The Grand Rehabilitation and Nursing At Rome

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627Nov 5, 2025

  Based on record review and interviews during the abbreviated survey (Complaint ID# 2613592), the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was discharged on 05/19/2025 to the Department of Social Services via family transportation without consulting the Department of Social Services to ensure the plan met the resident's health and safety needs, and preferences. The resident had no identification, and no supportive services in place, and was discharged without proper education and supplies to manage their diabetes and diabetic wounds. […]

• Immediate jeopardy, isolatedF689Oct 25, 2023

  Based on record review and interview during the abbreviated survey (NY00304388), the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a history of aspiration (inhalation of foods/fluids into the lungs) risk, was on an altered consistency diet (chopped solids) and required supervision and assistance with eating. On 4/26/2023, the resident was provided a sandwich and was not supervised while eating. Subsequently, approximately 30 minutes later, the resident was found without signs of life (no pulse or respirations), with food in their mouth, and was pronounced deceased . […]

• Actual harm, isolatedF689May 10, 2021

  Based on observation, record review, and interview during the abbreviated survey (NY 212) conducted on 5/10/21, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a history of seeking out the unit showers and wandered unsupervised to another unit where they were found in the shower. This resulted in actual harm to Resident #1 as they sustained first and second degree [CONDITION(S)] from the shower water. Findings include: The Routine Resident Checks policy dated 1/2021 documented the residents will be maintained in a safe environment that protects residents from actual harm. […]

• No harm, potential for more than minimal, patternF610Apr 17, 2026

  Based on record review and interviews (iQIES Intake 2740528), the facility failed to ensure alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of four (4) residents (Residents #11, #21, and #37) reviewed. Specifically, it was reported Certified Nurse Aide #31 was heard calling Resident #21 a liar and there was no documented evidence the facility investigated the allegation to rule out abuse; Resident #11 reported to several staff members that Licensed Practical Nurse #36 intentionally did not provide them with their pain medication and the allegation was not reported to administration to ensure an investigation was completed to rule out neglect or mistreatment; and Resident #37 used a broken plate to threaten another resident and there… […]

• No harm, potential for more than minimal, patternF698Apr 17, 2026

  Based on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #3 and #16) reviewed. Specifically, Residents #3 and #16 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments and there was no documented evidence the resident's Tesio catheter (access site for dialysis treatment) was routinely assessed. […]