDITION(S)], and major depressive disorder. […]