PINNACLE MULTICARE NURSING AND REHAB CENTER
For profit - Partnership
480 Beds
BENJAMIN LANDA
Data: November 2025
Trust Grade
55/100
#434 of 594 in NY
Photo by Pinnacle Multicare Nursing & Rehabilitation Center
Photo by Pinnacle Multicare Nursing & Rehabilitation Center
Photo by Pinnacle Multicare Nursing & Rehabilitation Center
1 / 5 photos
Last Inspection: June 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Pinnacle Multicare Nursing and Rehab Center has received a Trust Grade of C, indicating it is average compared to other facilities, neither excelling nor significantly lacking. It ranks #434 out of 594 in New York, placing it in the bottom half, and #40 out of 43 in Bronx County, suggesting there are only a few local options that perform better. Unfortunately, the facility is worsening, with the number of issues increasing from 2 in 2023 to 3 in 2025. Staffing is a relative strength with a 3 out of 5 stars rating and a low turnover rate of 24%, which is better than the state average. On the downside, there have been serious incidents, such as a resident who fell and sustained a major injury due to inadequate supervision, as well as concerns about improper garbage disposal and food safety practices.
- Trust Score
- C
- In New York
- #434/594
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New York facilities.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for New York. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Bottom 27%
Needs review
2 → 3 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 2 issues
2025: 3 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below New York average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below New York average (3.1)
Below average - review inspection findings carefully
Chain: BENJAMIN LANDA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 17 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification and Complaint Survey (Complaint #666294) conducted...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification and Complaint Survey (Complaint #666294) conducted from 07/28/2025 to 08/04/2025, the facility failed to ensure a resident received adequate supervision and assistance consistent with the resident's needs to prevent accidents. This was evident for one (1) (Resident #49) of seven (7) residents reviewed for accidents out of 35 total sampled residents. Specifically, Resident #49 fell and sustained major injury while being provided care in bed by Certified Nursing Assistant #2. This resulted in actual harm to Resident #49 that was not Immediate Jeopardy.The findings include:The facility policy titled Accidents/Incidents with a last revised date of 12/12/2022 documented Avoidable Accident - Resident had an accident and the facility failed to: 1) Identify environment hazards and individual resident risk for accident, including the need for supervision; 2) Implement interventions, including adequate supervision, consistent with resident's needs, goals and plan of care and recognized standards of practice, to reduce the risk of an accident; 3) Monitor the effectiveness of the interventions and modify the approaches as necessary, in accordance with relevant care standards.Resident #49 had diagnoses of Generalized Muscle Weakness, Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. ), and Cerebrovascular Accident (interruption in the flow of blood to cells in the brain). The Minimum Data Set (a resident assessment tool) dated 10/30/2024 documented Resident #49 had impaired memory, severely impaired cognitive skills, and had impairment on both sides of both upper and lower extremities. The assessment documented Resident #49 was dependent on staff (resident does none of the effort to complete the activity, staff does all the effort or requires the assistance of two (2) or more staff to complete the activity) for activities of daily living including upper and lower body dressing and rolling left and right. A comprehensive care plan for functional abilities was initiated on 11/20/2023. The care plan documented Resident #49 had self-care limitations and was dependent on staff for upper and lower body dressing. The care plan did not indicate the number of staff assistance required. The care plan was reviewed on 11/20/2024; the care plan notes documented by Minimum Data Set Assessor #1 stated plan of care was still applicable. A comprehensive care plan for mobility limitations was initiated on 07/29/2024. The care plan documented Resident #49 required substantial/maximal assistance (staff lifts or holds trunks or limbs and provides more than half the effort) for bed mobility or rolling left to right. The care plan did not indicate the number of staff assistance required. The care plan was reviewed on 11/20/2024; the care plan notes documented by Minimum Data Set Assessor #1 stated Resident #49 was non-ambulatory and required a mechanical lift for transfers. The Resident Nursing Instruction Form (contains instructions for Certified Nursing Assistants) documented on 01/11/2023, Resident #49 was totally dependent for bed mobility and required two (2) person physical assist; and was totally dependent for upper and lower body dressing and required one (1) person physical assist. The nursing instruction also documented Resident #49 was confused, at high risk for falls, and had left-sided weakness and left foot tremors. There was no documented evidence the comprehensive care plan nor the Resident Nursing Instruction Form was updated to include the Minimum Data Set assessment dated [DATE], indicating the resident was dependent, requiring two (2) or more staff for activities of daily living including upper and lower body dressing and rolling left and right.A plan of care notes by Registered Nurse #2 dated 12/18/2024 documented, Writer responded into a thud in Resident #49's room at 1:30 AM when resident was observed on the floor lying on their right side facing the bed with legs extended. Noted with nose injury and bleeding that appeared to be from the back of the head. As per staff assigned, Certified Nursing Assistant #2 was changing and removing resident's wet gown from feeding when the resident fell on the floor. Unable to fully assess the resident on the extent of injury due to their position on the floor. The resident was transferred to the hospital emergency room. The Nursing's Review of Accident/Incident Form completed by the Risk Manager dated 12/20/2024 documented that on 12/18/2024 at 1:30 AM, a thud was heard in Resident #49's room. The nursing supervisor and the floor nurse responded, and they observed Resident #49 on the floor lying on their right side, facing the bed with legs extended. The right side of the resident's nose was resting against the foot frame of the metal bed. The resident was nonverbal and unable to give an account. On assessment, the resident was noted with a nasal injury and bleeding that appeared to be from the right side of the head. 911 (emergency medical service) was immediately activated. According to Certified Nursing Assistant #2, they were changing the resident's wet gown and as they were removing the gown from the right hand, the resident reached over and began to slide off the bed. The Certified Nursing Assistant tried to pull the resident back to bed but was heavy and they slid off the bed. The facility investigation concluded that Resident #49 made an unpredictable maneuver during care as they reached over while the staff was removing their gown resulting in the resident sliding off the bed; there was no evidence to suggest that abuse or neglect occurred. The hospital Physician Discharge summary dated [DATE] documented Resident #49 was admitted on [DATE] and was discharged back to the nursing home on [DATE]. Resident #49 presented from the nursing home after a fall and was found to have nasal bone fractures (broken bones), right frontal scalp and right premaxillary (bones of the upper jaw) hematomas (areas of pooled blood), and with severe epistaxis (nose bleeding) as seen in the computed tomography scan (imaging test that uses a combination of x-ray and computer technology). The resident had high volume nosebleeds and was transferred to the intensive care unit for monitoring. The bleeding stopped on 12/24/2024 and had been stable since then. Resident #49 was also treated for lower lobe pneumonia (lung infection) while in the hospital. On 08/01/2025 at 8:01 AM, Certified Nursing Assistant #2, who was assigned to Resident #49 on the date and time of incident, was interviewed and stated they have been working in the facility for about a year and had Resident #49 in their assignment when they worked in the unit. They stated Resident #49 required assistance of two (2) staff for bed mobility. They stated on the day of the incident, the nurse asked them to change Resident #49's gown that got messed up with feeding. They stated, as they were changing the gown, the resident's hand swung, and the resident fell on the floor. They stated they were not able to hold the resident because the resident was too heavy. Certified Nursing Assistant #2 stated they thought they could change Resident #49's gown alone because the resident does not require a lot of turning. On 08/01/2025 at 8:13 AM, Registered Nurse #2, who was the nursing supervisor on duty on the day of the incident, was interviewed and stated they were at the nursing station during shift rounds when they heard a sound coming from Resident #49's room. They stated they went into the room and saw the resident on the floor, Certified Nursing Assistant #2 was on the opposite side of the resident's bed. They stated, according to Certified Nursing Assistant #2, they were trying to change the resident's gown when the resident fell off the bed. Registered Nurse #2 stated Resident #49 required one (1) assist for dressing, but based on resident's mobility and weight, the Certified Nursing Assistant should have asked for assistance from a second staff to prevent the resident from falling.On 08/01/2025 at 10:08 AM, Registered Nurse #3, who was the Unit Manager, was interviewed and stated the incident occurred overnight, and from the incident report, Certified Nursing Assistant #2 was trying to do resident care by themself during the night when Resident #49 fell from the bed and sustained injuries. Registered Nurse #3 stated that the fall could have been prevented if Certified Nursing Assistant #2 had another staff to assist them in the care that required moving the resident in bed. Registered Nurse #3 also stated Resident #49 needed total assist of one (1) for dressing but would require assistance of two (2) staff for bed mobility. On 08/04/2025 at 11:23 AM, the Risk Manager was interviewed and stated the investigation revealed Certified Nursing Assistant #2 followed the instructions on the Certified Nursing Accountability Record that documented Resident #49 required one (1) staff assistance for dressing and two (2) staff assistance for bed mobility. They stated Resident #49 moved and rolled out of bed when Certified Nursing Assistant #2 was taking off the resident's gown. On 08/01/2025 at 8:50 AM, Minimum Data Set Assessor #1 was interviewed and stated that based on the input from the staff and rehabilitation department, Resident #49 was assessed to be totally dependent of staff with two (2) staff assistance for bed mobility and dressing. They stated this was reflected on the Certified Nursing Assistant Instructions. The Assessor stated they cannot explain why the resident's bed mobility and dressing was done by only one (1) staff that resulted in fall and injury, because the instruction was clear. On 08/04/2025 at 11:44 AM, the Director of Nursing was interviewed and stated Resident #49 was assessed to be one (1) assist for dressing at the time of the incident, and they thought resident just moved while being dressed causing the resident to fall. The Director of Nursing stated it could have been better and safer if two (2) staff had given the care to the resident at the time.On 08/04/2025 at 11:50 AM, the Administrator was interviewed and stated the incident with Resident #49 occurred before they assumed office. The Administrator stated that if the resident required the assistance of two (2) staff and only one (1) staff was giving the care, there is going to be a problem.10 NYCRR 415.12(h)(2)
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573), the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573), the facility failed to thoroughly investigate an alleged violation of abuse. This was evident for one out of seven residents (Resident #1) sampled for abuse. Specifically, Resident #1's adult child reported to Registered Nurse Supervisor #1, on 12/18/2024, that they witnessed Certified Nursing Assistant #1 used the dining room table to shove Resident #1 to sit in their wheelchair on 12/18/2024 at 3:28 PM. The facility investigated the alleged allegation of abuse and concluded that abuse did not occur. The facility did not interview residents that were in the dining room and other staff that were on the unit to ascertain if there were any potential witness.
The findings are:
The facility Policy and Procedure titled Abuse Prevention supersedes on 10/2022 states that allegations of resident abuse, neglect, mistreatment, exploitation, and/or misappropriation of property will be thoroughly investigated; documented by the Administrator (or designee) and reported to the appropriate state agencies, physicians, families and /or representative. The Director of Nursing /designee will conduct the interviews with potential witnesses or staff who might be able to share needed information in a private room to establish lines of communication.
Resident #1 was admitted to the facility with diagnoses including Dementia, Persistent Mood Disorder, and Depression.
A Social Service assessment dated [DATE] documented Resident #1 had long and short-term memory problems and severely impaired cognition.
An Incident/Event Intake Form dated 12/18/2024 documented Resident #1's child reported on 12/18/2024 at 3:35 PM that they witnessed Certified Nursing Assistant #1 pushed a table against Resident #1 in the day room. Nurse Manager #1 conducted an assessment, and there were no visible injuries. Certified Nursing Assistant #1 was removed from the schedule the pending investigation. Certified Nurse Assistant #1 was interviewed on 12/20/2024 and stated Resident #1 was assisted to sit down due to the risk of falls. Based on investigation and re-enactment, the facility concluded there was no evidence of abuse.
An email, with Resident's #1 child feedback, dated 12/18/2024 at 6:00 PM documented they came to the day room and witnessed Certified Nursing Assistant #1 shoved Resident #1 with a table. Certified Nursing Assistant #1 shoved Resident #1 with the table to show the resident how to sit in their wheelchair.
The Resident Demographic Detail Report revealed there were 12 residents in the day room on 12/18/2024. Resident #2 was alert and oriented x3.
During an interview on 01/02/2024 at 1:07 PM, the Director of Nursing stated Nurse Manager #1 reported the allegation to them on 12/18/2024 after 3:30 PM and they immediately removed Certified Nursing Assistant #1 from the schedule. The Director of Nursing stated that they did a re-enactment of the incident and Certified Nurse Assistant #1's body did not move the table forward. The Director of Nursing stated the investigation concluded there was no evidence of abuse. The Director of Nursing stated they did not interview other residents who were sitting in the dining room, nor did they interview other staff members before ruling out abuse.
During an interview on 01/03/2024 at 1:15 PM, the Administrator stated they became aware of the alleged abuse incident on 12/18/2024 at around 3:47 PM. The Administrator stated that the Director of Nursing is responsible for the investigation and should have interviewed residents who were in the dining room and other staff members.
10 NYCRR 415.4 (b)(3)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573 & NY00364335), the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00366573 & NY00364335), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for two out of seven residents (Resident #1 and Resident #3) sampled for abuse.
Specifically,
On 12/18/2024 at 3:35 PM, Resident #1's adult child reported to Nurse Manager #1, on 12/18/2024, that they witnessed Certified Nursing Assistant #1 used the dining room table to shove Resident #1 to sit in their wheelchair on 12/18/2024 at 3:28 PM. The facility investigated the alleged allegation of abuse and concluded that abuse did not occur. The facility did not report the alleged allegation of abuse to New York State Department of Health within two hours. Additionally, the facility did not report the suspicion of abuse to local law enforcement within two hours. The facility reported the alleged abuse to New York State Department of Health and to local law enforcement on 01/03/2025 at 5:04 PM while the Department of Health Surveyors were onsite.
On 12/10/2024 at 3:50 PM, Resident #3 was observed with swelling and discoloration to their left middle finger. An x-ray result dated 12/10/2024 documented an acute comminuted fracture (a broken bone splintered into more than two pieces) of the 3rd proximal phalanx shaft extending to the base. Resident #3 was transferred to the hospital on [DATE] for further evaluation. The facility became aware of the fracture on 12/10/2024 and reported it to New York State Department of Health on 01/03/2025 at 7:15 PM while New York State Department of Health surveyors were onsite conducting the investigation.
The findings are:
The facility Policy and Procedure titled Abuse Prevention superseded on 10/2022 documented the Director of Nursing, Administrator or designee will notify local law enforcement and the New York State Department of Health immediately but no later than two hours if the alleged violation involves abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property after the allegation is made which involves abuse or resulted in serious bodily injury.
Resident #1 was admitted to the facility with diagnoses including Dementia, Persistent Mood Disorder, and Depression.
A Social Service assessment dated [DATE] documented Resident #1 had severe cognitive impairment.
An Incident/Event Intake Form dated 12/18/2024 documented Resident #1's child reported on 12/18/2024 at 3:35 PM that they witnessed Certified Nursing Assistant #1 pushed a table against Resident #1 in the day room. Nurse Manager #1 conducted an assessment, and there were no visible injuries. Certified Nursing Assistant #1 was removed from the schedule the pending investigation. Certified Nurse Assistant #1 was interviewed on 12/20/2024 and stated Resident #1 was assisted to sit down due to the risk of falls. Based on investigation and re-enactment, the facility concluded there were no evidence of abuse.
An email with Resident's #1 child feedback dated 12/18/2024 at 6:00 PM documented they came to the day room and witnessed Certified Nursing Assistant #1 shoved Resident #1 with a table. Certified Nursing Assistant #1 shoved Resident #1 with the table to show the resident how to sit in their wheelchair.
A Webform Submission from: Nursing Home Facility Incident Report dated 01/03/2025 showed the facility submitted the report to the New York State Department of Health on 01/03/2024 at 5:04 PM.
A Security Log dated 01/03/2024 documented two Police Officers came on site at 6:52 PM.
During an interview on 01/02/2024 at 1:07 PM, the Director of Nursing stated Nurse Manager #1 reported the allegation to them on 12/18/2024 after 3:30 PM and the Administrator was notified on 12/18/2024 at around 3:47 PM. The Director of Nursing stated they immediately removed Certified Nursing Assistant #1 from the schedule. The Director of Nursing stated that a re-enactment of the incident was done on 12/20/2024 by Certified Nurse Assistant #1. The Director of Nursing Stated Certified Nursing Assistant #1's body did not move the table forward when Certified Nursing Assistant #1 leaned over the table. The Director of Nursing stated the allegation was investigated and they concluded there was no evidence of abuse after the re-enactment. The Director of Nursing stated Certified Nurse Assistant #1 was terminated because they did not report the family's allegation of abuse to the nurse. The Director of Nursing stated they did not suspect that a crime had occurred, therefore, they did not report the alleged abuse to New York State Department of Health or to local law enforcement.
During an interview on 01/03/2024 at 1:15 PM, the Administrator stated they became aware of the alleged incident on 12/18/2024 at around 3:47 PM. The Administrator stated they did not call the police or report the incident to New York Department of Health because there was no evidence of abuse.
Resident #3 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression.
The Minimum Data Set, dated [DATE] documented that Resident #3 had severe cognitive impairment.
A Nursing Progress Note dated 12/10/2024 dated 12/10/2024 at 3:50 PM, by Registered Nurse #1, documented Resident #3 was observed with a slight swelling and discoloration to their left middle finger. An x-ray result dated 12/10/2024 documented an acute comminuted fracture of the 3rd proximal phalanx shaft extending to the base. Resident #3 was transferred to the hospital on [DATE] for further evaluation.
An Incident /Event Intake Form dated 12/16/2024 documented abuse did not occur and that Resident #3 most likely sustained injury to their left hand while ambulating without assistance looking for their wheelchair. Resident #3 reenacted the fall event, and it appears that Resident #3 broke their fall by grabbing on to an object (table). Resident #3 could have either squeezed or bent their finger causing them to sustain a fracture. Resident #3 was transferred to the hospital and returned with a splint and orthopedic follow-up.
A Webform Submission from the Nursing Home Facility Incident Report showed the facility reported the fracture to the New York State Department of Health on 01/03/2025 at 7:15 PM.
During an interview on 01/03/2025 at 12:50 PM, the Director of Nursing stated when Resident #3 returned from the hospital, the discharge summary documented Resident #3's fracture was due to abuse. The Director of Nursing stated the facility did an investigation but did not call the police, and they do not recall calling the Department of Health. The Director of Nursing stated the Risk Manager is responsible for reporting abuse to the Department of Health.
During an interview on 01/03/2025 at 1:25 PM, the Administrator stated they are obligated to report all abuse allegations to the Department of Health. The Administrator stated the hospital discharged paperwork alleged Resident #3 was abuse in the facility, therefore, the facility should have reported the allegation of abuse to the Department of Health.
During an interview on 01/03/2025 at 2:30 PM, the Risk Manager stated they did not report abuse to the Department of Health because they did not suspect abuse. The Risk Manager stated Resident #3 was interviewed and they reported they fell prior to going to the hospital.
10 NYCRR 415.4(b)(2)
Jun 2023
2 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that food was stored in accordance with professional standards ...
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Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, multiple items were observed in freezers and refrigerators without proper labeling and dating. This was evident during the Kitchen task.
The findings are:
A facility policy and procedure titled Food safety, last reviewed 5/22, documented that all aspects of food handling, from receiving and storing, are done according to guidelines, and monitored to keep foods free from harmful microorganisms, contaminants and ensure quality and freshness is preserved. The policy further stated that food items with expiration dates or best by or use by dates should be discarded once the date has passed.
On 06/01/23 at 09:49 AM an initial tour of the kitchen was conducted with the Director of Food and Nutrition (DFN), and the following was observed: in the sandwich refrigerator there were individually wrapped sandwiches (which were not on a tray) with no dates; in the walk-in refrigerator #1, multiple packages of bread were open and out of delivery boxes with no dates. In the vegetable ice chest, there was an unidentified package with no date, 6 bags of broccoli florets out of the box, undated, and 2 open bags of French fries out of the box, and undated. In another ice chest there was an open box of cookie dough with no open date.
In a freezer there were 3 bags of broccoli florets out of the box, undated, and a veggie burger box was open so that the item was exposed. In the salad area fridge, an open tub of macaroni salad was observed with no open date and no manufacturer expiration date.
On 06/01/23 at 10:15 AM, the DFN was interviewed and stated they were aware all stored foods had to be dated and labeled. The DFN stated sometimes kitchen workers forget to label or date the food items.
On 06/08/23 at 12:48 PM, Food Service Worker (FSW) #2 was interviewed and stated they receive deliveries from the loading dock and organize items in the kitchen. FSW #2 also stated they date the items with delivery dates, check delivery and expiration dates, and they carry a marker as they are supposed to write in the date an item was opened. FSW #2 further stated it is mainly their job to label the items, but other people sometimes go in the fridge and open packages which they are supposed to date. The FSW stated that everything needs to be dated, and if it is more than 3 days old, it is discarded.
415.14(h)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that garbage was properly disposed. Specifically, garbage was n...
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Based on observation, record review and interviews, during the Recertification survey from 6/1/23 to 6/8/23, the facility did not ensure that garbage was properly disposed. Specifically, garbage was not covered while being removed from the kitchen to the disposal area. This was evident during the Kitchen task.
The finding is:
The facility policy and procedure titled Waste Disposal created 4/2018 and last revised 3/2023, documented garbage will be disposed of as needed throughout the day and at the end of each day. The policy further stated that prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers, trash bags shall be sealed prior to removing them from the facility, and trash will be deposited into a sealed container outside the premises.
On 06/07/23 at 10:36 AM, Food Service Worker (FSW) #1 was observed disposing of kitchen garbage. FSW #1 removed tied, clear plastic bags from a covered garbage bin, placed them in a large, grey, rectangular wheeled container, then pushed the wheeled container through the back of the kitchen, behind the tray line where lunch was being served at the time. The container was not covered. FSW #1 pushed the container approximately 100 feet through a hallway and to a back door, out of the building to the compactor area. FSW #1 placed the garbage bags in the compactor and closed the compactor door.
FSW #1 was immediately interviewed and stated they had not been trained that the trash container needs to be covered during transport to the compactor area.
During an interview on 06/07/23 at 10:46 AM, the Director of Food and Nutrition (DFN) stated staff are supposed to take the garbage through the back of the kitchen, and the bags should be tied and covered. The DFN stated they thought the tied bags were enough as a cover and did not realize the container itself needed to be covered.
On 06/07/23 at 04:25 PM, the Facility Administrator (FA) was interviewed and stated that trash from the dietary department goes in a garbage barrel, where it is secured and sealed so that garbage does not come out of the barrel,. The FA also stated that they were not aware that the transport container should be covered.
415.14 (h)
Jul 2021
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #180 had diagnoses that included Seizure Disorder, Cerebrovascular Disorder, and Hemiplegia.
The Quarterly Minimum ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #180 had diagnoses that included Seizure Disorder, Cerebrovascular Disorder, and Hemiplegia.
The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] and Annual MDS dated [DATE] documented the resident had intact cognition and had impairment on one side of upper extremity.
On 7/16/21 at 9:42 AM, an interview was conducted with Resident #180. Resident #180 stated they did not receive quarterly statements.
On 07/23/21 at 09:16 AM, the Director of Social Work (DSW) was interviewed. The DSW stated that statements are obtained from the Finance Department and if the resident has a BIMS score of 11 or higher, they are provided the statements by the Social Worker which they sign for. The DSW also stated that Resident #180 was provided with statements but because of the resident's physical condition they are not able to use their hands and so could not sign for the statement. The DSW further stated they would provide copies of the statements that were provided to the resident.
Around 11:30 AM, 4 Resident Funds Ledger were provided for the following time periods: 4/1/20-6/30/20, 7/1/20-9/30/20, 10/1/20-12/31/20 and 1/1/21-3/31/21. Each document contained the note resident unable to sign. and were initialed and dated by the DSW. There was no statement provided for 4/1/21-6/31/21 period.
On 7/23/21 at 1:05 PM, Resident #188 was observed seated at a table in the day room. Resident had a pen in hand and was completing a word search puzzle. Resident was able to sign name on paper provided and maintained that they had not been provided with quarterly statements.
Review of the Resident Influenza Vaccine Consent/Declination Form dated 8/26/20 documented that resident's signature was affixed.
On 7/23/21 at 1:41 PM, a follow-up interview was conducted with the Director Social Worker (DSW). The DSW stated that they documented on quarterly paper that resident was provided a statement by signing and dating the document. The DSW was asked to clarify the discrepancy that the resident could not sign for statements as other signed documents were located in the resident's medical record and the resident was observed with a pen completing a word puzzle. The DSW then stated that the resident had refused to sign the documents when presented. The DSW also stated that they did not document the resident's behavior in the medical record and could not explain why unable to sign instead of refused to sign was documented on each statement.
415.26(h)(5)(i)
Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that residents received their personal needs account statements on a quarterly basis. Specifically, there was no documented evidence that 2 residents received their account statements on a consistent basis. This was evident for 2 out of 2 residents reviewed for Personal funds out of 38 sampled residents (Resident #180 and #388).
The findings are:
The facility policy Resident Funds Accounts (RFA), revised November 2020, documented the facility will provide on request, and at least quarterly to the resident or the resident's designated or legal representative, a statement showing the account balance including funds deposited and withdrawn and interest accrued.
1) Resident #388 was diagnosed with Peripheral Vascular Disease (PVD) and Depression.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #388 had intact cognition.
An interview was conducted with Resident #388 on 07/15/21 at 12:06 PM. Resident #388 stated the facility has not provided quarterly statements of their patient needs account activity.
The Resident Funds Ledgers dated 1/16/2020, 7/20/2020, 11/11/2020, and 1/26/2021 documented Resident #388 signed for quarterly statements on 1/20/2020, 7/21/2020, 11/19/2020, and 2/10/2021 respectively.
There was no documented evidence Resident #388 received a Resident Funds Ledger for 4/2020 and 4/2021.
An interview was conducted with the Executive Assistant (EA) responsible for patient accounts on 07/20/21 at 01:55 PM. The EA stated residents are provided with quarterly statements of their patient accounts by the Social Work (SW) Department. The social workers determine whether a resident is cognitively intact. Residents who are cognitively intact have their statements hand delivered by the social worker and sign that they received it. A record of the signed and delivered quarterly statements are kept in the social work office.
An interview was conducted with the Director of Social Work (DSW) on 07/20/21 at 02:11 PM. The DSW stated the SW Department receive the Resident Fund Ledgers from the business office and hand deliver the statements to those residents who are cognitively intact. This is determined by a resident's Brief Interview for Mental Status score of 11-15. A signed copy of resident receipt of statement is kept on file in the social work office and a second copy is left with the resident for their record keeping. The DSW will review and provide documentation of Resident #388 ledger receipts.
An interview was conducted with the Social Worker (SW) assigned to Resident #388 on 07/22/21 at 01:01 PM. The SW stated that the SW Department will continue to look for the missing statements from April 2020 and April 2021 for Resident #388. On 07/23/ 21 at 11:53 AM, the SW stated they were unable to locate documented evidence Resident #388 received a copy of their Resident Funds Ledger in April 2020 and April 2021. The SW was certain the resident was provided with these statements but may not have signed for them. The SW does not document receipt of quarterly statements anywhere else in the record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a cognitively impaired resident's designated representative was inform...
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Based on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a cognitively impaired resident's designated representative was informed of a change in medication. Specifically, a resident's medication to treat dementia was discontinued without documented evidence the family was made aware. This was evident for 1 of 2 residents reviewed for Notification of Change (Resident #55).
The findings are:
The facility policy and procedure titled Family Notification dated 2/4/21 documented the facility would notify a resident's family or responsible party upon a change in treatment. Family notification will be documented in the medical record.
Resident #55 had diagnoses which include Alzheimer's Disease and Unspecified Dementia without behavioral disturbances.
The Minimum Data Set 3.0 (MDS) assessments dated 12/04/2020 and 5/4/2021 documented Resident #55 was severely cognitively impaired. The resident and the resident's representative participated in the assessment.
A telephone interview was conducted with the designated representative for Resident #55 on 07/16/21 at 01:06 PM. The representative stated they were not informed by the facility that the Rivastigmine patch ordered to treat Resident #55's Dementia was discontinued several months ago.
The Physician's Orders dated 5/28/2020 documented orders for Rivastigmine 9.5mg/24-hour transdermal patch applied daily.
A Comprehensive Care Plan (CCP) related to Multiple Medication Use was initiated 6/14/2020 and documented the Medical and Nursing staff would discuss with the responsible party the number of medications the resident is receiving and the potential for drug interactions.
A Neurology Consult dated 12/13/2020 documented Resident #55 was assessed on 12/11/2020, and the Neurologist recommended to decrease Rivastigmine patch to 4.6 mg once daily for 10 days and then discontinue the medication.
The Physician's Orders dated 12/20/20 documented the Rivastigmine 9.5mg/24hr transdermal patch was patch discontinued and Rivastigmine 4.6 mg/24hr transdermal patch was ordered for topical application once daily.
The Physician's Orders dated 12/30/20 documented the Rivastigmine patch 4.6 mg/24hr was discontinued.
The Medication Administration Record (MAR) for December 2020 documented the resident received Rivastigmine 9.6 mg/24hr transdermal patch daily until 12/20/20. The MAR documented Resident #55 received Rivastigmine patch 4.6 mg/24hr transdermal patch from 12/21/20 until 12/30/20. The resident did not receive a Rivastigmine patch after 12/30/20.
There was no documented evidence in the Nursing, Medical Doctor, or Nurse Practitioner notes that the designated representative was notified that Resident #55's Rivastigmine was discontinued.
An interview was conducted with the Medical Director (MD) of the facility on 07/22/21 at 10:17 AM. The MD stated the MD is responsible for overseeing the Nurse Practitioner (NP) and any significant changes the NP makes to a resident's treatment regimen. The change in Rivastigmine order was recommended by the neurologist, reviewed by the NP, and changed accordingly. The family should be made aware if there are any changes in a resident's treatment plan or medication. The MD did not inform the family that a change in Resident #55's Rivastigmine order had been made. The prescribing NP or the Registered Nurse (RN) manager on the unit would be responsible for ensuring the designated representative was notified.
An interview was conducted with the NP on 07/22/21 at 11:04 AM. The NP confirmed the NP made the changes to Resident #55's Rivastigmine order as per the Neurologist's recommendation on 12/11/20. The NP did not recall informing the family that a change in medication had taken place and was unable to produce documented evidence the NP notified the family of this medication change. The facility policy is that NP, MD, or RN would notify the family of a resident any time there is a change in the resident's treatment plan. The NP would have documented this conversation with the resident's family in the medical record if it occurred.
An interview was conducted with RN #1 on 07/22/21 at 11:58 AM. RN #1 stated the RN unit manager or NP/MD are responsible for informing resident family members of changes in resident's medications. Although the NP may call and inform the family, the RN is responsible for calling to ensure the family/designated representative understands the changes to the resident's treatment plan. RN #1 did not recall notifying the designated representative of Resident #55 of the change and discontinuation of the Rivastigmine patch. RN #1 was unable to produce documented evidence that the designated representative was made aware.
415.3(e)(2)(ii)(c)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The following observations were conducted on the 4th floor during environmental rounds.
On 07/15/2021 at 10:39 AM, 7/20/21 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The following observations were conducted on the 4th floor during environmental rounds.
On 07/15/2021 at 10:39 AM, 7/20/21 at 10:36 AM, and 7/21/21 at 9:25 AM, room [ROOM NUMBER] was observed. There were brown splatter stains on the wall to the right of the door and on the right side of the A Bed headboard. The wall to the left of the door had 6 plastered areas on the wallpaper and 5 areas with nail holes measuring 1/2 to 2 inches in diameter. The wallpaper on the left side of the window had a missing section measuring 10 feet (ft) by 5 ft, exposing the drywall. The closet doors had gouges in the the wood. The shower in the bathroom had dust and hair inside and no shower curtain. The drywall was cracked to the right of the door where the doorknob hit the wall. The paint on the top of the radiator cover was scratched on top.
On 07/15/2021 at 11:28 AM and 07/20/2021 at 09:17 AM, room [ROOM NUMBER] was observed. The wall to the left of the door had 7 holes patched with plaster on the gray wallpaper. The bathroom shower faucet was missing a knob, and there was no shower curtain. The radiator cover was dusty.
On 07/20/2021 at 10:28 AM and 07/21/2021 at 09:32 AM, room [ROOM NUMBER] was observed. The wall to the left of the AC unit had cracked drywall. The window frame and radiator cover were painted gray, but the radiator cover had areas on the top that were missed with the original cream paint showing. The bathroom shower had yellow stains on the bottom.
On 07/20/2021 at 10:31 AM and 07/21/2021 at 09:36AM, Room # 410 was observed. The baseboard to the left of the door was coming off the wall, exposing 4 nails. The bathroom shower had no shower curtain, and there were brown stains around the rim of the drain and to the left of the drain on the shower floor.
On 07/16/2021 at 12:41PM and 07/21/2021 at 09:28 AM, the 4th floor shower room was observed. The vents above the sink and bath tub were dusty. The shower directly in front of the shower room entrance did not have a shower curtain, and there was no privacy curtain by the door to prevent people from seeing into the shower room when the door is opened. The floor tiles by the entrance had brown dirt buildup.
On 07/21/2021 at 10:10 AM, the 4th floor day room was observed. The grates on top of the AC unit were rusted and dusty, and the right side of the grate over the controller were caved in. The walls on the left and right sides of the dining room had chipped paint in many areas. There was a hole in the drywall underneath the wall-mounted computer kiosk.
3) The following observations were conducted on the 5th floor during environmental rounds.
On 07/19/2021 at 12:13 PM, Room # 526 was observed. The privacy curtain for the bed by the window did not provide full privacy. There was a 12 inch gap between the curtain and the wall.
On 07/15/2021 at 12:42 PM and 07/20/2021 at 12:26 PM, room [ROOM NUMBER] was observed . The bathroom shower faucet leaked around the knob when turned on. No water came out of the shower head, and there was hair in the bathroom drain.
On 07/20/2021 at 10:10 AM. LPN #1 was interviewed and stated LPN #1 conducts rounds of the unit which include resident rooms and bathrooms. LPN #1 was shown the areas of concern in Rooms #408, #410, and #406. LPN #1 stated the AC units are old and sometimes staff have to play with them to get them to work. LPN #1 stated the building needs help, and the work needs to start on the 3rd floor. LPN #1 did not notice the stains on the wall. LPN #1 stated the unit showers, works, and decorations need work, and the unit is not homelike.
On 07/20/2021 at 10:28 AM and 11:47 AM, an interview was conducted with the Housekeeper/Porter who stated that the cleaning of the vents is a side project scheduled for various housekeeping department staff as a weekend project. The Housekeeper cleans staff and resident bathrooms daily. The tile on the floor is old and would need to be replaced.
On 07/21/2021 at 11:22 AM, an interview was conducted with the Director of Nursing (DON) who stated the building is hold, and they have hired a nurse manager to focus on improving the Dementia units. Paintings and other items have been purchased for the 4th and 5th floors.
On 07/21/2021 at 11:41 AM, an interview was conducted with the Director of Housekeeping (DOHS) who stated the DOHS tours the units Monday to Friday to check for cleanliness. Housekeeping staff follow a cleaning checklist and were in-service on the correct way to clean the rooms. Staff clean tubs, showers, toilets, handrails, vents, walls, mirrors and lights above the sink. The DOHS went to the 4th and 5th floor on Monday to look at the resident rooms and bathrooms. The DOHS checks the condition of privacy curtains, and curtain rods are checked quarterly. Nursing informs Housekeeping of any issues. Housekeeping cleans and reports drainage problems to Maintenance. The DOHS noticed the discoloration of the showers and ordered a product to help with issues like rust. The DOHS stated they have back up curtains in stock (ordered in January 2021).
On 07/21/2021 at 03:20 PM, an interview was conducted with the Director of Environmental (DOE) who stated they are in the process of doing in house cleaning and painting. The air conditioning (AC) units in the day room are cleaned every 3 to 6 months. The coil is cleaned, and the top is changed if needed. Maintenance is called to the 4th floor to service the AC units more frequently due to issue with resident use (resident my urinate on or throw food and drinks on them).
415.5(h)(2)
Based on observations, interviews and record reviews conducted during the recertification survey, the facility failed to ensure a resident's equipment was maintained in good condition. Specifically, a resident's wheelchair had faulty hand brakes preventing it from being in the locked position, and resident rooms and common areas were observed with dirty walls, short privacy curtains, dusty vents and AC units, unfinished plastered areas on the walls, rust and stains in the showers, and stained ceiling tiles. This was evident for 1 of 8 residents (Resident #388) and 2 of 12 Resident units (Unit #4 and #5) reviewed for the Environment.
The findings are:
The facility did not have a policy and procedure related to maintaining resident's equipment in good condition.
On 07/15/21 at 12:13 PM, Resident #388 was interviewed and stated Resident #388 received a wide wheelchair approximately two weeks ago, and the left wheel brake is broken and does not lock. Resident #388 requested repair several times, but no repair was done. The wheelchair was observed, and there was no plastic covering on the left wheel brake. The surveyor attempted to push down the break, but it did not work. The surveyor was able to lock the left wheel brake, but once the wheelchair was moved, the brake released unintentionally.
On 7/20/21 at 4:03 PM, Resident #388 was interviewed and stated Resident #388 refused to be transferred to the wheelchair (w/c) because it is unsafe. Resident #388 made several complaints and requests for repair to the Nursing and Maintenance Departments. The w/c was still in disrepair.
Maintenance Department Repair Log Sheets documented Resident #388 requested wheelchair brake repairs on 4/28/21, 7/09/21, and 7/20/21. The log sheet documented the brakes were fixed on 4/28/21. There was no documented evidence the resident's wheelchair was repaired on 7/09/21 or 7/20/21.
An interview was conducted with Certified Nursing Assistant (CNA) #8, Unit Clerk for Resident #388's unit, on 07/20/21 at 04:09 PM. CNA #8 stated Resident #388 received a new wheelchair from the Rehab Department in April 2021. Resident #388 constantly complains the wheelchair brakes do not work. The unit staff communicates any requests for repairs to the Maintenance Department by filling in the Maintenance Department Repair Log Sheets. The Maintenance Worker (MW) is then responsible for following through with repairing the item. The MW then signs the log to document the repair has been completed.
An interview was conducted with the MW assigned to Resident #388's unit on 07/23/21 at 10:13 AM. The MW stated the logbook is checked every morning. The MW did not recall a repair request made for Resident #388 on 7/9/21, and MW was unaware the resident had any issue with wheelchair brakes until the log entry on 7/20/21. The MW was unable to repair the brakes and informed another Maintenance Worker who specializes in wheelchair repair. The MW did not follow-up after referring the repair to another staff member to ensure that it was addressed. The wheelchair repair person sometimes has many equipment repairs to manage and may not address the concern immediately. MW did not communicate this to the Director of Maintenance (DM). The MW did not personally observe the hand brakes on Resident #388's wheelchair.
An interview was conducted with the Director of Maintenance (DM) on 07/20/21 at 04:21 PM. The DM stated any issue with a resident's equipment, such as faulty hand brakes, are repaired immediately and the equipment is returned to the resident in the same day. If the MW is unable to take part in the repair, the MW should communicate this to the DM, and the DM will ensure that either another MW or the DM repairs the item immediately. The logbooks are checked every morning. The DM was unaware Resident #388 had a wheelchair with faulty brakes. Upon observation of the brakes on Resident #388's wheelchair, the DM confirmed the left-hand brake was non-functional and the right-hand brake was faulty. The DM stated this needed to be repaired immediately. The Maintenance Department does not have a policy and procedure regarding resident care equipment repair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the recertification survey, the facility did not ensure a resident is free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed with a lap buddy that had not been identified as a restraint. This was evident for 1 of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439).
The findings are:
The facility policy and procedures titled Restraints revised on 4/22/21 documented the following: the facility furthermore adheres to the CMS definition of a Physical Restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one's body. The policy also documented, if a request is made for a restraint, the Comprehensive Care Planning team will assess the resident's needs and medical symptoms. Alternative solutions are tried prior to the use of a restraint. The physician, as a member of the CCP team determines the most effective treatment for the resident's medical symptoms including the use of a restraint. If a restraint is used it must be the least restrictive intervention that manages the medical symptoms. Rehab will be requested to give recommendations regarding necessity and what is the least restrictive device.
The finding is:
Resident #439 was admitted to the facility with diagnoses which included Cerebral Infarction, Polyneuropathy, Contracture left elbow and wrist, and Hemiplegia.
The Annual Minimum Data Set (MDS) dated [DATE] documented resident had intact cognition and required extensive assist of one staff person for bed mobility, transfers, locomotion off and on unit, toilet use, and personal hygiene and total assistance of one staff person for dressing. The MDS also documented that the resident had impairment on one side of upper and lower extremity. The MDS also documented that a restraint was not used.
The Quarterly MDS dated [DATE] documented resident had intact cognition and required extensive assist of one staff person with bed mobility, transfers, locomotion off and on unit, dressing toilet use, and personal hygiene. The MDS also documented that the resident had impairment on one side of upper and lower extremity. The MDS also documented that a restraint was not used.
Physician orders dated 6/15/21 documented out of bed (OOB) to wheelchair with extensive assist X 1 and lap Buddy.
Physician orders initiated on 1/14/16 and renewed on 7/17/21 documented out of bed to wheelchair with lap board. Resident able to independently release on request thus not a restraint.
Occupational Therapy Note dated 1/10/19 documented that lap board edges were rubbing against resident's arm when resident was propelling wheelchair so resident was referred for evaluation. The note also documented that the resident was provided with a lap buddy to allow for full clearance when resident propelled wheelchair.
There was no documented evidence that the physician's order was changed to reflect the change from lap board to lap buddy until 7/16/21.
On 7/22/21 at 2:55 PM, Certified Nursing Assistant (CNA) #3 was interviewed. CNA #3 stated resident has a bar for use in the chair so they cannot slide out and resident is not able to remove bar. CNA #3 also stated that the resident has had the device since they were assigned to the floor in 2016. CNA#3 further stated that it is a struggle for the CNAs to place the lap buddy so the resident would not be able to remove it as they have weakness on one side of the body. CNA#3 also stated that the resident has had different devices over the years and has not removed any of the devices on their own.
On 7/22/21 at 3:00 PM, Resident # 439 was interviewed. Through use of a communication board, resident typed that they are not able to remove the lap buddy and staff has to take it out.
On 7/22/21 at 3:05 PM, Registered Nurse (RN) #2 was interviewed. RN #2 stated resident wears lap buddy for support in chair, always uses it when out of bed and the resident needs help to remove device. RN #2 also stated the device is not a restraint because it is removed and only used for support while resident is in wheelchair. Resident has weakness to one side and also uses lap buddy as a surface for the communication device. RN #2 further stated that the physician's order documents it is for support, not a restraint and resident able to remove independently so it so not considered a restraint.
On 7/22/21 at 4:04 PM, the Occupational Therapist (OT) was interviewed. The OT stated that currently resident is provided with a lap buddy and the order previously documented a lap tray. The OT also stated they provided resident with the lap buddy. The OT further stated that usually the resident can remove it and may have had some changes. The OT stated that the resident was just discharged from OT and on last evaluation resident was able to remove it. If resident is not able to remove, then it would be considered a restraint.
On 7/23/21 at 12:49 PM, the Director of Nursing (DON) was interviewed. The DON stated we do an interdisciplinary team (IDT) meeting to determine if a restraint is required or not. The DON also stated that if the resident is not able to freely remove the device or it restricts their body movements then it is considered a restraint. The DON further stated that the resident had a partial tray before that the resident would use to rest the communication board and the DON had not been informed when this had been replaced with a lap buddy. The DON stated that the use of devices with this resident had been questioned in the past, but OT informed Nursing that it was not a restraint as the resident was able to remove it. The DON further stated that staff has received in-service on what constitutes a restraint and should have known that if resident was not able to remove the device it would now be considered a restraint.
415.4 (a)(2-7)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during a Recertification survey, the facility did not ensure that a portio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review conducted during a Recertification survey, the facility did not ensure that a portion of the Minimum Data Set (MDS) Assessment accurately reflected the resident's status. Specifically, 1). a lap buddy was not coded as a restraint and 2). discharge and admission MDS did not accurately document resident's admission and discharge status. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 1 residents reviewed for Hospitalization out of sample of 38 residents. (Resident # 439 & Resident #451)
The findings are:
The policy and procedure titled Minimum Data Set (MDS) -Version 3.0 reviewed on 7/23/2021 documented the results of the assessment, which must accurately reflect the resident's status and needs, will be used to develop, review, and revise each resident's comprehensive plan of care. The policy also documented different sections of the form are completed accurately and signed by staff members from various professions including nursing, social services, therapeutic recreation activities, dietary, occupational therapy, MDS coordinator and other staff members.
1. Resident #439 was admitted to the facility with diagnoses which included Cerebral Infarction, Polyneuropathy, Contracture left elbow and wrist, and Hemiplegia.
Physician orders initiated on 1/14/16 and renewed on 7/17/21 documented out of bed to wheelchair with lap board. Resident able to independently release on request thus not a restraint.
The Annual Minimum Data Set (MDS) dated [DATE] documented resident with intact cognition and required extensive assist of one staff person for bed mobility, transfers, locomotion off and on unit, toilet use, and personal hygiene and total assistance of one staff person for dressing. The MDS also documented that resident had impairment on one side of upper and lower extremity. Section P of the MDS also documented that a restraint was not used.
The Quarterly MDS dated [DATE] documented resident with intact cognition and required extensive assist of one staff person with bed mobility, transfers, locomotion off and on unit, dressing toilet use, and personal hygiene. The MDS also documented that resident had impairment on one side of upper and lower extremity. Section P of the MDS also documented that a restraint was not used.
On 7/22/21 at 2:55 PM, Certified Nursing Assistant (CNA) #4 was interviewed. CNA #4 stated resident has a bar for use in the chair so they cannot slide out and the resident is not able to remove the bar. CNA #4 also stated that the resident has had the device since they were assigned to the floor in 2016. CNA#4 further stated that it is struggle for the CNAs to place the lap buddy so the resident would not be able to remove it as they have weakness on one side of the body. CNA#4 also stated that the resident has had different devices over the years and has not removed any of the devices on their own.
On 7/22/21 at 3:00 PM, Resident # 439 was interviewed. Through use of a communication board, resident typed that they are not able to remove the lap buddy and staff has to take it out.
The MDS Assessor who completed the MDS assessments was no longer employed at the facility and not available for interview.
On 7/23/21 at 10:48 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated that the MDS Assessor must do a visualization of the resident when doing the assessment and code a restraint if the resident is unable to remove it or if it restricts their movement. If a resident has a restraint the assessor would be expected to confirm there is an order and ensure that the resident is able to self-release the device because they are the one coding the MDS. The MDSC also stated that if the assessor determined the resident could not self-release the device, the team should be alerted to determine if the use is still appropriate.
2. Resident #451 was admitted to the facility with Altered Mental Status and Possible Seizure.
Nursing Progress note dated 4/29/21 documented resident was admitted to the facilty from an acute hospital on 4/1/21 and that the resident will be discharged to home on 4/30/21.
Social Service progress note dated 4/30/21 documented resident was discharged from the facility today at 11 am and was picked by family members via car.
The Discharge Assessment-Return not Anticipated MDS dated [DATE] documented that resident was discharged to the community on 3/19/18.
The admission MDS dated [DATE] coded resident as a re-entry to the facility from an acute hospital on 4/1/21 with an admission date of 2/28/2018.
The MDS did not accurately capture the resident's status as an admission on [DATE] and not as a re-entry to the facility.
The Discharge assessment dated [DATE] documented that the resident was discharged to an acute hospital on 4/30/21.
The MDS did not accurately capture that the resident had been discharged to the community on 4/30/21.
On 7/23/21 at 10:37 AM, the MDS Assessor was interviewed. The MDS Assessor stated resident was discharged in 2018 and admitted in April 2021 and upon return should have been considered an admission. The MDS Assessor also stated that if the resident was discharged home, when they return to the facility, this would be considered a new admission. If the resident had been discharged to the hospital and returned within 30 days, this would have been considered a reentry. The MDS Assessor further stated that the resident was discharged home with her son on 4/30/21 and the Discharge MDS should have been coded as a discharge to the community. The MDS Assessor stated that they do check the sections of the MDS that they complete but must have missed those areas.
On 7/23/21 at 10:46 AM, the MDS Director was interviewed. The MDS Director stated in this case, the resident should have been coded as an admission, not a reentry on 4/1/21. The MDS Director also stated that since the resident went home on 4/30/21, MDS should have been coded discharge to community. The MDS Director further stated that they check to ensure that the MDS is completed on time. In addition, if they notice inaccurate coding, they prompt the particular department. The MDS Director stated that the person who completes a specific section is responsible for accuracy of that section.
415.11(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey, the facility did not ensure that a Comprehens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, 1). care plans were not developed to address the use of a splint device and restraint and, 2). a care plan was not developed to address a resident's vision concerns. This was evident for 1 of 3 residents reviewed for Position, Mobility and 1 of 3 residents reviewed for Communication-Sensory out of sample of 38 residents (Resident # 439 & Resident # 334).
The findings are:
The policy and procedure titled Comprehensive Care Plan reviewed on 12/15/20 documented the CCP is to include resident's problems, strengths and needs. An individual CCP will be developed for each problem, strength or need. The policy further documented that each discipline is responsible for reviewing, evaluating, and revising care plans prior to the CCP completion date as outlined on the schedule.
1. Resident #439 was admitted to the facility with diagnosis which include Aphasia following Unspecified Cerebrovascular Accident, Cerebral Infarction, Polyneuropathy, Contracture left elbow and wrist and Hemiplegia.
Physician's order dated 6/15/21 documented the following:
Left-hand roll daily, remove during nursing care, range of motion (ROM), and skin checks,
Non-ambulatory right forearm stockinette sleeve during wheelchair mobility for safety and skin protection,
Soft cervical collar to be worn daily when out of bed (OOB) and removed every 2 hours, including during feeding, hygiene care, ROM, and skin integrity checks and,
Right upper extremity (R UE)- elbow protector to be worn OOB. Remove for skin checks and nursing care.
On 07/15/21 at 03:19 PM, Resident #439 was observed seated in a wheelchair with contracture of the left hand. There was no hand roll observed in resident's left hand. Resident indicated they have a left hand roll but it was not applied. A lap buddy was observed in place.
On 07/19/21 at 09:05 AM, Resident was observed lying in bed with no hand roll in left hand. A hand roll was observed on a table in the room.
On 07/19/21 at 02:00 PM and at 3:24 PM, Resident was observed seated in a wheel chair with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed in position across the wheelchair.
On 07/21/21 at 10:41 AM, Resident was observed seated in a wheel chair in room with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed positioned across the wheelchair.
On 07/22/21 at 10:25 AM, Resident was observed seated in wheel chair in their room with no hand roll in left hand. Right forearm elbow protector and cervical collar were both in place. A lap buddy was observed positioned across the wheelchair.
The Certified Nursing Aide (CNA) Accountability record contained no field in which the CNA could document placement or removal of the hand roll, elbow protector, or cervical collar.
There was no documented evidence that a Comprehensive Care Plan with measurable goals and device specific interventions had been developed to address the use of splint devices and a restraint.
On 7/22/21 at 2:37 PM, CNA #3 was interviewed. CNA #3 stated resident needs two staff to assist with transfers and is a one person assist for turning and positioning in bed. CNA #3 stated when resident gets out of bed, they put on the neck brace, elbow protector and something to keep fingers open. CNA #3 also stated that sometimes they are unable to find the devices that have been removed by the previous shift. CNA #3 further stated the instructions for devices are in the kiosk.
On 7/23/21 at 9:54 AM, Registered Nurse (RN) #2 was interviewed. RN #2 stated that the RN and MDS staff are responsible for care plans and a care plan is created when issues or potential issues are identified. If there is a consult we update with recommendations and review every 90 days. RN #2 also stated that a new care plan is added when there is a change or a new issue develops for a resident. RN #2 further stated the resident has a hand roll, elbow protector, soft neck brace and lap buddy and the care plan for the lap buddy was created on 7/22/21. RN #2 also stated they were not able to locate a care plan with interventions for the brace or elbow protector.
2. Resident # 334 was admitted to facility on 07/30/2020 with diagnoses that included Hypertension, Diabetes Mellitus, and Cerebrovascular Accident.
The Annual Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition and adequate vision with no glasses.
The Optometry Consult dated 2/3/21 documented the resident has Cataracts NS (Nuclear Sclerotic) and decreased BCVA (Best Corrected Visual Acuity) and mild Hypertension retinopathy-monitor for progression. Recommendation was for follow-up in 6 months and to continue Artificial Tears eye drops 1 drop to each eye two times per day for dry eyes.
Physician order dated 02/02/2021 and 04/18/2021 documented an Ophthalmology consult was ordered for resident complaint of vision problem. No recommendation was noted.
There was no documented evidence that a care plan with measurable objectives, time frames and appropriate interventions were developed to address the care of the resident with vision deficit.
On 07/23/21 at 11:19 AM, an interview was conducted with the RN Nurse Manager (RN #2). RN # 2 stated they are responsible for updating and initiating care plans on the unit. RN #2 stated they noticed no care plan for vision had been created since resident's admission and so they initiated a vision care plan on 07/16/2021 after the survey had begun.
On 7/23/21 at 12:49 PM, the Director of Nursing (DON) interviewed. The DON stated the Nurse Manager (NM) updates care plan daily. The DON also stated that the MDS nurses do the quarterly and annual care plans and the Nurse Managers are responsible for updates when issues arise between care plans. The DON further stated that the MDS staff will review prior to completing MDS to make sure the care plans are there. The DON stated that here should be a care plan for all devices which includes interventions and goals. The DON stated that the orders may not have been entered in the right way and so did not trigger the creation of a care plan. The DON also stated the CCP for vision deficit should have been in place upon admission for Resident # 334. The DON further stated that an in-service will be given to make sure all CCP's are in place on admission.
415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in ROM or mobility. Specifically, hand rolls, elbow splints, and cervical collar were not provided to residents as ordered. This was evident for 2 out of 3 residents reviewed for Position and Mobility out of a sample of 38 residents. (Resident # 439 and Resident #180).
The findings are:
The facility's policy Adaptive Device Policy reviewed August 2020 documented the responsibility of the Clinical Nurse supervisor or Supervising Nurse is to ensure that all shifts of nursing are in-serviced as to the proper use and wearing schedule of the device.
1. Resident #439 was admitted to the facility with diagnosis which include Aphasia following Unspecified Cerebrovascular Accident, Cerebral Infarction, Polyneuropathy, Contracture left elbow and wrist, and Hemiplegia.
Physician's order dated 6/15/21 documented the following:
Left-hand roll daily, remove during nursing care, range of motion (ROM), and skin checks,
Non-ambulatory right forearm stockinette sleeve during wheelchair mobility for safety and skin protection,
Soft cervical collar to be worn daily when out of bed (OOB) and removed every 2 hours, including during feeding, hygiene care, ROM, and skin integrity checks and,
Right upper extremity (R UE)- elbow protector to be worn OOB, Remove for skin checks and nursing care.
On 07/15/21 at 03:19 PM, Resident #439 was observed seated in a wheelchair with contracture of the left hand. There was no hand roll observed in resident's left hand. Resident indicated they have a left hand roll but it was not applied. A lap buddy was observed in place.
On 07/19/21 at 09:05 AM, Resident was observed lying in bed with no hand roll in left hand. A hand roll was observed on a table in the room.
On 07/19/21 at 02:00 PM and at 3:24 PM, Resident was observed seated in a wheel chair with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed positioned across the wheelchair.
On 07/21/21 at 10:41 AM, Resident was observed seated in a wheel chair in room with no hand roll in left hand, no right forearm elbow protector, and no cervical collar in place. A lap buddy was observed in position across the wheelchair.
On 07/22/21 at 10:25 AM, Resident was observed seated in wheel chair in their room with no hand roll in left hand. Right forearm elbow protector and cervical collar were both in place. A lap buddy was observed positioned across the wheelchair.
The Certified Nursing Aide (CNA) Accountability record contained no field in which the CNA could document placement or removal of the hand roll, elbow protector, or cervical collar.
On 7/22/21 at 2:37 PM, CNA #3 was interviewed. CNA #3 stated when resident gets out of bed, they put on the neck brace, elbow protector and something to keep the fingers open. CNA #3 also stated that sometimes they are unable to find the devices that have been removed by the previous shift. CNA #3 further stated the instructions for devices are in the kiosk. CNA #3 stated that if they are unable to locate the resident's devices, they inform the Nurse Manager.
2. Resident #180 was admitted to the facility with diagnoses that included Cerebral Infarction, Hemiplegia, and Primary Osteoarthritis of left ankle and foot.
On 7/16/21 at 9:55 AM and at 1:19 PM, resident was observed seated in a wheelchair in their room. No device was observed on resident's left hand.
On 7/19/21 at 9:08 AM and at 12:45 PM and on 7/20/21 at 9:20 AM and at 3:06 PM, resident was observed seated in a wheelchair in the dayroom. No device was observed on resident's left hand.
On 7/21/21 at 9:05 AM, resident was observed seated in wheelchair in the day room with WHFO applied in a twisted position on the resident's left hand.
The Physician's order dated 5/14/17 and renewed 7/8/21 documented left hand wrist hand finger orthosis (WHFO) to be worn during the day and removed every 2 hours, including at night, ROM, hygiene care and skin integrity check.
Annual Minimum Data Set (MDS) dated [DATE] and Annual MDS dated [DATE] documented splint or brace assistance 7 days in the last 7 calendar days.
A Comprehensive Care Plan (CCP) titled Contractures/At risk/Actual effective 10/30/15 and updated 5/28/21 documented a goal of: Resident will remain free from further contractures x 90 days to L hand/digits. Interventions included resident to use left hand splint as per MD order. Currently only able to tolerate 30 minutes duration. Splint/braces: See wearing schedule.
On 7/22/21 at 2:18 PM, CNA #5 was interviewed. CNA #5 stated resident has a hand roll and special boot for left leg and also has a hand rest for left arm. CNA #5 also stated they put devices on and document them in the general area on the kiosk. CNA #5 further stated they may have forgotten to put the device on. CNA#5 also stated the device gets placed on in the morning and is removed at bedtime.
On 7/23/21 at 9:54 AM, Registered Nurse (RN) #2 interviewed. RN #2 stated they make sure the residents have the devices and monitor to ensure that it is always on the resident. If I see a device is not in place, I will ask the aide to put the device on or I put the device on myself. RN #2 also stated that if the resident is out of bed, the expectation is that the device should be in place and aides should be documenting on the CNAAR. RN #2 further stated that there was never a time that the CNAs reported to them that they could not find devices and they actually did an audit recently to determine which residents had devices and any missing devices were replaced by Rehab.
On 7/23/21 at 12:49 PM, the Director of Nursing (DON) was interviewed. The DON stated that the expectation is that CNAs make sure the devices are in place and they should alert nurse immediately if a device is missing. The Nurse Manager is expected to follow up to get device located or replaced as soon as possible. The DON also stated that in addition, the Nurse Manager makes sure the devices are on the care plan and on the CNA accountability record. The DON further stated that the Nurse Manager is responsible for monitoring the CNAs and ensuring that they are completing all assigned tasks.
415.12(e)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
2. On 7/20/21 at 8:57AM, an observation of the 14th floor medication cart was conducted with LPN #4.
A packet of Healthylax was observed in the medication cart with an expiration date of 4/2021.
LPN...
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2. On 7/20/21 at 8:57AM, an observation of the 14th floor medication cart was conducted with LPN #4.
A packet of Healthylax was observed in the medication cart with an expiration date of 4/2021.
LPN #4 was interviewed immediately and stated they did not know why expired Healthylax is in the medication cart and this item should have been removed.
On 7/23/21 at 9:29 AM, RN #2 was interviewed. RN #2 stated they check medications once a month for expiration dates. RN #2 also stated that although this is the responsibility of nurses on floor, they do random checks also. RN #2 further stated that the nurses on overnight shifts check the medication cart and discard what is not being used and is expired. The expired Healthylax may have been there because there was one packet left and this may have been an oversight.
On 7/23/21 at 1:14 PM, an interview was conducted with the DON. The DON stated the nurses check the carts for medications that are not in use or expired. The DON also stated that an honor system is used and there is no documentation done when carts are checked.
415.18(a)
Based on observation, record review, and staff interview conducted during the Recertification and Abbreviated survey, the facility failed to ensure expired medications were identified timely and removed from current medication supply for disposition. Specifically, bags of intravenous fluids in the medication room on the 5th Floor and expired laxative medication was observed in the medication cart on the 14th Floor past the expiration date. This was evident on 2 of 12 units reviewed for Medication Storage (Unit 5 and Unit 14).
The facility policy and procedure titled Medication Storage reviewed 08/2020 documented medications must be stored in accordance with manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself.
1). On 07/19/2021 at 03:34 PM, an observation of the medication room on the 5th Floor conducted with Licensed Practical Nurse (LPN) #2. A cardboard box located inside the bottom cabinet located to the left of the door contained the following expired items: A 1000 ml (milliliter) bag of intravenous fluid (IV) 5% dextrose and 0.9% sodium chloride injection USP with a manufacturer expiration date of 02/2021. There were four 50 ml bags of 0.9% sodium chloride injection USP with a manufacturer expiration date of 08/2020. An intravenous start kit with a manufacturer expiration date of 04/30/2021.
On 07/19/2021 at 3:57 PM, an interview was conducted with LPN #2. LPN #2 stated that LPN #2 check's the medication room every two weeks before the pharmacy comes for their monthly check. LPN #2 checked the IV fluids in the cabinet last month, but sometimes items at the bottom are overlooked. LPN #2 stated the medication room should be checked daily, and they are not sure what the policy is. It is important to remove expired medication so they are not administered to residents. Expired medications may cause a resident to get sick or have an allergic reaction.
On 07/20/2021 at 12:58 PM, an interview was conducted with the Registered Nurse Manager (RN #1) assigned to the 5th floor. RN #1 stated they check the medication room during rounds weekly, and the night supervisor also checks the medication room. RN #2 stated the expired IV fluids were discarded. The expiration dates of the IV fluids and the IV starter kits are checked during the weekly rounds. RN #2 stated perhaps it was overlooked. Expired medication is not kept in the medication room to maintain the health and safety of the residents. No log is kept of the weekly rounds.
On 07/21/2021 at 11:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the DON conducts rounds on two to three units daily. The DON checks the medication rooms during rounds sometimes. The DON stated the DON looks to ensure staff personal items are not stored in med rooms. The DON also reviews the narcotic book and checks to see if the narcotic box is locked. The DON also looks under the sink to make sure items are not stored there inappropriately. The DON does not check IV bags. The DON stated expired items should be sent back to central supply to ensure the items are not used. Anything expired is a potential risk. The Pharmacy comes in once a month to look at the medication room, and the DON receives reports of their findings every time they come to inspect.
On 07/22/2021 at 3:26 PM, a phone interview was conducted with the Pharmacy Consultant who stated they check the medication rooms once per month on each floor, including the medication cart. The Pharmacy Consultant stated the last inspection of the 5th floor was done on 7/19/2021. They checked the cabinets in the medication room for medication and also looked at the IV solutions. The Pharmacy Consultant stated that the Pharmacy Consultant did not see the items that were expired during their inspection. Any findings, including expired items, are put on the monthly report for nursing to prevent potential medication errors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observations and interviews conducted during the recertification survey, the facility did not ensure that a safe, functional, sanitary and comfortable environment was provided for residents, ...
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Based on observations and interviews conducted during the recertification survey, the facility did not ensure that a safe, functional, sanitary and comfortable environment was provided for residents, staff and the public. Specifically, the staff bathrooms were observed with brown stained floor tiles, cracked ceiling tiles, rusted ceilings, toilet paper holders in disrepair, a cracked trash can, and loose shelving. This was evident for 2 of 12 resident units observed for the Environment (Units 4 and 5).
The findings are:
The policy for environmental services cleaning/maintenance was requested from the Director of Housekeeping and maintenance but not provided.
On 07/20/2021 at 09:53 AM and 07/21/2021 at 12:00PM, the 4th Floor staff bathroom was observed with cracked ceiling tiles and ceiling rust. The floor tiles had brown stains, and there was a plastic bottle below the toilet bowl flush lever with brown and black colored residue in inside. The toilet paper holder was in disrepair with a nylon string being used to hold up the toilet paper, and the trash can was cracked.
On 07/20/2021 at 03:38 PM and 07/21/2021 at 12:15 AM, the 5th floor staff bathroom was observed with cracked ceiling tiles and ceiling rust, a pink water pitcher used as toilet brush holder, floor tiles with brown stains, and a loose, crooked small metal ledge shelf underneath the mirror. The toilet paper holder was in disrepair with a nylon string being used to hold up the toilet paper. There was a plastic bottle below the toilet flush lever with black colored residue inside.
On 07/20/2021 at 12:48 PM, there were brown stains on the wall by the trash can inside the 5th floor nurses' station.
On 07/20/2021 at 10:10 AM the Licensed Practical Nurse (LPN #1) was interviewed and stated that they do rounds of the unit. LPN #1 did not notice stains on the walls.
On 07/21/2021 at 03:21 PM, the Registered Nurse Manager (RN #1) was interviewed and stated the tiles in the bathroom are old and clean. RN #1 seldom uses the bathroom on the unit.
On 07/21/2021 at 10:06 AM, the Recreation Aide was interviewed and stated the staff bathroom is clean and well-stocked with paper towels. The building is from the 70's, and things are worn but functional.
On 07/20/2021 at 10:28 AM and 11:47 AM, an interview was conducted with the Housekeeper/Porter who stated . The Housekeeper stated the Housekeeper cleans the staff and resident bathrooms daily. The Housekeeper did not notice any issues with the 4th floor staff bathroom. The Housekeeper mops daily, but the floor tiles are old and need to be replaced. The Housekeeper did not notice the issues on the ceiling or the toilet paper held on the string.
On 07/21/2021 at 11:22 AM, an interview was conducted with the Director of Nursing (DON) who stated they have not used the staff bathroom on the 4th or 5th floor. The DON stated the building has been around for a long time.
On 07/21/2021 at 11:41 AM, an interview was conducted with the Director of Housekeeping (DOHS) who stated they tour the units Monday to Friday. The DOHS has looked at the staff bathrooms on the 4th and 5th floors to check for supplies and cleanliness. The DOHS looks to see that the floor, sink, toilet, and walls are wiped down and clean.
415.29
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview conducted during the recertification survey, the facility did not mainta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview conducted during the recertification survey, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, a resident room was noted with numerous flies on several occasions. This was evident for 1 out of 12 units observed for Environmental Observations (Unit 4).
The finding is:
The surveyor requested the pest control policy and procedure, and none was provided.
On 07/15/2021 at 10:29 AM, One small fly noted flying in dining room on the 4th floor. On 07/20/2021 at 11:03 AM during staff interview a fly was noted flying around at the nurse's station of the 4th Floor.
On 07/19/2021 at 05:05 PM, room [ROOM NUMBER] P bathroom was observed with flies flying in the drain area, The bathroom trash can contained supplement and food waste. There were 9 flies on the bathroom wall.
On 07/20/2021 at 09:17 AM, room [ROOM NUMBER]P bathroom was observed again. The trash can empty. There were 12 flies on the wall and one fly flying around.
On 07/20/2021 at 11:26 AM and 3:57 PM, room [ROOM NUMBER]P bathroom was observed with 2 flies on the wall and 2 flies on the shower curtain rod.
The pest control reports were reviewed from 1/4/2021 to 7/14/2021. The pest control report dated 7/12/2021 documented that the facility was inspected and common areas on all floors were treated preventatively for roaches and mice. Treated rooms [ROOM NUMBERS] for roaches. There were no reports for any additional areas treated on the 4th floor.
On 07/20/2021 at 09:27 AM, the Certified Nursing Assistant (CNA #1) was interviewed and stated CNA #1 had not noticed as many flies. CNA #1 stated CNA #1 saw the exterminator one day last week. CNA #1 points out areas for the exterminator to treat ahead of time. CNA #1 noticed there were little flies on the wall of the bathroom in room [ROOM NUMBER], but CNA #1 did not notice any flies yesterday. CNA #1 stated if there are flies flying around, it indicates there is a mess somewhere that needs to be disinfected.
On 07/20/2021 at 09:46 AM, an interview was conducted with the Housekeeper/Porter who stated they cleaned room [ROOM NUMBER]P yesterday. The Housekeeper stated the resident in room [ROOM NUMBER]P puts a lot of food in the garbage, and the trash bag is changed in the morning. Sometimes there is food in the bottom trash can, and if needed, the trash can is rinsed out. The Housekeeper noticed flies in the room as a result of leaving food in the can. RN #1 noticed the flies and asked the Housekeeper to get rid of the trash. The Housekeeper sprays the wall with disinfectant to clean the area. Since the weather changed, fruit flies are prevalent. The Housekeeper stated they did don't know if the flies are entering through the window in room [ROOM NUMBER] or another window, but normally flies are not an issue.
On 07/20/2021 at 10:10 AM, the Licensed Practical Nurse (LPN #1) was interviewed and stated they have not noticed any flies on the unit. No one reported flies to LPN #1. LPN #1 stated they would report any flies to the manager/supervisor so they can call maintenance and pest control. LPN #1 stated LPN #1 checked room [ROOM NUMBER]P and the bathroom inside during rounds, and they did not see any flies in the room.
On 07/21/2021 at 10:05 AM, an interview was conducted with CNA #8 who stated that sometimes the unit does not have a housekeeper overnight and the garbage overflows. CNA #1 notices the garbage in the morning when they report to work.
On 07/21/2021 at 01:04 PM, an interview was conducted with the Registered Nurse (RN #1). RN #1 received no complaints of flies on the unit, and RN #1 did not notice any flies on the unit. Any complaints would be reported to the housekeeping department. RN #1 stated flies pose a health and safety issue, and flies should not be on the unit. RN #1 observed room [ROOM NUMBER]P and noted the flies an odor in the bathroom.
On 07/21/2021 at 11:22 AM, the Director of Nursing (DON)/Infection Preventionist (IP) was interviewed and stated no issues with vermin were reported to the DON/IP. Staff would inform the DON/IP if they saw any issues.
On 07/21/2021 at 11:41AM, an interview was conducted with the Director of Housekeeping (DOHS) who stated they tour the units Monday through Friday to ensure rooms and bathrooms are clean. Staff clean the tubs, showers, walls, vents, handrails, light fixtures, and mirrors. The DOHS went to the 4th and 5th floor on Monday . The DOHS was notified on 7/20/21 that there were flies in room [ROOM NUMBER]P after the surveyor identified the issue. The exterminator came staff wiped down the bathroom again.
415.(5) (h)(1),415.5 (h) (1)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for f...
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Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Specifically, metal trays of raw fresh chicken were observed placed on top of cardboard boxes in the refrigerator and sandwiches were not maintained at an appropriate temperature. This was evident during the Kitchen Observation Task.
The findings are:
The facility policy and procedure titled, Food Handling Temperature Guideline, reviewed October 2020 documented to maintain all potentially hazardous cold foods, i.e. meats, milk products, at 40 degrees F. or below to prevent spoilage and contamination.
On 07/15/21 at 09:55 AM, a metal pan of seasoned chicken covered with plastic wrap was observed stored in the refrigerator on top of other boxes of raw chicken.
On 07/20/2021 at 11:10AM, a metal tray with raw fresh chicken was observed placed on top of cardboard boxes in the refrigerator.
On 07/20/2021 at 12:43 PM, the Food Service Director removed a turkey sandwich from the refrigerator and tested the temperature. Thermometer registered the temperature of the sandwich at 60 degrees F. The temperature of a cheese sandwich was also checked and registered at 50 degrees F.
On 07/22/2021 at 12:16 PM, the Food Service Director removed a ham sandwich from the refrigerator and tested the temperature of the sandwich which registered at 59 degrees F. The temperature of an egg salad sandwich was also tested and registered at 50 degrees F. Sandwiches were observed being placed on resident trays after temperature was observed to be out of range.
On 07/22/2021 at 12:24 PM, an interview was conducted with the Dietary Aide (DA) who prepared the sandwiches. The DA stated that sandwiches for lunch are usually prepared around 10:30am and then are placed in the trayline refrigerator. The DA also stated they do not check the temperature of the refrigerator before placing the sandwiches in.
On 07/22/2021 at 12:47 PM, the Food Service Director (FSD) was interviewed. The FSD stated that after sandwiches are prepared, they are stored in the refrigerator for 2 hours prior to being served. The FSD also stated that sandwich temperatures are not checked as part of the tray line temperature checks. The temperature of sandwiches are checked by the supervisor and today were checked by the FSD around 11:30am and were at 40 degrees. The FSD further stated that the temperature of the sandwiches is not recorded anywhere. Sandwiches that are not within an acceptable range should be discarded and new sandwiches prepared. The FSD was asked why sandwiches had not been discarded and were being served and stated they forgot and would go remove them now. The FSD also stated that pans of meat should not be placed on boxes in the refrigerator as there was a risk of causing cross-contamination.
415.14(h)
May 2019
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure, during the Recertification Survey, that a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure, during the Recertification Survey, that a resident with impaired skin integrity receive the necessary care and treatment services to promote healing. Specifically, a pressure relieving device was not provided for a resident with right foot Osteomyelitis and cellulitis of the right lower extremity. This was evident for 1(one) of three (3) residents investigated for Pressure Ulcer Care. (Resident # 571).
The finding is:
Resident # 571 was admitted on [DATE] with diagnosis that included Osteomyelitis of Right Lower Extremity and Cellulitis of Right Lower Extremity.
On 05/26/19 at 10:30 AM, the resident was observed while bed and was awake and alert. The right lower leg/foot had a dressing that was visible from the top end of the sock. The right foot was resting on a thin pillow. The resident stated that she has a bone infection in her ankle and receives wound care treatment, including visits to the Infectious Disease doctor. She stated that she uses the pillow to rest her foot and to relieve pressure on her foot. She stated that the pillow is thin but it is better than nothing. When asked about pressure relieving devices, she stated that she has never had one since being a resident.
On 05/27/19 at 10:28 AM, the resident was observed resting her right foot on a thin pillow. A dressing on her right foot was observed.
On 05/29/19 at 9:24 AM, the resident was observed while in bed, and was awake and alert. The right foot was resting on a thin pillow. A dressing was observed to her right foot.
On 05/29/19 at 09:57 AM, the resident was observed with a right foot heel protector while in bed. The resident stated that her foot, feels so much better. I feel no pressure on my foot. The heel protectors make a big difference.
Review of Medical note dated 05/14/19 documented a history of Diabetes and Right foot ulcer due to Peripheral Arterial Disease (PAD). Further documentation included, exposed right Achilles tendon, and right lower extremity, open area to right mid lateral area and opening to inner and outer ankle.
Review of Wound Care Specialist note dated 05/15/19 documented a history of Osteomyelitis of Right ankle and foot. Treatment plan included, heel protector of Right heel.
A review of the Care Plan (CP) for pressure ulcer dated 05/19, documented treatment that included, heel protector to right foot.
Review of the Certified Nurse Assistant (CNA) accountability record for 05/2019 documented, heel protector to right foot.
On 05/29/19 at 09:49 AM, the assigned CNA was interviewed. The CNA stated that she should have known to place the heel protector on the resident because the resident already has a wound to her heel. She stated that the heel protectors help take pressure off of the heel and prevents further skin damage.
On 05/29/19 at 09:52 AM, the Unit Manager (UM) was interviewed. The UM stated that morning reports are held everyday and she further communicates with her staff on a daily basis when it comes to the needs of resident care and services.
415.12
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New York facilities.
- • 24% annual turnover. Excellent stability, 24 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • 17 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Pinnacle Multicare Nursing And Rehab Center's CMS Rating?
CMS assigns PINNACLE MULTICARE NURSING AND REHAB CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Pinnacle Multicare Nursing And Rehab Center Staffed?
CMS rates PINNACLE MULTICARE NURSING AND REHAB CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 24%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Pinnacle Multicare Nursing And Rehab Center?
State health inspectors documented 17 deficiencies at PINNACLE MULTICARE NURSING AND REHAB CENTER during 2019 to 2025. These included: 1 that caused actual resident harm and 16 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Pinnacle Multicare Nursing And Rehab Center?
PINNACLE MULTICARE NURSING AND REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BENJAMIN LANDA, a chain that manages multiple nursing homes. With 480 certified beds and approximately 463 residents (about 96% occupancy), it is a large facility located in BRONX, New York.
How Does Pinnacle Multicare Nursing And Rehab Center Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, PINNACLE MULTICARE NURSING AND REHAB CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Pinnacle Multicare Nursing And Rehab Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Pinnacle Multicare Nursing And Rehab Center Safe?
Based on CMS inspection data, PINNACLE MULTICARE NURSING AND REHAB CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Pinnacle Multicare Nursing And Rehab Center Stick Around?
Staff at PINNACLE MULTICARE NURSING AND REHAB CENTER tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 24%, meaning experienced RNs are available to handle complex medical needs.
Was Pinnacle Multicare Nursing And Rehab Center Ever Fined?
PINNACLE MULTICARE NURSING AND REHAB CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Pinnacle Multicare Nursing And Rehab Center on Any Federal Watch List?
PINNACLE MULTICARE NURSING AND REHAB CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.