ALTAMONT, NY - Federal inspectors documented serious medication administration failures at The Grand Rehabilitation and Nursing at Guilderland, where a resident experienced a psychiatric crisis and required hospitalization after missing nearly two weeks of essential antipsychotic medication.
The March 7, 2025 inspection revealed a pattern of medication errors affecting multiple residents, with one case reaching immediate jeopardy status - the most serious citation level indicating immediate risk to resident health and safety.
Psychiatric Medication Gap Leads to Hospitalization
The most serious incident involved a resident with schizophrenia who was prescribed Clozapine, a critical antipsychotic medication. After returning from a hospital stay on November 25, 2024, where the resident had been monitored for suicidal ideation, the facility failed to consistently administer the prescribed 375-milligram nightly dose.
According to inspection records, the medication was marked as "not given" on November 25, 26, and 28, with staff documenting the drug was "awaiting pharmacy delivery" or "enroute from pharmacy." While the medication administration record showed doses given on November 27, 29, and 30, pharmacy dispensing records provided no evidence that Clozapine was actually delivered to the facility during November 2024.
On November 29, just four days after returning from psychiatric hospitalization, the resident told nursing staff "I want to die. I want to go to the hospital." The facility assigned a staff member to monitor the resident and called 911. The resident was transported to the emergency department at 9:00 AM and returned later that afternoon.
The medication gaps continued into December. Records show the drug was not administered on December 1 and 5, again documented as awaiting pharmacy delivery. The first confirmed delivery didn't occur until December 6 at 9:49 PM - nearly two weeks after the initial order.
Consequences of Medication Interruption
By December 8, the resident's condition had deteriorated significantly. A registered nurse documented finding the resident "flailing their arms around and flipping their body over continuously," attempting to get on the floor. The resident, normally oriented and familiar with staff, could not recall the nurse's name or identify the facility's name. The nursing note stated the resident "has not received their psychiatric medication in a week and the resident was not functioning safely."
The resident was again transported to the hospital by ambulance at 7:36 PM. Hospital emergency documentation noted the chief complaint as "altered mental status" and specifically recorded that the resident "has not been given their clozapine for unknown time/unreason."
Clozapine requires careful management due to its effects on brain chemistry. Abrupt discontinuation can cause the recurrence of psychotic symptoms. The medication's manufacturer guidelines specify that if treatment must be stopped, doses should be gradually reduced over one to two weeks, and patients should be carefully monitored for returning psychiatric symptoms.
Laboratory results from December 6 showed the resident's Clozapine blood level was below 10 nanograms per milliliter - far below the therapeutic range of 350-600. A physician progress note documented "questionable medication adherence" and noted the medication administration report showed five instances where the resident did not receive medication, with unclear reasons why.
Multiple Residents Affected by Antibiotic Delays
The medication administration problems extended beyond psychiatric drugs. Inspectors documented that a resident with a urinary tract infection caused by enterococcus faecalis bacteria in "critically high amounts" missed 10 of 20 prescribed doses of intravenous antibiotics.
The resident had initially been prescribed oral Amoxicillin on January 2, 2025, but nursing staff reported the resident was spitting out pills and refusing oral medication. A physician switched the order to intravenous Ampicillin - 2 grams to be administered every six hours for seven days.
However, the resident missed the first scheduled dose on January 2 at 6:00 PM. On January 3, the resident missed all three doses at midnight, 6:00 AM, and noon. A physician progress note attributed the missed doses to "a delay in delivery by the pharmacy and a staff shortage."
Throughout the seven-day treatment period, the resident did not receive doses on multiple occasions with no documented explanation. The attending nurse practitioner noted they had to modify the treatment plan "to account for no staffing," switching to Levofloxacin (Levaquin) administered once daily instead of four times daily "for better medication compliance."
Even with the simplified once-daily regimen, the resident missed the third dose. The provider had to order an additional one-time dose to complete the course of treatment.
Critical Laboratory Results Not Addressed
Another resident faced delays in treatment for dangerously elevated potassium levels. Laboratory results from December 17, 2024 showed a potassium level of 5.2 - above the normal range of 3.5 to 5.1. Elevated potassium can cause serious cardiac complications, as potassium plays a critical role in nerve and muscle function, particularly in the heart.
Despite the abnormal result, there was no documentation that nursing staff notified a provider of the critical finding. A nurse practitioner saw the resident on December 18 and reviewed the laboratory work, noting the resident's kidney function was "slowly improving," but made no mention of addressing the high potassium.
The elevated potassium wasn't treated until December 21 - four days after the abnormal result - when a different nurse practitioner ordered Lokelma 10 grams for hyperkalemia. Even then, nursing staff documented they contacted the pharmacy and were told the medication was "waiting for approval." The medication wasn't delivered until later, and there was no evidence the resident received any dose on December 21 or 22.
Follow-up laboratory work on December 23 showed the potassium had risen further to 5.4. A physician progress note dated December 24 indicated the resident received "one dose" of the potassium-lowering medication for the level of 5.2 on December 21, though medication administration records provided no confirmation of when or if this actually occurred.
Systemic Staffing and Communication Failures
During interviews, a nurse practitioner told inspectors they had been forced to alter medication orders "to account for no staffing" since approximately October 2024. The provider stated nurses were documenting medications as unavailable but failing to notify physicians, requiring providers to prescribe duplicate antibiotic coverage because they couldn't be certain residents received all prescribed doses.
An attending physician interviewed about another resident's topical antifungal medication expressed surprise at learning their detailed prescribing instructions hadn't been followed. The physician stated they would "not expect the patient to use it themselves" and that administration instructions were "for the nurse, not the patient."
Inspection findings revealed the facility consistently failed to meet New York State minimum staffing requirements during the two-week period from February 22 through March 6, 2025. The facility housed 123 residents on three units but did not maintain the state-mandated 3.5 hours of nursing care per resident per day.
Licensed nurse staffing fell short of requirements on February 22, 23, and 28, and March 3 and 6. More significantly, certified nurse aide staffing failed to meet minimum requirements on every single day during the reviewed period, with shortfalls ranging from 102 to 146 hours per day.
During a resident council meeting on February 24, residents stated there were not enough staff members. One resident reported receiving only two showers since arriving in January, despite being scheduled for weekly showers, with staff citing short staffing as the reason for delays.
A registered nurse interviewed on February 27 stated "the unit was short staffed, and they had never worked with such low staffing numbers." The nurse described having to complete care plans for two units and characterized the situation as "very hard to run two units."
Additional Quality Concerns
The inspection also documented inadequate staff training and competency verification. Education files for multiple certified nurse aides and licensed practical nurses showed incomplete or missing annual training records required by the facility's own assessment.
One newly hired certified nurse aide's orientation checklist was not signed by an instructor, and competency evaluations for donning and doffing personal protective equipment and mechanical lift operation lacked required evaluator signatures.
A registered nurse assigned to complete care plan updates for residents admitted they were "not proficient in updating care plans" and, when questioned by inspectors, was uncertain about basic hand hygiene requirements before and after resident care.
The facility's medication error rate exceeded the federal threshold during observation periods. During 30 medication administration observations involving 11 residents, inspectors documented two significant errors, resulting in a 6.87 percent error rate - above the 5 percent maximum allowed under federal regulations.
Medication storage practices also raised concerns. Inspectors found multiple stock medications without dates indicating when bottles were opened, eye drops for residents lacking date labels, and an insulin bottle with no label identifying which resident it belonged to or when it was opened. Narcotic count logbooks showed inconsistent documentation of the required two-nurse verification between shifts.
Administrative Response
When presented with findings, the facility administrator stated they were "not aware of the multitude of issues brought up by the survey team." The administrator indicated they had "never heard that there were not enough staff at the facility to get medications passed or resident care done."
The Director of Nursing similarly stated they had "never been told something could not be done because of no staff" and were unaware the facility used medication error reporting forms.
Following the inspection, facility leadership indicated they would implement daily monitoring of medication administration reports, provide house-wide education on medication availability procedures, and increase oversight of clinical documentation and quality assurance processes.
The full federal inspection report contains detailed findings on multiple regulatory violations and is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Grand Rehabilitation and Nrsg At Guilderland from 2025-03-07 including all violations, facility responses, and corrective action plans.
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