SAPPHIRE CENTER FOR REHAB & NURSING
For profit - Partnership
227 Beds
SAPPHIRE CARE GROUP
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
7/100
#445 of 594 in NY
Photo by Sapphire Center for Rehabilitation and Nursing of Central Queens
Photo by Sapphire Center for Rehabilitation and Nursing of Central Queens
Photo by Hui Phing Grace Tan
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Sapphire Center for Rehab & Nursing has received a Trust Grade of F, indicating significant concerns about the care provided, which is among the lowest ratings possible. They rank #445 out of 594 facilities in New York, placing them in the bottom half of all nursing homes in the state, and #48 out of 57 in Queens County, meaning only a few local options are worse. The facility's trend shows improvement, as the number of reported issues decreased from 14 in 2024 to just 2 in 2025. Staffing is a relative strength with a 3 out of 5 rating and a turnover rate of 27%, which is better than the state average, while RN coverage is higher than 87% of New York facilities. However, the nursing home has concerning fines of $87,741, indicating compliance problems, and there have been critical incidents, including a staff member physically abusing a resident, leading to a serious injury, and failures to report abuse allegations promptly.
- Trust Score
- F
- In New York
- #445/594
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 27% annual turnover. Excellent stability, 21 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $87,741 in fines. Lower than most New York facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 51 minutes of Registered Nurse (RN) attention daily — more than average for New York. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
7/100
Bottom 26%
Review needed
14 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 2 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (27%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (27%)
21 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
Federal Fines: $87,741
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: SAPPHIRE CARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 28 deficiencies on record
3 life-threatening
May 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
Deficiency F0559
(Tag F0559)
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 during a recertification and complaint survey, NY00371941, the facility did ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification and complaint survey, NY00371941, the facility did not ensure the resident's/family's right to receive notice, including the reason for resident's room change before the resident's room in the facility was changed. This was evidence for 1 of the 1 resident reviewed of out 38 residents sampled. (Resident #212) Specifically, the facility changed Resident's room without providing the resident's family with advanced notification.
The findings are:
The policy titled Room transfers/ assignment of private rooms last revised 1/2025, documented that notification will be provided to residents and their family members/ authorized or legal representatives as soon as practicable prior to a change in room assignment and /or roommate. The policy also documented that the purpose is to establish guidelines and a standard of practice for the inclusion of residents, family members, authorized or legal representatives in team discussions as the mechanism for notifying the individual of a change of room assignment or roommate.
dated 2/12/25 Complaint received from the New York State Department of Health intake, documented that complainant reported room changes that took place that the family was not made aware of. Complainant observed behavioral changes in the resident following the room changes and requested that the resident returned to their previous room.
Resident #212 was admitted to the facility with diagnoses that include Multiple fractures, Aphasia, and Traumatic hemorrhage of left cerebrum
The admission Minimum Data Set, dated [DATE] documented that resident's cognition as severely impaired, BIMS as 99 needs moderate assistance for eating, dependent for bed mobility, chair transfer and no toilet use, and that resident and family participated in assessment and goal setting.
The Comprehensive Care Plan titled Cognitive loss, start date 12/26/24, manifested by moderately impaired decision making, decisions poor, cues/ supervision required. Goals include resident will show awareness of present situation and express needs, target date 7/4/25. Interventions include give simple directions using simple words and short sentences.
The Comprehensive Care Plan Titled Falls created 1/7/25 as related to impaired cognition with poor judgement, insight, unsteady gait, poor balance and unpredictable behavior. Goals include resident will have no incidents or sustain an injury x 90 days, target date 7/3/25. Interventions include place resident in highly visible area for close supervision.
A nurse's note dated 2/11/25 documented that resident was observed sitting on the floor mat at the left side of the bed at 6:05am. Body assessment done, no visible injury, no limitations in range of motion, no complaint of pain. Resident to be taken out of bed and placed in area with increased supervision near the nursing station. Next of kin notified of the resident's fall.
A nurse's note dated 2/11/25 documented resident transfer to the 3rd floor for better placement.
A Social worker's note dated 2/11/25 documented that resident was moved from 410A to 302B for more compatibility unit secondary to language barrier. Resident's daughter was called and made aware. Social worker will monitor for adjustment and any changes.
A nurse's note dated 2/11/25 documented post bed transfer from 302A to 410A, all medication and personal belongings endorsed to the 4th floor nurse.
On 05/05/25 at 10:29 AM, Certified Nursing Assistant #2 was interviewed and stated that Resident #212resident is usually on a 1:1 needs assistance with activities of daily living, total assist with showers, can say at times if they want to use the toilet. Resident #212 speaks Mandarin, although it may not be the same dialect, helps calm down the Resident, however Resident #212 doesn't always understand and sometimes just repeat one's sentence.
On 05/05/25 at 10:05 AM, Social Worker was interviewed and stated that the staff uses the language line when the family comes to visit, and that the family are kept up to date on the resident's care. They are working together to get the resident home and to get more home care hours.
05/05/25 03:07 PM, Social Worker was further interviewed and stated that when a resident has a room transfer, the family is called first, and they have a right to say yes or no. Social Worker also stated that both they and the 3rd floor Unit manager, where Resident #212 was being transferred to, called the resident's family since the unit manager speaks Mandarin. Social Worker stated that the family initially agreed, but then they came in and changed their mind, so the facility then transferred Resident#212 back to the 4th floor.
On 05/05/25 at 03:20 PM, Registered Nurse #1 was interviewed and stated that they work on the 3rd floor, and that they called the family prior to moving the resident and that the family agreed for the resident to come to the floor. Registered Nurse #1 said that when Resident#212's family came on the floor and saw the room, they did not like the room and asked for Resident#212's to go back to their prior room, so the staff transferred back the resident.
On 05/06/25 at 11:10 AM, the Social Worker Director was interviewed and stated that the facility's practice is to notify the resident/ the family that they will be transferred to another room. They would also inform the roommates that they will be getting another roommate. This would be the Social Workers who would make the call, and in cases where there is a communication barrier, the Nurse may help in notifying the family. If the resident/ family request to see room, then they would show them the room that the resident would be transferred to. The Social Worker Director also stated that if the resident is cognitively impaired and if the family is in the building, then the staff can show the family the room prior to moving. Normally, once the family is aware of the room transfer, then they would document it right away. As soon there is a decision for a room change, we would notify the family. The Social Worker Director also stated they don't recall the details of Resident #212.
On 05/06/25 at 12:38 PM, Registered Nurse #2 Supervisor for the 4th floor, was interviewed and stated that Resident #212 resided on the 4th, and that the Social Worker called the family before the transfer. Registered Nurse #2stated that they told the Social Worker to call the resident's family, but they were not there when the call was made and that the Social Worker probably call from their office. Registered Nurse #2 stated that they chose the 3rd floor because the Registered Nurse on that unit speaks the resident's language and there is 2 Certified Nursing Assistants that speak the resident's language. Registered Nurse #2 stated that the decision was made between them and the Social Worker to transfer the resident to the 3rd floor, because of the language.
On 05/06/25 at 02:27 PM, the Director of Nursing was interviewed and stated the staff is aware that they must notify the families of the room transfers prior to the residents' room changes. The Director of Nursing also stated it is not the intent of the staff, that the resident 's family was notified. It was the way that the Staff wrote the note, All Staff knows to call the family before the transfer is made.
10 NYCRR 415.5(e)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that infection control practices were maintained. This was evi...
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Based on observation and interview during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that infection control practices were maintained. This was evident for 2 (Resident #7 and Resident #158) residents during the Dining Task. Specifically, Certified Nursing Assistant #1 failed to clean their hands in between residents while assisting both residents with eating.
The findings are:
The facility's policy titled Hand Hygiene, effective 04/19, last reviewed 01/2025, documented that since hand washing has been identified as the single-most effective means of preventing and controlling the spread of infection, it is the policy of this facility that all staff carry out handwashing techniques in accordance with facility procedures. The policy also stated that this should be before, during, and after each direct care giving contact and the preparation and handling of foods.
During an observation of Dining conducted on the 4th floor on 04/29/2025 between 11:00AM and 12:00 PM, Certified Nursing Assistant #1 was observed assisting Resident #7 with feeding. Certified Nursing Assistant #1 then walked over to Resident #158, removed bread out of the plastic wrapping with their bare hands, handed it to Resident #158, and then returned Resident #7 and continued feeding them. At no time was Certified Nursing Assistant #1 observed performing hand hygiene between assisting Resident #7 and Resident #158.
On 04/29/2025 at 12:12 PM, Certified Nursing Assistant #1 was interviewed and stated that they were taught to wash their hands before feeding the residents and to wash their hand between feeding and assisting all residents. Certified Nursing Assistant #1 also stated that they did not do it because the situation was very stressful and that they did their best.
On 05/06/2025 at 12:47 PM, Registered Nurse #2 was interviewed and stated that the staff is always in-serviced and reminded that they are to sanitize and wash their hands between the residents. Registered Nurse #2 stated that they do not know why Certified Nursing Assistant #1 would give Resident #158 the bread as Registered Nurse #2 was just about to assist Resident #158 themselves.
On 05/06/2025 at 02:27 PM, the Director of Nursing was interviewed and stated that the staff were all in-serviced on hand hygiene, and this is ongoing. The Director of Nursing also stated the Supervisors, and the Charge nurses are responsible to ensure compliance.
10 NYCRR 415.19 (b)(4)
Dec 2024
1 deficiency
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
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on record review and interviews conducted during the abbreviated complaint investigation survey (NY00356207) from 12/27/2024 to 12/30/2024, the facility did not ensure it was administered in a m...
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Based on record review and interviews conducted during the abbreviated complaint investigation survey (NY00356207) from 12/27/2024 to 12/30/2024, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Application for Employment submitted by the Assistant Director of Nursing dated 05/18/23. Specifically, the facility did not ensure that background information was properly completed and verified prior hiring the staff.
The findings including, not limited to:
The Facility Application for Employment dated 05/18/2023 documented: Please provide complete and legible information. An incomplete application may affect your consideration for employment.
On May 18, 2023, the prospective Assistant Director of Nursing submitted an incomplete Application for Employment form that was verified by the Administration before the applicant was hired for the management position at the facility. The background information question about whether the applicant had ever been convicted of a crime was not answered. The applicant was hired as the Assistant Director of Nursing by the Administration on 05/23/2023, and later promoted to Director of Nursing without further clarification of the background information, and was responsible for the collection, documentation and disposal of unused residents' prescription medication.
Intake Number: NY00356207 dated 10/03/2024 documented the Director of Nursing has been accused with the theft of more than 1500 oxycodone pills meant for destruction between two nursing homes and has also been accused of falsifying records and leaving blank the question regarding prior criminal conviction on the application to both facilities, although they had two prior convictions.
Queens County District Attorney Office Release #103-2024 dated August 14, 2024, documented that the Director of Nursing was arraigned on drug charges following an investigation into their past employment as the nursing director at two nursing homes, accused of stealing more than 1,500 oxycodone pills, which were meant to be destroyed, from the facilities.
On 12/30/2024 at 10:30 am, the Administrator was interviewed and stated that they were not in the facility when the former Director of Nursing was hired. The Administrator stated that they believed the background investigation should have been carried out by the previous administration, and they should have ensured that the application form was properly completed before hiring. The names and contact numbers of the former Human Resources Personnel and former Administrator were provided.
On 12/30/24 at 12:28 PM, Former Human Resources Personnel was interviewed and stated they were not responsible for the hiring the Nursing staff including the Director of Nursing, they only check the background of the newly hired administrative staff and social services.
On 12/30/24 at 1:29 PM Message left for the former Administrator with no response. Follow up call was also made 12/31/2024 at 10:15 am to speak with the previous Administrator with no success.
10 NYCRR 415.26.
May 2024
13 deficiencies
3 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (NY00340290) survey fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (NY00340290) survey from 4/29/2024 to 5/9/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #77) of 3 residents reviewed for abuse out of 39 total sampled residents. Specifically, surveillance camera footage revealed on 4/23/2024 at 12:06 PM, Certified Nursing Assistant #1 struck Resident #77 causing the resident to fall backwards onto the floor. Certified Nursing Assistant #1 then grabbed Resident #77 by their wrists, lifted the resident off the floor, and pulled them to their room. Registered Nurse #1 and Certified Nursing Assistant #2 witnessed the incident and did not intervene. Subsequently, Resident #77 was diagnosed with a left wrist fracture because of the incident. This resulted in Substandard Quality of Care that was Immediate Jeopardy that resulted in serious injury for Resident #77 with the likelihood of a serious adverse outcome occurring to other residents on the unit.
The findings are:
The facility policy titled Abuse Prevention/Prohibition dated 11/2022 stated that all residents will be screened for potential abuse, an investigation will be conducted, the Administrator is responsible for completing the investigation report, any person having reasonable cause to believe that an older adult is in need of protective services may report such information to the local provider, and all interventions will be documented in the resident's medical record.
Resident #77 had diagnoses of dementia and osteoarthritis (degeneration of joint cartilage and underlying bone.)
The Minimum Data Set 3.0, a resident assessment instrument, dated 1/14/2024 documented Resident #77 was severely cognitively impaired, did not display inappropriate behavior, ambulated with supervision or touch assistance, and required assistance when using a wheelchair.
A Comprehensive Care Plan related to potential for abuse and neglect initiated 1/7/2024 and last reviewed 4/24/2024, documented Resident #77 was at risk for abuse due to their dementia diagnosis and one-to-one interaction would be provided until the resident was calm.
The facility's video surveillance dated 4/23/2024 at 12:05 PM revealed Resident #77 was in the hallway on their unit and attempted to walk into their room. Certified Nursing Assistant #1 exited the room and stood in between Resident #77 and the entrance to their room. Resident #77 slapped Certified Nursing Assistant #1. Certified Nursing Assistant #1 then struck Resident #77 causing the resident to fall backwards and land on the floor in a supine position (flat on their back). Certified Nursing Assistant #1 grabbed Resident #77's wrists, lifted the resident to their feet, and pulled the resident into their room. Registered Nurse #1 and Certified Nursing Assistant #2 were seated at the nursing station directly in front of Resident #77 and Certified Nursing Assistant #1 when the incident occurred. Registered Nurse #1 and Certified Nursing Assistant #2 did not intervene during the incident.
The facility's Accident/Incident Report on 4/23/2024 documented Resident #77 was pacing in the hallway on their unit, hit Certified Nursing Assistant #1, and then fell to the floor causing a left wrist fracture.
The Nursing Note written by Registered Nurse #1 was dated 4/23/2024 at 12:08 PM and documented Resident #77 became physically aggressive toward staff, slapped a Certified Nursing Assistant, fell to the floor, and reported left wrist pain. Resident #77's left wrist was swollen, the Medical Doctor was informed, and an x-ray was done. At 10:29 PM, a Registered Nurse on the evening shift documented Resident #77's next of kin requested the resident be sent to the hospital for evaluation and Resident #77 was transferred to the hospital.
A Nursing Note dated 4/24/2024 documented Resident #77 returned from the hospital with a cast to their left wrist due to left wrist fracture.
The Summary of Investigation completed by the Director of Nursing, dated 4/25/2024, documented video surveillance footage and staff statements were reviewed. Registered Nurse #1 failed to report Resident #77's incident accurately, falsified documentation, and misled the investigation. Abuse of Resident #77 did occur on 4/23/2024.
A review of facility inservice and training records from 1/2023 to 4/2024, revealed no documented evidence that Certified Nursing Assistant #1 received training on the abuse policy and procedures in 2023 or 2024. A review of staffing sheets dated 4/23/2024 and 4/24/2024, revealed that Certified Nursing Assistant #1 was still scheduled and continued to work on the unit with residents after the incident involving Resident #77.
On 4/29/2024 at 10:30 AM and 5/06/2024 at 10:28 AM, Certified Nursing Assistant #2 was interviewed and stated they were assigned to Resident #77 on 4/23/2024. They heard a loud noise while sitting at the nursing station and saw Certified Nursing Assistant #1 grab Resident #77 off the floor and bring the resident back to their room. Certified Nursing Assistant #2 stated they were confused about what they saw and did not know how to react. Registered Nurse #1 went to Resident #77's room to follow up after Certified Nursing Assistant #1 brought the resident there.
On 4/29/2024 at 10:52 AM, Registered Nurse #2 was interviewed and stated they were the supervisor for the building on 4/23/2024 at the time of the incident involving Resident #77 and Certified Nursing Assistant #1. Registered Nurse #1 reported to them that Resident #77 fell, and they both viewed the video at 1:40 PM on 4/23/2024. Registered Nurse #2 stated they could not determine what transpired from watching the surveillance footage and reported the incident to the Inservice Coordinator because Registered Nurse #2 was busy.
On 4/29/2024 at 12:01 PM, Registered Nurse #1 was interviewed and stated they were the charge nurse on Resident #77's unit on 4/23/2024. They were seated at the nurse's station, heard a loud slapping sound, and looked up to see Resident #77 lying on the floor. Registered Nurse #1 stated they were unable to determine what transpired in front of them, so they reviewed the surveillance footage. They stated Certified Nursing Assistant #1 provided their statement of occurrence to them and reported that Resident #77 fell after slapping Certified Nursing Assistant #1. Registered Nurse #1 stated after reviewing the surveillance footage, they believed Certified Nursing Assistant #1 provided assistance to assisted Resident #77 when lifting them off the floor and taking them to their room. Registered Nurse #1 informed the supervisor, Registered Nurse #2, of the fall incident so that another Registered Nurse could provide input into the events that transpired on surveillance footage.
On 4/29/2024 at 1:17 PM, an interview was conducted with the Medical Director who stated they were informed on 4/25/2024 of Resident #77's incident on 4/23/2024, saw the surveillance footage with the Administrator, and advised the Director of Nursing and the Administrator to report the incident to the New York State Department of Health.
On 4/29/2024 at 3:10 PM, the Administrator was interviewed and stated they were made aware of Resident #77's incident on 4/25/2024, reviewed the surveillance footage, and contacted the New York City Police Department to report Certified Nursing Assistant #1 was involved in an abuse incident. The Administrator was unable to provide an explanation for staff members' inability to identify and adequately address incidents of abuse. The Administrator stated the staff did receive inservices and education regarding abuse prior to the incident on 4/23/2024; however, the staff needed more in-service and training regarding abuse prevention and reporting.
On 5/09/2024 at 2:59 PM, the Director of Nursing was interviewed and stated they became aware of an incident involving Resident #77 on 4/24/2024.Registered Nurse #1 reported the resident hit Certified Nursing Assistant #1. The Director of Nursing saw the surveillance footage at 5:00 PM on 4/24/2024 and determined Certified Nursing Assistant #1 struck Resident #77 and picked the resident up off the floor by themselves. The Administrator was not in the facility at the time and the Director of Nursing informed the Administrator the next day on 4/25/2024. Certified Nursing Assistant #1 and Registered Nurse #1 were terminated as a result of the Director of Nursing's investigation. Registered Nurse #2 should have informed the Director of Nursing if they were unsure of the events that took place on the surveillance footage and was suspended for 1 day due to their failure to inform the Director of Nursing after reviewing surveillance footage related to Resident #77.
Multiple attempts were made to contact Certified Nursing Assistant #1, who was no longer employed at the facility. Certified Nursing Assistant #1 did not return calls for an interview.
On 4/29/2024 at 8:22 PM, Immediate Jeopardy was identified and declared. The facility's Administrator and the Director of Nursing were notified.
On 5/03/2024 at 2:00 PM, a removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility:
-Termination Letter documents Certified Nursing Assistant #1 was terminated dated 4/26/2024 and letter was sent to Certified Nursing Assistant #1 dated 5/1/2024.
-Termination letter documents dated 4/29/2024 for Registered Nurse #1 for failing to accurately report and document instance of abuse, not intervening on behalf of the resident and improperly completing the Accident and Incident Report related to abuse, mistreatment, and neglect.
-Resident #77's care plan was updated on 4/24/2024, and resident was seen by a psychiatrist on 5/02/2024, who documented resident does not appear to be suffering from emotional stress from the incident and will be followed up as necessary.
- The facility's investigation regarding abuse allegation was completed on 4/25/2024 by the Director of Nursing.
-The policy on Behavior and Dementia Care and Abuse prevention were reviewed 1/2022, 1/2023, 4/2024.
-The following documents were received and reviewed. Social worker care plan for abuse prevention was updated, Medical Doctor assessment and evaluation dated 4/24/2024; Registered Nurse assessment dated [DATE].
- Lesson plans on Abuse, neglect and mistreatment, Behavioral Health, Alzheimer's Disease and Dementia and Incident reporting, with attendance and sign-in sheets were reviewed and documented that 76% (182 of 239) of all staff in serviced, including Certified Nursing Assistants= 80%, Licensed Practical Nurses= 75%, Registered Nurses= 65%, Recreation = 81%, and Social Services= 100%.
-Multiple observations were conducted on Resident #77 from 4/24/2024 - 5/09/2024 and no concerns noted.
-Team observation on staff while performing resident care did not reveal any sign of abuse, neglect, or mistreatment.
Based on observation, interview and record review conducted on 5/03/2024, the facility fully implemented the Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 5/03/2024 at 2:00 PM.
10 NYCRR 415.4(b)(1)(i)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to 5/9/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 5 (Resident #77, Resident #32, Resident #111, Resident #79, and Resident #91) of 39 total sampled residents. Specifically, 1) an allegation of staff-to-resident abuse involving Certified Nursing Assistant #1 and Resident #77 occurred on 4/23/2024 and was not reported to the New York State Department of Health until 4/25/2024, 2) the facility did not report to the New York State Department of Health when Resident #32 was found on the floor and determined to have a left wrist fracture, 3) Resident #111 sustained swollen wrist which was an injury of unknown origin, was not reported New York State Department of Health within 2 hours of occurrence. 4) the facility did not report to the New York State Department of Health when Resident #79 was found on the floor with a laceration to the forehead that required an evaluation at the hospital, and 5) Resident #91 was hit in the arm by another resident and the facility did not report the allegation of resident-to-resident abuse to the New York State Department of Health.
This resulted in Substandard Quality of Care that was Immediate Jeopardy which resulted in serious injury for Resident #77 with the likelihood of a serious adverse outcome of occurring to other residents on the unit.
The findings include but are not limited to:
The facility policy titled Reporting Suspected Crimes under the Federal Elder Justice Act dated 10/2022 states that covered individuals must report suspicion of a crime to the New York State Department of Health and local law enforcement immediately, but not later than 2 hours after forming suspicion if the events involved serious bodily injury. If the reportable event does not result in serious bodily injury, the covered individual must report the suspicion not later than 24 hours after forming suspicion.
1) Resident #77 had diagnoses of dementia and osteoarthritis (degeneration of joint cartilage and underlying bone.)
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #77 was severely cognitively impaired, did not display inappropriate behavior, ambulated with supervision or touch assistance, and required assistance when using a wheelchair.
A Comprehensive Care Plan related to potential for abuse and neglect initiated 1/7/2024 and last reviewed 4/24/2024 documented Resident #77 was at risk for abuse due to their dementia diagnosis and one-to-one interaction would be provided until the resident was calm.
The facility's video surveillance dated 4/23/2024 at 12:05 PM revealed Resident #77 was in the hallway on their unit and attempted to walk into their room. Certified Nursing Assistant #1 exited the room and stood in between Resident #77 and the entrance to their room. Resident #77 slapped Certified Nursing Assistant #1. Certified Nursing Assistant #1 then struck Resident #77 causing the resident to fall backwards and land on the floor in a supine position (flat on their back). Certified Nursing Assistant #1 grabbed Resident #77's wrists, lifted the resident to their feet, and pulled the resident into their room. Registered Nurse #1 and Certified Nursing Assistant #2 were seated at the nursing station directly in front of Resident #77 and Certified Nursing Assistant #1 when the incident occurred. Registered Nurse #1 and Certified Nursing Assistant #2 did not intervene during the incident.
The facility's Accident/Incident Report initiated on 4/23/2024 documented Resident #77 was pacing in the hallway on their unit, hit Certified Nursing Assistant #1, and then fell to the floor causing a left wrist fracture.
The Nursing Note written by Registered Nurse #1 was dated 4/23/2024 at 12:08 PM and documented Resident #77 became physically aggressive toward staff, slapped a Certified Nursing Assistant, fell to the floor, and reported left wrist pain. Resident #77's left wrist was swollen, the Medical Doctor was informed, and an x-ray was done. At 10:29 PM, a Registered Nurse on the evening shift documented Resident #77's next of kin requested the resident be sent to the hospital for evaluation and Resident #77 was transferred to the hospital.
A Nursing Note dated 4/24/2024 documented Resident #77 returned from the hospital with a cast to their left wrist due to left wrist fracture.
The Summary of Investigation completed by the Director of Nursing, dated 4/25/2024, documented video surveillance footage and staff statements were reviewed. Registered Nurse #1 failed to report Resident #77's incident accurately, falsified documentation, and misled the investigation. Abuse of Resident #77 did occur on 4/23/2024.
There was no documented evidence the facility reported Resident #77's abuse incident to the New York State Department of Health within 2 hours of occurrence.
On 4/29/2024 at 10:52 AM, Registered Nurse #2 was interviewed and stated they were the supervisor of the building on 4/23/2024 when Resident #77 was involved in an abuse incident and sustained a fractured left wrist. Registered Nurse #2 stated they could not determine what transpired from watching the surveillance footage and reported the incident to the Inservice Coordinator because Registered Nurse #2 was busy. Registered Nurse #2 stated they thought the Inservice Coordinator would inform the Director of Nursing.
On 4/29/2024 at 12:01 PM, Registered Nurse #1 was interviewed and stated they were the charge nurse on the unit and was present and initiated the Accident/Incident investigation when Resident #77's incident occurred. Registered Nurse #1 stated they were unable to determine whether abuse occurred when they viewed the surveillance footage and informed the building supervisor, Registered Nurse #2, so they could view the surveillance footage.
On 4/29/2024 at 3:10 PM, the Administrator was interviewed and stated they were made aware of Resident #77's incident on 4/25/2024, reviewed the surveillance footage, and contacted the New York City Police Department to report Certified Nursing Assistant #1 was involved in an abuse incident. The Administrator was unable to provide an explanation for staff members' inability to identify and adequately address incidents of abuse. The Administrator stated the staff needed more in-service and training regarding abuse prevention and reporting.
On 5/09/2024 at 2:59 PM, the Director of Nursing was interviewed and said they initially were made aware of the incident on 4/24/2024 and they didn't rush to review the surveillance footage or report the incident because they didn't realize the incident was serious. The Director of Nursing reviewed the surveillance footage at 5:00 PM on 4/24/2024, observed the incident of abuse involving Resident #77, and informed the Administrator the next day, on 4/25/2024. The Director of Nursing stated they should have called the New York State Department of Health within the 2 hours of becoming aware of the alleged violation.
2) Resident #32 had diagnoses of dementia and generalized osteoarthritis.
The Minimum Data Set 3.0, a resident assessment instrument, dated 11/10/2023 documented Resident #32 had severely impaired cognition.
The facility Accident/Incident Report dated 12/4/2023 documented staff responded to Resident #32 calling for help and observed the resident sitting on the floor complaining of left wrist pain. The Medical Doctor was made aware, Resident #32 was hospitalized , and x-ray revealed Resident #32 had a closed fracture of their left wrist.
There was no documented evidence Resident #32's unwitnessed incident and left wrist fracture were reported to the New York State Department of Health.
On 5/08/2024 at 10:18 AM, Registered Nurse #8 was interviewed and stated the Registered Nurses were responsible for initiating investigations of incidents and submitting their completed reports to the Administrator and the Director of Nursing.
On 5/08/2024 at 11:02 AM, the Director of Nursing was interviewed and stated they were aware of Resident #32's left wrist fracture. The facility's Accident/Incident Report was completed in a timely manner, but the alleged violation was not reported to the New York State Department of Health.
On 5/09/2024 at 10:14 AM, the Administrator was interviewed and stated they were not aware that Resident #32's left wrist fracture was not reported to the New York State Department of Health. The Administrator stated the Director of Nursing had access to the reporting system and should have reported the incident within 2 hours of occurrence.
3) Resident #111 had diagnoses of seizure disorder and schizophrenia (a mental condition involving the breakdown in the relation between thought, emotion, and behavior).
The Minimum Data Set 3.0, a resident assessment instrument, dated 02/03/2024 documented Resident #111 had moderately impaired cognition.
The Nursing Note dated 4/05/2024 documented Resident #111 was evaluated by the Nurse Practitioner following a fall without injury.
The Nursing Note dated 4/14/2024 documented Resident #111 was observed with discoloration to their left knuckles of unknown origin. Resident #111 was unable to state how the discoloration occurred and an ice pack was applied to Resident #111's knuckles.
There was no documented evidence Resident #111's injury of unknown origin to their left knuckles was reported to the New York State Department of Health.
On 5/02/2024 at 10:02 AM, Registered Nurse #5 was interviewed and stated they have been covering as the supervisor for the building at times and was responsible for completing the Accident/Incident Reports for the Director of Nursing. Registered Nurse #5 stated there was no Accident/Incident Report or Investigations completed for Resident #111's fall on 4/05/2024 or for the injury to their left knuckles on 4/14/2024.
On 5/08/2024 at 12:16 PM, Registered Nurse #15 was interviewed and stated they were made aware of Resident #111's left knuckles discoloration and did not initiate an investigation or report the incident to the Director of Nursing or the New York State Department of Health. Registered Nurse #15 stated they only worked at the facility per diem on the day shift as a supervisor and there was no one available for them to consult with when they did not know how to address an incident or situation.
On 4/29/2024 at 8:22 PM, Immediate Jeopardy was identified and declared. The facility's Administrator and the Director of Nursing were notified.
On 5/03/2024 at 2:00 PM, a removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility:
-Termination Letter documents Certified Nursing Assistant #1 was terminated dated 4/26/2024 and letter was sent to Certified Nursing Assistant #1 dated 5/01/2024.
-Termination letter documents dated 4/29/2024 for Registered Nurse #1 for failing to accurately report and document instance of abuse, not intervening on behalf of the resident and improperly completing the Accident and Incident Report related to abuse, mistreatment, and neglect.
-Resident #77's care plan was updated on 4/24/2024, and resident was seen by a psychiatrist on 5/02/2024, who documented resident does not appear to be suffering from emotional stress from the incident and will be followed up as necessary.
- The facility's investigation regarding abuse allegation was completed on 4/25/2024 by the Director of Nursing.
-The policy on Behavior and Dementia Care and Abuse prevention were reviewed 1/2022, 1/2023, 4/2024.
-The following documents were received and reviewed. Social worker care plan for abuse prevention was updated, Medical Doctor assessment and evaluation dated 4/24/2024; Registered Nurse assessment dated [DATE].
- Lesson plans on Abuse, neglect and mistreatment, Behavioral Health, Alzheimer's Disease and Dementia and Incident reporting, with attendance and sign-in sheets were reviewed and documented that 76% (182 of 239) of all staff in serviced, including Certified Nursing Assistants= 80%, Licensed Practical Nurses= 75%, Registered Nurses= 65%, Recreation = 81%, and Social Services= 100%. -Multiple observations were conducted on Resident #77 from 4/24/2024 - 5/09/2024 and no concerns noted.
-Team observation on staff while performing resident care did not reveal any sign of abuse, neglect, or mistreatment.
Based on observation, interview and record review conducted on 5/03/2024, the facility fully implemented the Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 5/03/2024 at 2:00 PM.
10 NYCRR 415.4(b)(2)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00340290) Survey from 4/29/2024 to 5/9/2024, the facility failed to ensure that all alleged violations involving abuse, neglect, and mistreatment were thoroughly investigated, prevent further potential abuse while an investigation was in progress, and report the results of the investigation to the New York State Department of Health within 5 working days. This was evident for 2 (Resident #77 and Resident #111) of 39 total sampled residents. Specifically, 1) an allegation of staff-to-resident abuse involving Certified Nursing Assistant #1 and Resident #77 occurred on 4/23/2024 and the investigation results were not reported to the New York State Department of Health until 5/3/2024. Additionally, Certified Nurse Assistant #1 was not removed from direct care of residents on the unit until 4/25/2024. 2) Investigations were not conducted when Resident #111 fell on 4/05/2024 and sustained discoloration of unknown origin to their left knuckles on 4/14/2024.
This resulted in Substandard Quality of Care that was Immediate Jeopardy which resulted in serious injury for Resident #77 with the likelihood of a serious adverse outcome of occurring to other residents on the unit.
The findings are:
The facility policy titled Abuse Identification and assessment dated 11/2022 states the facility was required to report the final investigation report to the New York State Department of Health within 5 days of the incident.
1) Resident #77 had diagnoses of dementia and osteoarthritis (degeneration of joint cartilage and underlying bone.)
The Minimum Data Set 3.0, a resident assessment instrument, dated 1/14/2024 documented Resident #77 was severely cognitively impaired, did not display inappropriate behavior, ambulated with supervision or touch assistance, and required assistance when using a wheelchair.
A Comprehensive Care Plan related to potential for abuse and neglect initiated 1/07/2024 and last reviewed 4/24/2024 documented Resident #77 was at risk for abuse due to their dementia diagnosis and one-to-one interaction would be provided until the resident was calm.
The facility's video surveillance dated 4/23/2024 at 12:05 PM revealed Resident #77 was in the hallway on their unit and attempted to walk into a room. Certified Nursing Assistant #1 exited the room and stood in between Resident #77 and the entrance to their room. Resident #77 slapped Certified Nursing Assistant #1. Certified Nursing Assistant #1 then struck Resident #77 causing the resident to fall backwards and land on the floor in a supine position (flat on their back). Certified Nursing Assistant #1 grabbed Resident #77's wrists, lifted the resident to their feet, and pulled the resident into their room. Registered Nurse #1 and Certified Nursing Assistant #2 were seated at the nurse's station directly in front of Resident #77 and Certified Nursing Assistant #1 when the incident occurred. Registered Nurse #1 and Certified Nursing Assistant #2 did not intervene during the incident.
The facility's Accident/Incident Report initiated on 4/23/2024 documented Resident #77 was pacing in the hallway on their unit, hit Certified Nursing Assistant #1, and then fell to the floor causing a left wrist fracture.
The Nursing Note written by Registered Nurse #1 was dated 4/23/2024 at 12:08 PM and documented Resident #77 became physically aggressive toward staff, slapped a Certified Nursing Assistant, fell to the floor, and reported left wrist pain. Resident #77's left wrist was swollen, the Medical Doctor was informed, and an x-ray was done. At 10:29 PM, a Registered Nurse on the evening shift documented Resident #77's next of kin requested the resident be sent to the hospital for evaluation and Resident #77 was transferred to the hospital.
A Nursing Note dated 4/24/2024 documented Resident #77 returned from the hospital with a cast to their left wrist due to left wrist fracture.
The Summary of Investigation completed by the Director of Nursing, dated 4/25/2024, documented video surveillance footage and staff statements were reviewed. Registered Nurse #1 failed to report Resident #77's incident accurately, falsified documentation, and misled the investigation. Abuse of Resident #77 did occur on 4/23/2024.
Staffing Attendance Sheets dated 4/23/2024 to 4/25/2024 documented Certified Nursing Assistant #1 worked after the incident on 4/23/2024 at 12:00 PM - their entire shift of 4/23/2024 until 3:00 PM, the entire shift from 7:00 AM to 3:00 PM on 4/24/2024, and from 7:00 AM to 1:00 PM on 4/25/2024 - before being removed from patient care.
There was no documented evidence Certified Nursing Assistant #1 was removed from duty to prevent further potential abuse following the incident with Resident #77 on 4/23/2024.
There was no documented evidence the facility reported the results of the investigation to the New York State Department of Health into Resident #77's abuse incident until 5/03/2024, more than 5 working days after the investigation initiation.
On 5/09/2024 at 2:59 PM, the Director of Nursing was interviewed and stated they were made aware of Resident #77's abuse incident on 4/24/2024. The Director of Nursing did not realize the seriousness of the incident. They stated they should have reported the incident to the New York State Department of Health within 2 hours of occurrence and should have reported the completion of the investigation to the New York State Department of Health within a timely manner. The Director of Nursing further stated they were initially told the incident was a fall occurrence and upon further interview with Registered Nurse #1 on 4/24/2024, they were told that Certified Nursing Assistant #1 hit Resident #77. They completed their investigation on 4/24/2024 and reported the abuse incident to the Administrator on 4/25/2024. They suspended Certified Nursing Assistant #1 on 4/25/2024. 2) Resident #111 had diagnoses of seizure disorder and schizophrenia (a mental condition involving the breakdown in the relation between thought, emotion, and behavior).
The Minimum Data Set 3.0, a resident assessment instrument, dated 2/03/2024 documented Resident #111 had moderately impaired cognition.
The Nursing Note dated 4/05/2024 documented Resident #111 was evaluated by the Nurse Practitioner following a fall without injury.
The Nursing Note dated 4/14/2024 documented Resident #111 was observed with discoloration to their left knuckles of unknown origin. Resident #111 was unable to state how the discoloration occurred and an ice pack was applied to Resident #111's knuckles.
There was no documented evidence Resident #111's fall on 4/05/2024 or the injury of unknown origin to their left knuckles on 4/14/2024, were thoroughly investigated or communicated to the Medical Doctor.
On 5/02/2024 at 10:02 AM, Registered Nurse #5 was interviewed and stated they have been covering as the supervisor for the building at times and were responsible for completing the Accident/Incident Reports for the Director of Nursing. Registered Nurse #5 stated there was no Accident/Incident Report or Investigation completed for Resident #111's fall on 4/5/2024 or for the injury to their left knuckles on 4/14/2024.
On 5/08/2024 at 12:16 PM, Registered Nurse #15 was interviewed and stated they were made aware of Resident #111's left knuckles discoloration and did not initiate an investigation or report the incident to the Director of Nursing or the New York State Department of Health. Registered Nurse #15 stated they only worked at the facility per diem on the day shift as a supervisor and there was no one available for them to consult with when they did not know how to address an incident or situation.
On 4/29/2024 at 8:22 PM, Immediate Jeopardy was identified and declared. The facility's Administrator and the Director of Nursing were notified.
On 5/03/2024 at 2:00 PM, a removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility:
-Termination Letter documents Certified Nursing Assistant #1 was terminated dated 4/26/2024 and letter was sent to Certified Nursing Assistant #1 dated 5/01/2024.
-Termination letter documents dated 4/29/2024 for Registered Nurse #1 for failing to accurately report and document instance of abuse, not intervening on behalf of the resident and improperly completing the Accident and Incident Report related to abuse, mistreatment, and Neglect.
-Resident #77's care plan was updated on 4/24/2024, and resident was seen by a psychiatrist on 5/02/2024, who documented resident does not appear to be suffering from emotional stress from the incident and will be followed up as necessary.
- The facility's investigation regarding abuse allegation was completed on 4/25/2024 by the Director of Nursing.
-The policy on Behavior and Dementia Care and Abuse prevention were reviewed 1/2022, 1/2023, 4/2024.
-The following documents were received and reviewed. Social worker care plan for abuse prevention was updated, Medical Doctor assessment and evaluation dated 4/24/2024; Registered Nurse assessment dated [DATE].
- Lesson plans on Abuse, neglect and mistreatment, Behavioral Health, Alzheimer's Disease and Dementia and Incident reporting, with attendance and sign-in sheets were reviewed and documented that 76% (182 of 239) of all staff in serviced, including Certified Nursing Assistants= 80%, Licensed Practical Nurses= 75%, Registered Nurses= 65%, Recreation = 81%, and Social Services= 100%. -Multiple observations were conducted on Resident #77 from 4/24/2024 - 5/09/2024 and no concerns noted.
-Team observation on staff while performing resident care did not reveal any sign of abuse, neglect, or mistreatment.
Based on observation, interview and record review conducted on 5/03/2024, the facility fully implemented the Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 5/03/2024 at 2:00 PM.
10 NYCRR 415.4(b)(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 the Recertification Survey from 04/29/2024 to 05/09/2024, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/09/2024, the facility did not ensure each resident was treated with respect and dignity. This was evident for 4 (Resident #s 24, 125, 5, and 87) of 39 total sampled residents. Specifically, 1) Resident #24's Foley drainage bag was not placed in a dignity bag and was visible from the hallway, and 2) care was provided to Resident #125 without a privacy curtain and was visible to their 3 roommates, and 3) Resident #5's and #87's point of care testing was carried out in the unit day room without providing privacy for the residents.
The findings are:
The facility policy titled Providing Resident Dignity dated 04/08/2023 documented all residents will be provided with respect and dignity, ensuring the residents 's privacy is maintained at all encounters. Catheter bags are covered for privacy.
1) Resident #24 had diagnoses of benign prostatic hyperplasia and obstructive and reflux uropathy.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #34 was moderately cognitively impaired.
On 04/29/2024 at 10:03 AM and 05/01/2024 at 02:25 PM, Resident #24 was observed in bed in their room with their Foley catheter drainage bag uncovered and hanging at their bedside. Resident #24 was visible to passersby in the hallway.
The Physician Order dated 4/11/2024 documented Resident #24 be provided with a Foley catheter drainage bag cover every shift for privacy.
On 05/08/2024 at 10:05 AM, Certified Nursing Assistant #25 was interviewed and stated they asked the supply person for a Foley drainage bag cover for Resident #24 last week and was told a cover was not available. Certified Nursing Assistant #25 did not make any further attempts to obtain a cover for the drainage bag.
On 05/09/2024 at 11:10 AM, Licensed Practical Nurse #1 was interviewed and stated they were not aware Resident #24 did not have a cover for their Foley catheter drainage bag.
On 05/09/2024 at 01:55 PM, Registered Nurse #11 was interviewed and stated they were just made aware that Resident #24 did not have a cover for their Foley catheter drainage bag. Registered Nurse #11 stated they went to the supply closet and was able to obtain a cover. Foley catheter drainage bags were kept covered to preserve a resident's dignity and privacy.
On 05/10/2024 at 01:58 PM, the Director of Nursing was interviewed and stated Registered Nurse Supervisors were responsible for checking all Foley catheter drainage bags to ensure they were covered.
3) On 05/01/24 at 08:40 AM, during the medication administration observation, Registered Nurse #5 was observed administering Insulin to Resident #87 in the first-floor dining room. Another resident was sitting next to Resident #87 at the time. Registered Nurse #5 did not provide privacy for Resident #87 prior to administering the insulin.
On 05/01/2024 at 11:39 AM, Registered Nurse #5 was observed checking Resident #5's blood glucose using a finger stick in the unit dining room with other residents and staff waiting for lunch.
On 05/01/2024 at 11:46 AM, Registered Nurse #5 was interviewed and stated they always check residents' blood glucose and administer their insulin in the dining room before meals.
On 05/08/2024 at 12:45 PM, the Director of Nursing was interviewed and stated that checking a resident's blood glucose should not be done in the dining room, except when there is an emergency.
10 NYCRR 415.3(d)(1)(i)
2. ) Resident #125 had diagnoses of diabetes mellitus and hypertension.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #125 was moderately cognitively impaired and required assistance with activities of daily living.
On 04/29/2024 at 10;33 AM, Resident #125 was observed in bed receiving a bed bath from Certified Nursing Assistant #24. The room door was closed and the privacy curtain for Resident #125 was not drawn. Resident #125's 3 roommates were observed in the room and Resident #125 was visible to all 3 roommates while they received care. Certified Nursing Assistant #24 was immediately interviewed and stated they should have drawn the privacy curtain while providing care to Resident #125.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey from 4/29/2024 to 5/9/2024, the facility di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey from 4/29/2024 to 5/9/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand. This was evident for 3 (Resident #159, #191, and #195) out of 39 total sampled residents. Specifically, 1) Resident #159 was Korean-speaking and was not provided with language interpretation services, 2) Resident #191 was Cantonese-speaking and was not provided with language interpretation services, and 3) Resident #195 was Mandarin-speaking and was not provided with language interpretation services.
The findings are:
The facility policy titled Communication with Persons with Limited English Proficiency dated 8/22/2017 documented the facility would take reasonable steps to ensure that persons with Limited English Proficiency have meaningful access and equal opportunity to participate in services, activities, programs, and other benefits.
1. Resident #159 had diagnoses of Alzheimer's disease and hypertension.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #159 was severely cognitively impaired, preferred to communicate in the Korean language, and required an interpreter to communicate with the Medical Doctor and staff.
On 5/09/2024 at 11:05 AM, Resident #159 was interviewed in Korean using interpretation services. Resident #159 stated they enjoyed attending group activities but were unaware when activities were offered because the staff did not speak to them in a language they understood. Resident #159 stated staff attempted to use body language to communicate with them but did not use a communication board and there were no Korean-speaking staff on their unit. There was no communication board or interpretation devices observed Resident #159's room at the time of the interview.
The Comprehensive Care Plan related to health literacy dated 11/9/2023 documented Resident #159 had a language barrier and required an interpreter.
The Comprehensive Care Plan related to communication dated 11/9/2023 documented Resident #159 had a diagnosis of dementia and required a translator to reduce their language barrier.
There was no documented evidence a communication board or interpretation services were used to communicate with Resident #159 in their preferred Korean language.
On 5/06/2024 at 10:33 AM, Certified Nursing Assistant #7 was interviewed and stated Resident #159 spoke Korean and had limited understanding of English communication. Certified Nursing Assistant #7 stated they were not aware of any communication board or interpretation services available to help better communicate with Resident #159 or any other non-English speaking residents.
2. Resident #191 had diagnoses of hypertension and hyperlipidemia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #191 was severely cognitively impaired, preferred to communicate in Cantonese, and required an interpreter.
On 5/09/2024 at 9:24 AM, Resident #191 was interviewed in Cantonese using interpreter services. Resident #191 stated they were not aware of what activities were offered because staff did not communicate with them using an interpreter or communication board. During the interview, there was no communication board or other interpretation services observed in Resident #191's room.
The Comprehensive Care Plan related to communication dated 1/29/2024 documented Resident #191 had a language barrier and required a translator to communicate effectively.
The Therapeutic Recreation assessment dated [DATE] documented Resident #191 required a Cantonese interpreter for translation and enjoyed watching Cantonese television programming.
There was no documented evidence Cantonese translation services were provided to effectively communicate with Resident #191.
On 5/06/2024 at 10:24 AM Certified Nursing Assistant #8 was interviewed and stated they were hired approximately 8 months ago and started working with Resident #191 a few weeks ago. Resident #191 spoke Chinese and Certified Nursing Assistant #8 attempted to communicate with Resident #191 using simple words. Certified Nursing Assistant #8 stated they were unaware of any available interpreter or communication board to provide translation services to Resident #191.
On 5/07/2024 at 11:02 AM, Recreation Leader #1 was interviewed and stated they invited all residents to activity programs occurring on the main floor of the facility. Recreation Leader #1 stated Resident #191 spoke Cantonese and they attempted to communicate with the resident using body language and gestures.
3) Resident #195 had diagnoses of hypertension and thyroid disorder.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #195 had mild cognitive impairment.
On 05/02/2024 at 11:44 AM, Resident #195 was interviewed using Mandarin interpretation services. Resident #195 stated they were unable to communicate with staff without an interpreter and there was no communication board to make their simple needs known. During the interview, there were no observations of a communication board or language interpreter services available in Resident #195's room.
The Comprehensive Care Plan related to communication dated 02/08/2024 documented Resident #195 had a language barrier, and a translator should be used to reduce the language barrier and communicate with the residents.
There was no documented evidence effective translation services were utilized to communicate with Resident #195 in their Mandarin language on a regular basis.
On 05/02/2024 at 11:00AM, Certified Nursing Assistant #5 was interviewed and stated they do not know how to communicate with Resident #195 in Mandarin and did not have an interpreter.
On 05/07/2024 at 12:33 PM, Certified Nursing Assistant #6 was interviewed and stated Resident #195 spoke Mandarin and did not understand any English. Certified Nursing Assistant #6 stated they try to point and gesture to communicate with Resident #195. There was no language line interpretation services or communication boards available to communicate with Resident #195.
On 05/07/2024 at 2:45 PM, Certified Nursing Assistant #4 was interviewed and stated they were regularly assigned to Resident #195 and used gestures to communicate with the resident because the resident only spoke Mandarin. The facility did not have any Mandarin-speaking staff to communicate with Resident #195. The facility did not have a communication board that Certified Nursing Assistant #4 knew of and there were no language interpretation line services available.
On 05/03/2024 at 10:45 AM, Registered Nurse #14 was interviewed and stated they were currently the supervisor for the building and would find out about a language line to provide interpretation services for residents. After looking for information for a language line, Registered Nurse #14 provided a phone number and personal identification number for a language interpretation service. Registered Nurse #14 attempted to call the language line service and was unable to complete the call as the personal identification number was no longer active. Registered Nurse #14 was unable to provide information on the last time the service was used to communicate with residents that did not speak English.
On 05/03/2024 at 3:00PM, the Administrator was interviewed and stated they just paid the bill for language line service and was provided with a new personal identification number. The Administrator stated they would ensure the new information was posted on all the units.
10 NYCRR 415.3(f)(1)(i)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
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 the Recertification Survey from 04/29/2024 to 05/09/2024, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/09/2024, the facility did not ensure ea resident's right to privacy. This was evident for 4 (Resident #s 24, 125, 5, 87)) of 39 total sampled residents. Specifically, 1) Resident #24's foley drainage bag was not placed in a dignity bag and was visible from the hallway, 2) care was provided to Resident #125 without a privacy curtain and the resident was visible to their 3 roommates, and 3) Resident #5's and #87's point of care testing was carried out in the unit day room without providing privacy for the residents.
The findings are:
The facility policy titled Providing Resident Dignity dated 04/08/2023 documented all residents will be provided with respect and dignity, ensuring the residents 's privacy is maintained at all encounters. Catheter bags are covered for privacy.
1) Resident #24 had diagnoses of benign prostatic hyperplasia and obstructive and reflux uropathy.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #34 was moderately cognitively impaired.
On 04/29/2024 at 10:03 AM and 05/01/2024 at 02:25 PM, Resident #24 was observed in bed in their room with their foley catheter drainage bag uncovered and hanging at their bedside. Resident #24 was visible to passersby in the hallway.
The Physician Order dated 4/11/2024 documented Resident #24 be provided with a foley catheter drainage bag cover every shift for privacy.
On 05/08/2024 at 10:05 AM, Certified Nursing Assistant #25 was interviewed and stated they asked the supply person for a foley drainage bag cover for Resident #24 last week and was told a cover was not available. Certified Nursing Assistant #25 did not make any further attempts to obtain a cover for the drainage bag.
On 05/09/2024 at 11:10 AM, Licensed Practical Nurse #1 was interviewed and stated they were not aware Resident #24 did not have a cover for their foley catheter drainage bag.
On 05/09/2024 at 01:55 PM, Registered Nurse #11 was interviewed and stated they were just made aware that Resident #24 did not have a cover for their foley catheter drainage bag. Registered Nurse #11 stated they went to the supply closet and was able to obtain a cover. Foley catheter drainage bags were kept covered to preserve a resident's dignity and privacy.
On 05/10/2024 at 01:58 PM, the Director of Nursing was interviewed and stated Registered Nurse Supervisors were responsible for checking all foley catheter drainage bags to ensure they were covered.
3) On 05/01/24 at 08:40 AM, during the medication administration observation, Registered Nurse #5 was observed administering Insulin to Resident #87 in the first-floor dining room. Another resident was sitting next to Resident #87 at the time. Registered Nurse #5 did not provide privacy for Resident #87 prior to administering the insulin.
On 05/01/2024 at 11:39 AM, Registered Nurse #5 was observed checking Resident #5's blood glucose using a finger stick in the unit dining room with other residents and staff waiting for lunch.
On 05/01/2024 at 11:46 AM, Registered Nurse #5 was interviewed and stated they always check residents' blood glucose and administer their insulin in the dining room before meals.
On 05/08/2024 at 12:45 PM, the Director of Nursing was interviewed and stated that checking a resident's blood glucose should not be done in the dining room, except when there is an emergency.
10 NYCRR 415.3(e)(1)(ii)
2. ) Resident #125 had diagnoses of diabetes mellitus and hypertension.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #125 was moderately cognitively impaired and required assistance with activities of daily living.
On 04/29/2024 at 10;33 AM, Resident #125 was observed in bed receiving a bed bath from Certified Nursing Assistant #24. The room door was closed and the privacy curtain for Resident #125 was not drawn. Resident #125's 3 roommates were observed in the room and Resident #125 was visible to all 3 roommates while they received care. Certified Nursing Assistant #24 was immediately interviewed and stated they should have drawn the privacy curtain while providing care to Resident #125.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #91 had diagnoses of bipolar disorder and non-Alzheimer's dementia.
The Minimum Data Set 3.0 assessment dated [DATE]...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #91 had diagnoses of bipolar disorder and non-Alzheimer's dementia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #91 was severely cognitively impaired and did not display behavior symptoms.
The Comprehensive Care Plan related to behavior initiated 07/27/20 and last reviewed 1/12/2024 documented Resident #91 displayed verbally and physically abusive behavior and was disruptive.
The Comprehensive Care Plan related to titled abuse potential initiated 5/13/2022 and last reviewed 1/12/2024 documented Resident #91 was at risk for abuse and for abusing others due to their inappropriate behavior.
The Nursing Note dated 4/14/2024 documented Resident #91 suddenly punched another resident's arm in the unit hallway. Both residents were immediately separated.
On 05/08/2024 at 12:35 PM, an interview was conducted with the Director of Nursing who stated each unit was supposed to have a Registered Nurse supervisor responsible for reviewing and revising resident care plans. Three units did not have regular supervisors, and this contributed to the lack of review and revision of resident care plans.
On 05/09/2024 at 12:31 PM, the Administrator was interviewed and stated they were not aware that nursing staff were not updating or reviewing care plans. The Administrator stated the nursing staff required more supervision and received inadequate training resulting in care plans not being updated.
10 NYCRR 415.11(c)(2)(i-iii)
Based on record review and interviews conducted during the Recertification survey from 04/29/2024 to 05/09/2024, the facility did not ensure resident comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment. This was evident for 6 (Resident #s 116, 197, 91, 125, 462, and 195) of 39 total sampled residents. Specifically, 1) the care plan related to fall risk was not revised to reflect new interventions following Resident #116's fall, 2) Resident #197's CCP related to tracheostomy care was not revised to reflect the resident's tracheostomy removal, 3) the care plans related to behavior and abuse potential for Resident #91 were not revised following a resident-to-resident altercation, 4) the care plan related to Resident #125's activities of daily living was not reviewed or revised, 5) the care plan related to recreational activities for Resident #462 was not reviewed or revised, and 6) the care plan related to communication for Resident #195 was not reviewed and revised.
The findings include but are not limited to:
The facility policy titled Comprehensive Care Planning dated 1/2024 documented the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, the desired outcome is not met, the resident has been readmitted to the facility from a hospital stay, and at least quarterly.
1. Resident #116 had diagnoses of schizophrenia and bipolar disorder.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #116 had moderate cognitive impairment and required assistance from staff to perform activities of daily living.
The Comprehensive Care Plan related to falls created 4/27/2023 and last updated 2/11/2024 documented interventions to prevent Resident #116 from falling included keeping their bed at the lowest position, ensuring call lights were accessible, and keeping pathways unobstructed.
The Nursing Note dated 4/30/2024 documented Resident #116 was found sitting on the floor with an abrasion to their forehead.
The Accident/Incident Investigation dated 5/1/2024 documented the Resident #116 would be toileted every 2-4 hours to prevent falls caused by the resident attempting to go to the bathroom without assistance.
There was no documented evidence Resident #115's care plan related to falls was reviewed and revised following their fall on 4/30/2024.
On 05/09/2024 at 12:53 PM, Registered Nurse #8, a supervisor, was interviewed stated the supervisors were responsible for reviewing and revising resident care plans when the resident had a change in condition or a fall. Registered Nurse #8 did not have an explanation for the lack of revision to Resident #116's care plan related to falls following the resident's fall on 4/30/2024.
2. Resident #197 had diagnoses of respiratory failure and rib fractures.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #197 was cognitively intact and received oxygen therapy, suctioning, and tracheostomy care.
The Comprehensive Care Plan related to tracheostomy care dated 2/13/2024 documented Resident #197 had a tracheostomy tube for breathing and required suctioning every shift and as needed.
The Nursing Note dated 2/26/2024 documented Resident #197 had their tracheostomy tube removed and was decannulated as planned.
There was no documented evidence the care plan related to tracheostomy care was reviewed and revised to reflect removal of the Resident #197's tracheostomy tube.
On 05/06/2024 at 10:47 AM, Registered Nurse #6 was interviewed and stated Resident #197 had their tracheostomy tube removed on 2/26/2024 and the resident's care plan should have been revised to reflect the change in condition. Registered Nurse #6 was not aware that Resident #197's care plan was not revised and stated the supervisor should have updated it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 the recertification survey from 4/29/2024 to 5/9/2024, the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey from 4/29/2024 to 5/9/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the residents. This was evident for 4 (Resident #191, #260, #107 and #462) of 39 total sampled residents. Specifically, 1) Resident #191 was not engaged in an ongoing activity program in accordance with their preferences, 2) Resident #260 was observed for extended periods of time without meaningful activities, 3) there were multiple observations of Resident #107 not being engaged in meaningful activities, and 4) Resident #462 was not observed engaged in a meaningful activities program.
The findings include but are not limited to:
The facility policy titled Recreation dated 1/2/2024 documented the interdisciplinary team will evaluate personal history and preferences and consider medical condition and prognosis in identifying relevant recreational and cultural activities.
1. Resident #191 had diagnoses of hypertension and hyperlipidemia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #191 was severely cognitively impaired, preferred to communicate in Cantonese, and required an interpreter. Activity preferences included listening to music, doing favorite activities, participating in religious services, keeping up with news, doing things with groups, and interacting with animals/pets.
On 4/30/2024 from 10:04 AM to 11:05 AM, Resident #191 was observed sitting in their wheelchair across from the nursing station with 7 other residents in the unit hallway. There was no interaction or activity happening on the unit. The April 2024 Central Activity Calendar posted on the unit bulletin documented 4/30/2024 Morning Program: Flower Painting at 10:00 AM.
On 5/01/2024 from 9:00 AM to 10:20 AM, Resident #191 was observed sitting in their wheelchair across from the nursing station with 8 other residents in the unit hallway. There were no ongoing activities or interaction with residents on the unit. The May 2024 Central Activity Calendar posted on the unit bulletin documented 5/1/2024 Morning Program: Sitcom Hour at 10:00 AM.
On 5/06/2024 from 9:12 AM to 11:36 AM, Resident #191 was observed sitting in their wheelchair across from the nursing station. There were no ongoing unit activities and no Recreation Leader observed on the unit. The May 2024 Central Activity Calendar posted on the unit bulletin documented 5/6/2024 Korean Service and Coloring Hour at 10:00 AM.
On 5/09/2024 at 9:24 AM, Resident #191 was interviewed and stated via interpreter that they primarily speak Cantonese Resident #191 did not know what recreational activities the facility provided because they were not invited to activities, and they could not understand the activity calendar in their room because it was in English.
The Comprehensive Care Plan related to adjustment dated 1/30/2024 documented Resident #191's goals included participating in programs of choice on and off the unit.
The Therapeutic Recreation assessment dated [DATE] documented Resident #191 enjoyed watching television, reading the newspaper, and music therapy.
The Activity Attendance Log from 2/1/2024 to 4/30/2024 documented Resident #191 participated in 5 activity programs in 90 days: one-to-one visit on 3/2/2024 and 3/30/2024; variety group on 4/12/2024; and bingo on 4/13/2024 and 4/20/2024.
There was no documented evidence Resident #191 was offered or engaged in an ongoing activity program to meet their interests and needs.
On 5/06/2024 at 10:24 AM, Certified Nursing Assistant #8 was interviewed and stated Recreation staff did not engage Resident #191 in any activities on the unit. Resident #191 mostly sat at the nursing station without staff interaction.
2. Resident #260 had diagnoses of intellectual disabilities and Bell's Palsy.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #260 had severely impaired cognition and their activity preferences included listening to music, having animals/pets, doing things people, doing their favorite activities, and participating in religious activities.
On 4/29/2024 from 10:15 AM to 11:05 AM, Resident #260 was observed self-propelling their wheelchair aimlessly in the hallway and then sitting at the nursing station. There was no interaction or ongoing activity program occurring on the unit.
On 4/30/2024 from 10:00 AM to 11:11 AM, Resident #260 was observed sitting in their wheelchair by the nursing station with several other residents. Resident #260 had a verbal outburst and threw a doll they were holding onto the floor. Staff did not interact with Resident #260 and there were no ongoing activity programs on the unit. The April 2024 Central Activity Calendar posted on the unit bulletin documented 4/30/2024 Morning Program: Flower Painting at 10:00 AM.
On 5/01/2024 from 9:22 AM to 11:12 AM, Resident #260 was observed sitting in the hallway by the nursing station without any interaction from staff and no activity program happening on the unit. The May 2024 Central Activity Calendar posted on the unit bulletin documented 5/1/2024 Morning Program: Sitcom Hour at 10:00 AM.
The Comprehensive Care Plan related to adjustment dated 12/1/2023 documented Resident #260 would participate in on and off unit programs of their choosing 1 to 2 times a week.
The Therapeutic Recreation assessment dated [DATE] documented Resident #260 enjoyed music therapy, animal therapy, mind and sensory stimulating program, and watching television/movies. The recreation plan included staff visiting with Resident #260 to offer independent materials, socialize, invite, and escort to activities of interest.
The Activity Attendance Log from 4/1/2024 to 4/30/2024 documented Resident #260 participated in 4 activities out of 30 days: variety group activity on 4/12/2024; bingo on 4/13/2024 and 4/20/2024; movie night/snack on 4/14/2024.
There was no documented evidence Resident #260 was engaged in an ongoing meaningful activity program in accordance with their needs and preferences.
On 5/07/2024 at 11:02 AM, Recreation Leader #1 was interviewed and stated they invite all residents to activities daily and assist in escorting them to the main floor from 9:30 AM to 10 AM. A monthly activity calendar was provided to residents and posted on the unit bulletin board. Resident #191 participated in group activities and received the Chinese newspaper when available. Resident #191 did not refuse to go to activity programs when invited. Recreation Leader #1 stated Resident #260 enjoyed music therapy, dancing, and group activities. Resident #260 received visits from Recreation Leader #1 for 5 minutes to engage the resident in conversation if staff reported the resident was agitated.
On 5/07/2024 at 10:18 AM, the Assistant Director of Recreation was interviewed and stated activity programs occurred on the main floor daily. Recreation Leaders provided activity programs on the units to residents who refused to go to the main floor activities. The Assistant Director of Recreation stated they were not aware that the on-unit activities displayed on the monthly calendar did not occur as scheduled on the 4th floor.
3.) Resident #107 had diagnoses of anemia and dementia.
The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #107 was severely cognitively impaired.
On 05/02/2024 at 11:43 AM, 05/06/2024 at 8:58 AM and from 2:00 PM to 4:30 PM, and 05/03/2024 at 9:45AM and from 2:00 PM to 4:30 PM, Resident #107 was observed in their room or at the nursing station on the unit alert and responsive. Resident #107's television was off and there was no music playing. Recreation Leader #2 was observed on the unit interacting with and transporting residents to the main floor for recreational activities. There was no staff interaction with Resident #107, Recreation Leader #2 did not engage with Resident #107, and Resident #107 did not participate in any activities.
The Comprehensive Care Plan related to activities initiated 11/6/2020 documented Resident #107 received 1-to-1 visits and enjoyed listening to music.
The Activity Attendance Log from 4/1/2024 to 4/30/2024 documented Resident #107 received 1-to-1 interaction. The Log did not document the time, duration, and content of the interaction. There was no documented evidence Resident #107 was provided with music or invited to attend music programs.
There was no documented evidence Resident #107 was engaged in an ongoing meaningful activities program based on their needs and preferences.
On 05/08/2024 at 12:00PM, the Activity Director was interviewed and stated Recreation Leaders were tasked with engaging with residents during activity programs held on the main floor instead of interacting with residents on the unit. The calendar of on-unit activities did not include any afternoon programs because the Recreation Leaders were needed on the main floor.
10 NYCRR 415.5(f)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and staff interviews conducted during the Recertification and Extended Survey on 04/29/2024 to 05/09/2024, the facility did not ensure that infection control prevention practices ...
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Based on observation and staff interviews conducted during the Recertification and Extended Survey on 04/29/2024 to 05/09/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident for 3 of 6 units observed during the Medication Administration task. Specifically, licensed nurses were observed not practicing hand hygiene, not sanitizing medical equipment in between residents' use, and failed to practice Enhanced Barrier Precaution.
The findings are:
The facility policy titled Cleaning and Disinfection of Resident Care Items and Equipment with a last reviewed date of 01/2023 documented resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to Center for Disease Control and Prevention recommendations for disinfection and the Occupational Safety and Health Administration standard. Reusable items are cleaned and disinfected or sterilized between residents.
The facility policy titled Hand Hygiene dated 05/2022 documented all personnel working in the facility are required to perform hand hygiene with soap and water or use an alcohol based hand rub before and after resident contact and before and after performing any procedure. The policy documented that wearing gloves is not a substitute for hand hygiene and to always clean the hands after removing gloves.
The facility policy titled Enhanced Barrier Precautions with an effective date of 04/2024 documented that Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms to residents. Enhanced Barrier Precautions employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for Enhanced Barrier Precautions include device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).
On 04/30/2024 at 09:47 AM, during medication administration observation on the 4th floor, Registered Nurse #2 was observed administering medication and treatment to Resident #105. Registered Nurse #2 did not perform hand hygiene prior to and after administering the medication. Registered Nurse #2 was observed putting on gloves without sanitizing their hands, then applied treatment cream to Resident #105. During interview, Registered Nurse #2 stated today was their first time on the unit, they were nervous, and forgot to sanitize their hands.
On 05/01/2024 at 08:49 AM, Registered Nurse #4 was observed administering medications on the 2nd floor. Registered Nurse #4 administered medications via tube feeding to Resident #130 without wearing a gown. Registered Nurse #4 was further observed checking Resident #130's blood pressure without sanitizing the blood pressure cuff. At 09:29 AM, Registered Nurse #4 went to Resident #150 and used the same blood pressure machine without sanitizing the cuff.
On 05/01/2024 at 09:30 AM, Registered Nurse #4 was interviewed and stated that the blood pressure cuff should be sanitized before using and in-between every resident. They stated they have disinfecting wipe at the nursing station and that it slipped out of their memory to sanitize the blood pressure machine during use. Registered Nurse #4 further stated they were given training on enhanced barrier precautions, but they did not know they have to practice it on residents with tube feeding.
On 05/01/2024 at 11:36 AM, during the medication administration observation on the 1st floor, Registered Nurse #5 was observed performing blood glucose (simple sugar that your body uses for energy) check for Resident #87. The glucometer (a medical device for determining the approximate concentration of glucose in the blood) dropped on the floor after checking Resident #87's blood glucose. Registered Nurse #5 picked up the glucometer from the floor, placed it on a tray without sanitizing it, and went to the dining room to check Resident #5's finger stick at 11:39 AM. Registered Nurse #5 changed their gloves without performing hand hygiene prior, and did not sanitize the glucometer prior to using it on Resident #5. Resident #5 then proceeded to administering insulin to Resident #5 without changing their gloves and / or performing hand hygiene.
On 05/01/2024 at 11:46 AM, Registered Nurse #5 was interviewed and stated that the glucometer was sanitized every shift. They stated they have been working in the facility since June 2023 and they were regularly educated on infection control protocol.
On 05/02/2024 at 09:32 AM, an interview was conducted with the Infection Preventionist. They stated residents' care equipment was supposed to be sanitized after every resident's use. Infection Preventionist stated they have not fully implemented the Enhanced Barrier Precautions because they have not fully compiled the list of residents on Enhanced Barrier Precautions, and they were still in the process of gathering signages.
On 05/08/2024 at 12:45 PM, the Director of Nursing was interviewed and stated residents' care equipment must be sanitized after use in between residents. They stated they have 2 glucometers in the cart to ensure proper infection control was being followed. The Director of Nursing stated that recently had COVID-19 outbreak which might indicate that staff were not practicing adequate infection control.
10 NYCRR 415.19 (b)(4)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, the facility did not ensure that performance reviews of every nurse aide ...
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Based on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, the facility did not ensure that performance reviews of every nurse aide were conducted at least once every 12 months This was evident for 12 of 12 Certified Nursing Assistants reviewed for nurse aides' training requirements. Specifically, the facility was unable to provide evidence that Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 were provided 12 hours of in-service training, including dementia and resident abuse prevention training.
The findings are:
The facility policy titled In-Service Training; Nurse Aide dated 2/2024 documented performance reviews were completed for nurse aides at least every 12 months.
On 5/1/2024 at 3:02 pm, the Surveyor reviewed the personnel files of Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18. There was no documented evidence the Certified Nursing Assistants received performance reviews in accordance with their hire date within the last 12 months.
On 5/3/2024 at 12:24 PM, the In-service Coordinator was interviewed and stated they were hired in January 2024, and they do not know how the facility conducted performance reviews for Certified Nursing Assistants in 2023.
On 5/7/2024 at 1:06 PM, the Director of Nursing was interviewed and stated they reviewed the files and in-service records for Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 and were unable to find performance reviews within the past 12 months.
On 5/09/2024 at 1:24 PM, the Administrator was interviewed and stated the nursing department was responsible for ensuring performance evaluations were conducted annually for Certified Nursing Assistants. The facility went through many personnel changes and the responsibility of performance reviews fell through the cracks.
10 NYCRR 415.26(c)(2)(iii)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review conducted during the recertification and extended survey from 4/29/2024 to 5/9/2024, the facility did not ensure it was administered in a manner th...
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Based on observations, interviews, and record review conducted during the recertification and extended survey from 4/29/2024 to 5/9/2024, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Resident Rights, Abuse, Activities, and Staffing. Specifically, 1) an Immediate Jeopardy related to abuse, abuse reporting, and abuse investigation identified areas of concern with training and inservice that should have been identified by Administration, 2) Recreation staff were not administered adequately to ensure the activity needs and preferences of all residents throughout the facility were addressed, and 3) the Administration allowed the language line telephone interpretation service payments to lapse and was aware non-English speaking residents resided in the facility and were in need of language interpretation services.
The findings are:
1) Please refer to F600, F609, F610, F730, and F947.
There was no documented evidence Administration effectively implemented a training and performance review program for their Certified Nursing Assistants and other staff to ensure policies and procedures related to abuse, abuse reporting, and abuse investigation were adequately implemented to prevent abuse and immediate jeopardy.
2) Please refer to F679.
There was no documented evidence that, despite adequate staff in the Recreation Department, the Administration ensured staff and resources were used to provide ongoing meaningful activities to all residents that met their needs and preferences.
3) Please refer to F552.
There was no documented evidence Administration ensured adequate interpretation services for non-English speaking residents, including paying the language-line service to ensure staff had access to interpretation services.
On 05/09/2024 at 3:13 PM, the Administrator was interviewed and stated staff were inexperienced and did not know the regulatory requirements for reporting abuse. This was the reason staff did not know how to report abuse to the New York State Department of Health or to Administration in a timely manner. The Administrator stated staff training was ineffective and was unable to provide documented evidence that training and inservice on abuse occurred. The facility's Inservice Coordinator employed from 1/2024 to 4/2024 resigned and the facility did not have a replacement or plan in place to address the need for inservice and training at this time. The Administrator stated they spoke with staff daily at morning report and was available most days to discuss concerns.
10 NYCRR 415.26
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification and Extended Survey on 4/29/2024 to 5/9/2024, the facility did not ensure that certified nurse aides were provided the required 12 hours of in-service training per year, including dementia management and resident abuse prevention training, to ensure continuing competence. This was evident for 12 of 12 Certified Nursing Assistants reviewed for nurse aides' training requirements. Specifically, the facility was unable to provide evidence that Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 were provided 12 hours of in-service training, including dementia and resident abuse prevention training.
The findings are:
The Facility assessment dated [DATE] documented that required in-service training for nurse aides must be sufficient to ensure their continuing competence but must be no less than 12 hours per year.
The facility's policy titled In-Service Training, Nurse Aide with a reviewed date of 2/2024 documented all nurse aide personnel must participate in regular in-service education. Annual in-services are no less than 12 hours per employment year and include training in dementia management and resident abuse prevention.
On 5/1/2024 at 3:02 pm, the Surveyor reviewed the personnel files of Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18. They were all currently employed by the facility and were due for their required annual in-service training by the end of 2023 based on their employment anniversary date and/or calendar year.
The facility was unable to provide documented evidence that Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 were provided 12 hours of annual in-service training. There was no documented evidence that they were provided dementia and resident abuse prevention training.
On 5/3/2024 at 12:24 PM, the In-service Coordinator was interviewed and stated they were hired in January 2024, and they do not know how the facility conducted the in-service trainings for Certified Nursing Assistants in 2023. The In-service Coordinator stated they have not found any completed staff in-service trainings for 2023.
On 5/7/2024 at 1:06 PM, the Director of Nursing was interviewed and stated they were the Assistant Director of Nursing in 2023 and was responsible in overseeing the trainings and orientation of newly hired staff. The Director of Nursing stated they reviewed the files and in-service records for Certified Nursing Assistants #1, #2, #9, 10, #11, #12, #13, #14, #15, #16, #17, and #18 and have not found any in-service records for them. They stated they were not able to locate the completed in-service trainings from 2023.
10 NYCRR 415.26(c)(1)(iv)
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
Based on record review and interviews conducted during the Recertification survey from 04/29/2024 to 05/09/2024, the facility did not ensure Minimum Data Set 3.0 assessments were electronically transm...
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Based on record review and interviews conducted during the Recertification survey from 04/29/2024 to 05/09/2024, the facility did not ensure Minimum Data Set 3.0 assessments were electronically transmitted within 14 days of completion. This was evident for 3 (Resident #1, #156, and #211) of 3 residents reviewed for resident assessment out of 39 total sampled residents. Specifically, the Minimum Data Set 3.0 assessments for Residents #1, #156, and #211 were not transmitted within 14 days of completion.
The findings are:
The facility policy titled Minimum Data Set 3.0 dated 10/2023 documented all assessments must be transmitted in a timely manner.
The Minimum Data Set 3.0 assessment for Resident #1 documented a completion date of 03/20/2024 and transmission date of 05/01/2024, more than 14 days after the completion date.
The Minimum Data Set 3.0 assessment for Resident #156 documented a completion date of 03/20/2024 and transmission date of 04/27/2024, more than 14 days after the completion date.
The Minimum Data Set 3.0 assessment for Resident #211 documented a completion date of 01/09/2024 and transmission date of 04/01/2024, more than 14 days after the completion date.
On 05/09/2024 at 01:47 PM, Registered Nurse #12, the Minimum Data Set 3.0 Coordinator, was interviewed stated their department was short of staff and this was the reason that some assessments, including those for Resident #1, #156, and #211, were transmitted more than 14 days after completion. Registered Nurse #12 stated they informed the Administrator of their staffing concerns.
On 05/09/2024 at 01:49 PM, the Administrator was interviewed and stated the Minimum Data Set 3.0 Coordinators communicated and the Administrator was aware that staffing concerns have caused issues with completion and transmission dates of assessments. The Administrator stated the facility utilized staffing agencies to overcome their staffing shortages and will would audit assessments to ensure more compliance.
10 NYCRR 415.11
Nov 2023
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
Deficiency F0657
(Tag F0657)
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 Abbreviated Survey (NY00309995), the facility failed to ensure that a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during Abbreviated Survey (NY00309995), the facility failed to ensure that a resident's discharge care plan was reviewed and revised by the interdisciplinary team. This was evident in 1 out of 4 residents (Resident #1) sampled. Specifically, Resident #1 was discharged on 12/31/22. The care plan was not reviewed and revised to reflect that Resident #1 was discharged home on [DATE].
The findings are:
The facility's Policy and Procedure Discharge Planning/Discharge Summary, the purpose is to identify the discharge goals and needs of each resident. The potential for a resident's return to the community will be evaluated by the interdisciplinary care planning team (CPT) along with the resident/designated representative. The discharge care plan in the electronic medical records (EMR) documents the developing discharge plan. The discharge care plan is updated as the resident/designated representative continue to identify the best plan for the resident's discharge.
Resident #1 was admitted to the facility with diagnoses including Cervical Disc Disorder with Myelopathy and Difficulty in Walking.
The Minimum Data Set (a resident assessment tool) dated 12/20/22 documented that Resident #1 had intact cognitive. Resident #1 required extensive assistance with most activities of daily living (ADL).
A Discharge Potential Care Plan dated 09/20/22 documented interventions to educate Resident #1 regarding arrangements required for safe discharge and to review the interdisciplinary plan with Resident #1 and family.
A Social Worker's Progress Note dated 12/26/22 documented that Resident #1 requested to be discharged home on [DATE]. The Social Worker also documented that the necessary equipment was ordered and referral to home health agency with contact person. Resident #1 will be picked up by family via private transportation.
The care plan was revised on 12/26/22 stating that Resident #1 remains for short term care.
A nursing progress note dated 12/31/22 documented that Resident #1 was discharged home. discharged Instructions and prescriptions given to Resident #1 who verbalized understanding.
The care plan was not reviewed and revised to reflect that Resident #1 was discharged home on [DATE].
During an interview on 11/21/23 at 09:35 am, the Director of Nursing (DON) stated that Resident #1's discharge care plan should have been updated by Interdisciplinary Team (IDT).
10 NYCRR 415.11
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
Deficiency F0661
(Tag F0661)
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 an Abbreviated Survey (NY00309995), the facility did not provide a discha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (NY00309995), the facility did not provide a discharge summary to a resident that includes, but is not limited to, the following: a recapitulation of the residents stay that includes, but is not limited to diagnoses, course of illness/ treatment or therapy, pertinent lab work, radiology, and consultation results. This was evident for 1 out of 4 (Resident #1) residents reviewed for discharged . Specifically, there was no documented evidence of a final discharge summary identifying that Resident #1 was medically cleared for discharge. Additionally, there was no physician's order to discharge Resident #1.
The findings are:
The facility Policy and Procedure of Transfer or Discharge Documentation states that should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility and Physician discharge summary will be completed.
Resident #1 was admitted to the facility with diagnoses including Cervical Disc Disorder with Myelopathy and Difficulty in Walking.
The Minimum Data Set, dated [DATE] identified the resident's cognitive patterns as cognitively intact. Resident #1 required extensive assistance with most activities of daily living (ADL).
A Social Worker's Progress Note dated 12/26/22 documented that Resident #1 requested to be discharged home on [DATE]. The Social Worker also documented that the necessary equipment was ordered and referral to home health agency with a contact person. Resident #1 will be picked up by family via private transportation. The Medical Doctor (MD) and Nursing Department were notified.
A Discharge Plan and Instructions dated 12/26/22 states Community Service Referrals, medications listed, and Treatment. The form also includes Physical and Occupational (PT/OT) evaluation and recommendations. Diet regimen and instructions for Resident #1 to follow up with their Primary Medical Doctor in one week.
A Medical Doctor (MD) Progress Note dated 12/28/22 documented that Resident #1 was seen and examined for complaints of a cough. The MD documented that Resident #1 was on PT and OT for improving mobility and Activity of Daily Living performance. Resident #1 was close to reaching maximum potential for a safe discharge.
A nursing progress note dated 12/31/22 documented that Resident #1 was discharged to home. discharged Instructions and prescriptions given to Resident #1 who verbalized understanding.
There was no documented evidence of a recapitulation of Resident #1' stay and a final summary of the Resident's status. Additionally, there was no physician's order to discharge Resident #1.
During an interview on 11/02/23 at 11:30 am, the Assistant Director of Nursing (ADON) stated that they did not see a discharge summary for Resident #1.
During an interview on 11/02/23 at 2:19 pm, MD #1 stated they usually writes their discharge summary in the progress note. MD #1 further stated that they evaluated Resident #1 on 12/28/22 for a cough and maybe that summary can be considered a discharge summary.
During an interview on 11/09/23 at 11:00 am, the Director of Nursing (DON) stated that once physician is notified of a resident's discharge, the physician would make a final assessment, writes a progress note, discharge medications, and an order for the resident to be discharged . The DON stated that they did not see an order for discharge and did not see a discharge summary from the physician.
10 NYCRR 415.11 (d)(I)(2)
Oct 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Recertification survey conducted 10/25/22 to 10/31/22, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Recertification survey conducted 10/25/22 to 10/31/22, the facility did not ensure that residents received services with reasonable accommodation of resident's needs. Specifically, a resident's ability to use a call bell or other form of device to call for staff assistance if needed based on the resident's functional ability was not evaluated or assessed in a timely manner. This was evident for 1 of 2 residents reviewed for the Environmental Task out of a sample of 38 residents. (Resident # 30)
The findings are:
The facility policy and procedure titled Call Bell dated 10/2021 documented that policy is for timely and courteous response to resident's requests and needs.
Resident #30 was admitted with diagnoses that included Central Cord syndrome, Injury at C4, and Pressure Ulcer of sacrum.
The admission Minimum Data Set assessment dated [DATE] that resident had intact cognition, required extensive of two staff for bed mobility and transfer, and extensive assistance of one staff for all other Activities of Daily Living. The MDS also documented that Resident #30 had impairment on both sides of upper and lower extremity, had a catheter and was always incontinent of bowel.
On 10/25/22 at 01:59 PM, during an interview Resident #30 stated that they could not use the call bell provided as they are unable to close their fingers but are able to move their hands up and down. Resident #30 also stated that when they need staff assistance, they have to yell to call the nurse.
On 10/25/22 at 01:59 PM, a call bell was observed clipped to right hand side of the bottom sheet near the head of the bed.
On 10/28/22 at 10:53 AM, Resident #30 was observed lying in bed in a supine positions with both arms outstretched. Resident's hands were also outstretched and the resident stated they are not able to close hands because their upper body is stiff. A call bell was observed clipped to the bed sheet near residents right shoulder and resident stated they are not able to reach or use the call bell.
On 10/31/22 at 12:57 PM, Resident's roommate approached the nurse's station and informed the Registered Nurse Supervisor (RNS) #6 that Resident #30 was calling out for assistance. Resident could not be heard calling out at the nurse's station.
The Physical Therapy Note dated 10/21/22 documented resident was referred to Rehab by nursing noted requiring more assistance with bed mobility, increased tightness on bilateral upper and lower extremities making it increasingly difficult to perform upper and lower body dressing. The note also documented that the resident was placed on skilled Physical Therapy 5-6x a week to improve functional mobility.
There was no documented evidence that Resident #30 was evaluated for the use of a call bell or provided with an alternate device in order to request staff assistance as needed.
On 10/28/22 at 02:29 PM, an interview was conducted with Certified Nursing Assistant (CNA) #5. CNA #5 stated that the resident had been on the unit for the past two weeks and had required total assistance of staff for care. CNA #5 also stated that they have to feed the resident because the resident is not able to use their hands. CNA #5 further stated that the resident's roommate will call the CNA if Resident #30 needs assistance, and they also listen out to hear if the resident is calling for assistance.
On 10/31/22 at 12:47 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #5. RNS #5 stated that Resident #30 is not able to use the call [NAME] as they cannot bend their hands. RNS #5 also stated that the resident's roommate will tell the staff when the resident needs something and at other times the resident will call out until someone hears the resident.
On 10/31/22 at 01:39 PM, an interview was conducted with Certified Occupational Therapist (COTA) #1. COTA #1 stated that they had been working with Resident #30 on Range of Motion exercises. COTA #1 also stated that the resident is not able to use the call bell at the bedside even though they had worked on this as the resident was not able to grip the bell or press the button to activate the call bell. COTA #1 further stated that given the resident's limited range of motion, Resident #30 would not be able to use a call bell placed at the resident's shoulder level and call bell should have been placed closer to the residents fingers. The COTA also stated resident is able to move their hands up and down from the wrist and that other call bell options had not been explored with Resident #30.
415.5(e)(1)
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 record review and staff interview conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document the presence of pain for a resident. This was evident for 1 of 4 residents investigated for Pain Management out of 38 sampled residents. (Resident #161).
The findings are:
The facility policy and procedure titled MDS/RAI Process Completion) dated 10/01/2019 documented staff will complete the MDS sections assigned to them by resident assessment, resident interview, staff interview and observation of the resident while performing routine activities. The policy also documented that staff shall utilize information in the medical record to assist with completion of the MDS which included MARs (Medication Administration Records) and TARs (Treatment Administration Records) and information used for this purpose must fall within the look back period. In addition, the policy documented that the MDS Coordinator is responsible for ensuring that assessments are accurate, completed timely and according to procedure and the RAI Manual.
Resident #161 was admitted with diagnoses that included Alzheimer's Disease, Anxiety Disorder, and Unspecified Osteoarthritis.
The EMR Data Profile titled Pain located in the Visual Electronic Medical Record documented that the resident experienced pain rated 7 of 10 on two occasions on 9/25/22, 6 of 10 on two occasions on 9/26/22, 7 of 10 and 6 of 10 on 9/27/22, 6 of 10 on two occasions on 9/28/22, and 5 of 10 on one occasion on 9/29/22.
The Annual Minimum Data Set (MDS) dated [DATE] documented resident sometimes understands, had severe cognitive impairment (BIMS score=3-able to repeat 3 words after first attempt), and had impairment on both sides of lower extremity. The MDS also documented that the resident received scheduled pain regimen and was interviewed for pain assessment and denied pain.
The MDS did not accurately reflect the presence of pain for a cognitively impaired resident.
On 10/31/22 at 10:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) #4. CNA #4 stated that they had been assigned to Resident #161 for the past 3-4 months and resident will always say they are in pain. CNA #4 stated that when the resident complains of pain, they report it to the nurse and who will go see the resident.
On 10/31/22 at 10:40 AM, Registered Nurse (RN) #2 was interviewed. RN #2 stated that Resident #161 always complains of pain either in the knee or the stomach. RN #2 stated resident that since the resident is cognitively impaired, they code the resident's pain record based on the resident's facial expression.
On 10/31/22 at 10:18 AM, Registered Nurse Supervisor (RNS) #6 was interviewed. RNS #6 stated that resident frequently complains of pain and has to be monitored for non-verbal cues also as the resident is not reliable when they give information.
On 10/31/22 at 10:29 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated that interviews are conducted with the resident on or before the day of the assessment. If resident is cognitively impaired, we review the nurses notes and it would become a staff interview. The MDSC also stated that they would look at the orders and documentation in the chart and the indication of the pain medications. The MDC further stated that maybe for this MDS assessment checking the pain documentation was missed for the resident and the MDS should have been coded yes that the resident had pain. The MDSC stated that they check all the sections that they code to make sure it is accurate.
On 10/31/22 at 12:53 PM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that MDS issues was one of the issues on the last survey so the facility has paid a lot of attention to this area. The ADON stated that the gatekeeper is our MDS Coordinator who monitors and is responsible for ensuring that the MDS assessments are accurate. The ADON further stated that other tools for evaluation of pain would have to be looked at for a resident who is cognitively impaired.
415.11(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification survey conducted 10/25/22- 10/31/22, the facility di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification survey conducted 10/25/22- 10/31/22, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. This was evident for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASARR) out of 38 sampled residents. (Resident #146)
The findings are:
The facility's policy titled LTC Patient Screening (PASSAR), dated 10/8/21, documented that the preadmission screening is to determine whether an individual requires active treatment for a mental illness or mental retardation or a related illness and is therefore ineligible for RHFC placement. The policy also documented that the screen is for anyone seeking admission to a residential health care facility as required by the federal NH Reform Acts.
Resident #146 was admitted to the facility on [DATE] with diagnoses that include Cerebrovascular Accident, Paraplegia, and Schizophrenia.
The admission Minimum Data Set (MDS) dated [DATE] documented that the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation.
The Comprehensive Care Plan (CCP) titled IPRO level II, created on 08/12/22, documented as related to diagnosis(dx) of Mental Illness (MI) with IPRO Level II determination. Goals included resident's mental health status will remain stable x 3 months. Interventions included monitor resident for changes in mood and behavior, Psych consult and follow up as per Medical Doctor (MD) orders and PRN.
The CCP titled Schizophrenia/Mood disorder, created on 06/18/22 documented that potential for behavior and mood alteration secondary to h/o Schizophrenia and mood disorder (refuses meds, vaccine). Goals included resident will not manifest signs of behavior and mood alterations x 90 days. Interventions included Psychiatrist evaluation and follow up, encourage resident to participate in program of their choosing.
The Director of Social Services (DSS) note dated 06/17/22 documented resident was admitted from the hospital, alert, and oriented x 3, triggered for depression, insomnia, restlessness. Resident declined psychological services and denied history of trauma. Baseline care plan reviewed with resident.
The SCREEN Form DOH-695 dated 08/08/22 and signed by Director of Social Services (DSS) on 08/11/22 for Resident #146 documented in section Level 1 Review for Possible Mental Illness that the resident has a serious mental illness, and that a Level II referral was done.
There was no documented evidence that a PASSAR screen was completed prior to resident's admission on [DATE].
On 10/27/22 at 02:34 PM, Social Worker (SW) #1 was interviewed and stated that the facility had a copy of the PASSAR dated 06/14/22, but it was misplaced so they did a new PASSAR dated 8/8/22. SW #1 brought a copy of the PASSAR dated 10/22 and said that they tried to get the one dated for June 2022, but that the sending hospital did not have a copy.
On 10/31/22 at 09:53 AM, SW #1 was re-interviewed and stated that on admission, the SWs must check the PASSAR from the hospital records to see if any further follow up is needed, such as in the case of Resident #146. SW #1 also stated that the PASSAR screen should be dated prior to the time that the resident was admitted to the facility, and that they would go to check the chart and check the screen to see if it is a Level II or any other thing needs processing. SW #1 further stated that they did not know what happened with the screen for Resident #146 and that the SW Director is responsible for the initial admission assessment, and they are responsible for quarterly assessments. SW #1 stated they usually coordinate the care plan meeting, but do not usually review the SCREEN form.
0n 10/28/22 at 11:23 AM, the Director of Social Services (DSS) was interviewed and stated that they were not able to use the PASSAR screen that was initially done from the hospital on admission on [DATE], since it was not done correctly and did not trigger for Serious Mental Illness. The DSS also stated that during an audit in August, the incorrect PASSAR was found and a new one was initiated on 08/08/22. The DSS further stated that the facility is currently looking for the PASSAR that was initially sent with the admission package on 06/16/22, however, it was not presented to the State Surveyor for review at any time during the survey.
415.11(e)
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 observations, record review and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no documented evidence that a CCP was developed and implemented for at risk for Abuse for a resident who had behavioral symptoms of yelling and screaming. This was evident for 1 of 4 residents reviewed for Accidents out of 38 sampled residents. (Resident #22)
The findings are:
The facility's Policy and Procedure titled Care Plans Comprehensive with a revised date of 02/01/18, documented that assessment of residents are ongoing and care plans are revised as information about the resident condition changes.
Resident #22 was admitted to the facility with diagnoses that included Psychotic Disorder, Depression, and Alzheimer's Disease.
On 10/25/22 at 12:00 PM, Resident #22 was observed yelling and screaming in the dayroom.
On 10/26/22 at 1:00 PM and 10/31/22 at 1:00PM, Resident #22 was observed yelling and screaming in front of the resident's room.
The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident's cognition was moderately impaired, verbal behavioral symptoms occurred 1-3 days and the resident received Antipsychotic medication on 7 of 7 days.
The Physician's orders dated 06/22/22 documented Seroquel 25mg 1 tablet every 12 hours.
The Comprehensive Care Plan (CCP) titled Behavioral Symptoms created on 02/11/22, documented disruptive as evidenced by (AEB) by yelling, screaming and very loud for no apparent reason, restless at times, very mobile in bed and chair. Goals include resident's behavior episodes will be reduced in 90 days. Interventions include maintain calm safe environment, keep bed in lowest position with floor mattress.
Psychiatry note dated 08/16/22 documented that resident was still yelling out but was not in pain. The note also documented that the medication Nudexta was ineffective and was changed to Valproic acid.
The Licensed Practical Nurse note dated 10/03/22 documented resident continued on Quetiapine Fumarate 25 mg tab with mild effect. Resident noted with unprovoked screaming at times.
The Licensed Practical Nurse note dated 10/26/22 documented resident noted screaming more than before, inconsolable and disrupting peers. Tolerated 50% of supper, spoon fed by Staff. Monitoring continued.
There was no documented evidence that a care plan had been created that identified the resident as at risk for abuse related to the resident's screaming and disruptive behavior on the unit.
On 10/28/22 at 02:28 PM, Registered Nurse (RN) #4 was interviewed and stated that the facility does not do at risk for abuse care plans and as far as they can recall, they had not done any at risk for abuse care plans. RN #4 stated that there should have been at risk for abuse care plan for any residents that are vulnerable, but they have not been doing them. RN #4 said that there should be one for Resident #22, since the resident is at risk as they yell and scream for no apparent reason, while they are in the dining area and in front of the resident's room.
On 10/28/22 at 02:38 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that they were not aware that at risk for Abuse care plan was not part of the resident's care plans. The ADON also stated that residents with impaired cognition and behaviors did not have any care plans for at risk for abuse as they had never implemented these care plans for at risk residents.
415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on interview and record review conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that residents received proper treatment and assistive devices to ...
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Based on interview and record review conducted during a Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities. Specifically, the resident did not receive Ophthalmology follow-up care as recommended. This was evident for 1 of 3 residents reviewed for Communication/Sensory out of a sample of 38 residents. (Resident #88)
The findings are:
The policy and procedure titled Consultants dated 1/2019 documented that consultants provide the Administrator with written, dated, and signed reports of each consultation visit. Such reports contain the consultants recommendations, plans for implementation of his/her recommendations, findings and plans for continued assessments.
On 10/25/22 at 02:24 PM, during an interview Resident #88 stated they had been having problems seeing recently and needed to get their glasses rechecked. Resident #88 also stated they were not sure when last they had seen the eye doctor.
The Comprehensive Care Plan titled Vision dated 5/27/20 last revised 6/4/22 included goal of resident will function within limitation daily x 1 year. Interventions included Ophthalmology follow-up as needed, provide adequate lighting, provide large print materials, provide ongoing assessment of visual impairment.
The Optometry consult dated 3-1-22 documented visit was requested due to blurred vision. Recommendations included monitor for progression, continue current treatment. Glasses not ordered. Cataracts.
The Ophthalmology consult dated 3/9/22 documented Cataracts, Hypertension Retinopathy. No present treatment. Observe re Cataracts in 4-6 months.
There was no documented evidence that resident had been scheduled for Ophthalmology follow-up.
On 10/31/22 at 10:10 AM, an interview was conducted with Registered Nurse Supervisor (RNS) #5. RNS #5 stated that Resident #88 had not been seen as currently the Ophthalmologist was on vacation and out of country. RNS #5 also stated that residents were last seen at the beginning of September and they did not know who provided coverage in the Ophthalmologists absence. RN#5 further stated that the resident would be scheduled to be seen upon the return of the Ophthalmologist.
On 10/31/22 at 12:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that Ophthalmology is one the regular consults and residents are seen on admission and as needed. The ADON further stated that the Ophthalmologists provides services once a week and will usually let staff know in advance of any leave planned so that any residents due to be seen can be seen before they go on vacation. The ADON further stated that the Ophthalmologist was last at the facility on 9/28/22, and if a resident had an emergency and needed to be seen, they would be sent to the Emergency Room.
415.12(3)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, the physician did not review the Rehab assessment and place an order for the resident's use of bed side rails. This was evident for 1 of 2 residents reviewed for Physical Restraints out of a sample of 38 residents reviewed. (Resident #189).
The findings are:
The facility Policy titled Side Rails, dated 08/2021, last reviewed on 02/22 documented after assessment, the resident will be provided with side rails. MD will order side rails according to patient's diagnosis and symptoms.
Resident #189 was admitted to the facility 08/12/2022 with diagnoses that included Hypertension, Fracture, and Anxiety Disorder.
The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status and required extensive assistance of staff for most Activities of Daily Living including bed mobility and transfer.
The Comprehensive Care Plan (CCP) titled Side Rail dated 08/12/2022 documented that Resident #189 was in need of a device (1/2 SR) to hold on and to aid with bed mobility.
Goal's included: - Resident will use 1/2 side rails to hold on and to aid with bed mobility x 90 days. Interventions included: - Cue resident to hold on to 1/2 side rails to aid with bed mobility and for turning and repositioning; Frequent visual monitoring when in bed with 1/2 side rails; Ongoing monitoring for ability to use 1/2 side rail; Periodic review for the need of 1/2 side rails use every 3 months and as needed.
On 10/25/22 at 11:30 AM, Resident #189 was observed in bed with 2 upper side rails up. Resident stated that the side rails are used to pull up and reposition self while in bed and has been using the side rails since admission.
The IDT Side Rail Screen and Evaluation dated 10/17/22 documented that Resident #189 is currently on skilled PT and OT program and has goals for bed mobility rolling from side to side and supine to sit with the use of the side rail. It is also used for reaching and pushing off from the bed for sitting and standing activities.
There was no documented evidence that a physician's order had been provided for resident's side rail use.
On 10/27/22 at 11:41 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #2. CNA #2 stated that Resident #189 uses the side rail for support and to move in the bed. CNA #2 also stated that the resident is sometimes assisted in raising or lowering of the side rail as needed.
On 10/27/22 at 11:53 AM, an interview was conducted with the Registered Nurse (RN) #1. RN #1 stated that resident and family requested for side rail use, resident was evaluated by rehab, and consent received for the bed rail. RN #1 also stated that they thought that the resident's side rail had a physician's order in place but was surprised not to see an order. RN #1 further stated that they are not sure when resident started the use of the rail.
On 10/27/22 at 12:00 PM, an interview was conducted with the RN Supervisor (RNS) #2. RNS #2 stated that resident and family requested for side rail use, resident was evaluated by the rehab, and consent received for the use. RNS #2 further stated that the resident was properly assessed for side rail use, the missing Physician's order was an error of omission.
On 10/27/22 at 12:08 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that the physician's order was omitted for the side rail use, which had not been noticed by the nursing staff. The ADON also stated that the physician would be called to provide the telephone order immediately.
On 10/27/22 at 12:45 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated that the Interdisciplinary Team (IDT)met with the resident and the family when they requested for side rail use, an assessment was done by rehab and resident was found to be able to use the rail safely. The DOR also stated that after the completion of rehab assessment, it is documented in the resident's chart in the form IDT Side Rail Screen and Evaluation that is made available for all the Team members, including nursing and the physician, to review and sign off on. The DOR further stated that nursing was made aware after the evaluation and the final recommendation, and they are expected to get the physician's order for the side rail.
On 10/28/22 at 11:09 AM, an interview was conducted with Nurse Practitioner (NP) #1. NP #1 stated that they are in the facility 3-4 days per week to see the residents, review the residents' any recommendations in the resident's chart, and sign off pending orders as needed. NP #1 also stated that the nurses will call the physician at any time if any resident is given any recommendation that needs to be ordered immediately. NP #1 further stated that they were not notified of the Rehab's recommendations for the Resident #189's side rail.
415.15(b)(2)(iii)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility policy and procedure titled Residents' Rights revised 9/28/17 documented that resident has the right to communic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility policy and procedure titled Residents' Rights revised 9/28/17 documented that resident has the right to communicate privately by mail or telephone with anyone including but not limited to relatives, friends, caseworkers, client advocates, lawyers, medical and psychiatric facilities, health care professionals and member of public agencies.
Resident #81 was admitted to the facility with diagnoses that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus.
The Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact and required extensive assistance with two staff for transfer and total dependence with one staff person for locomotion on unit.
On 10/28/22 at 9:55 AM, Resident #81's documents requested as part of the complaint investigation were transferred to the surveyor via Health Commerce. Upon review, the documents were found to include a letter from New York State Department of Health's Centralized Complaint Intake unit regarding confidential concerns Resident #81 reported about Flushing Nursing and Rehabilitation Center. The letter dated 9/16/22 was addressed to Resident #81. The letter further documented that the concerns resident reported have been assigned with Case ID# NY00302339 and that it will be forwarded to New York City Regional Office for investigation.
On 10/28/22 at 12:35 PM, the Director of Nursing (DON) stated the NYS DOH letter regarding Resident #81 was received by the Administrator and they were not able to provide any additional information about the letter and why it had not been provided to the resident.
On 10/31/22 at 9:36 AM, Resident #81 was interviewed and stated they are not currently receiving any exercises. Resident #81 also stated they inquired about regular sessions of exercises to maintain and strengthen the legs but was told that it can only be done periodically. Therefore, Resident #81 emailed the concerns to the New York State Department of Health (NYS DOH) Complaint Hotline. Resident #81 stated that they did not receive a letter from the NYS DOH, but the resident printed the complaint intake form after it was submitted for reference.
On 10/31/22 at 12:33 PM, the Administrator was interviewed and stated that Resident #81's mail was opened in error by the administrator. All incoming mail are first sorted by departments and for residents by the Business Office manager. Resident mail is delivered to the recreational department and distributed individually by the recreational staff. The Administrator also stated that the facility also receives letters from NYS DOH; therefore, they did not realize that it was addressed to Resident #81 until after it was opened. The Administrator further stated that the DNS was made aware about Resident #81's letter but they could not recall if Resident #81 was informed about the incident and if the letter was delivered to Resident #81.
On 10/31/22 at 12:45 PM, the Accounts Receivable Office Manager (AROM) was interviewed and stated mail is received and sorted daily five days a week by the AROM. The AROM stated that mail delivered on Saturdays is distributed to the residents by the recreational staff. The AROM stated they did not know that Resident #81's mail was accidentally sorted in with the Administrator's mail and that the resident had not received that mail.
415.3(d)(1)
Based on observation, interview and record review conducted during the Recertification and Complaint survey (NY00302339) from 10/25/22 to 10/31/22, the facility did not ensure that the resident's personal privacy was maintained. Specifically, (1) a Nurse Practitioner was observed examining a resident in the hallway corridor, and (2) a resident's mail was not unopened and delivered in a timely manner. This was evident for 1 of 4 residents reviewed for Privacy and 1 of 3 residents reviewed for Activities of Daily Living out of a sample of 38 residents (Resident #84 & #81).
The finding is:
1. The facility Policy and Procedure (P&P) dated 02/2019 titled, Routine Resident Care, documented, providing an environment that contributes to a positive self-image, preserves dignity, and ensures privacy, including, including, confidentiality of resident information is maintained by all staff at all times.
Resident #84 was admitted to the facility with diagnoses that included Aphasia and Cerebrovascular Accident (CVA).
The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident with no speech, rarely understood/understands, short and long term memory impairment, and severely cognitively impaired.
On 10/27/22 at 10:45 AM, Nurse Practitioner (NP) #2 was observed performing an examination of Resident #84 in the 3rd floor hallway corridor, across from room [ROOM NUMBER]. NP #2 placed a stethoscope on the resident's chest and back and then pressed their gloved hand on the resident's abdomen. NP #2 was heard asking the resident, are you confused?
On 10/27/22 at 10:55 AM, an interview was conducted with NP #2 who stated that they needed to examine the resident in order to complete their comprehensive physical examination, which was due. The examination consisted of listening to the residents lung sounds, heart beat and checking the abdomen for tenderness. NP #2 stated that the correct approach for examining the resident would have been to take the resident to their room and examine them there. The Health Insurance Portability and Accountability Act (HIPPA) Federal law require residents are to be provided with privacy.
On 10/28/22 at 8:45 AM, the Medical Director (MD) was interviewed and stated that there is an expectation of treating the residents in a manner that shows respect for their privacy. This is a basic rule. The approach would have been to knock on the door of a resident before entering, then, close the door and draw privacy curtains closed, if the room is shared, before examining any resident. The MD also stated that if the resident is outside of their room, then the approach should have been, to inform the resident of what the visit is about and ask to take them to their room for further dialog and or exam.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #111 was admitted to the facility on [DATE], with diagnoses that included Hypertension, Non-Alzheimer's Dementia, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #111 was admitted to the facility on [DATE], with diagnoses that included Hypertension, Non-Alzheimer's Dementia, and Depression.
The admission Minimum Data Set (MDS) assessments dated 3/6/22 and 4/21/22 documented the resident with an intact cognitive status.
On 10/25/22 at 09:59 AM, during an interview Resident #111 stated that no written summary of the baseline care plan had been given since their admission into the facility.
The Social Services progress note dated 2/14/2022 documented that resident admitted for STR (Short Term Rehab). Resident alert and oriented x 3 and able to make all needs known with no confusion, cooperative and responsive during the interview .Baseline care plan reviewed. Will monitor and offer support as needed.
There was no documented evidence that Resident #111 was provided with a written summary of the baseline care plan.
3. Resident #189 was admitted to the facility on [DATE], with diagnoses that included Hypertension, Fracture, Anxiety Disorder, and Depression.
The admission Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status. The MDS also documented that resident participated in assessment and goal Setting, family or significant other did not participate in the assessment, and resident has no guardian or legally authorized representative
On 10/25/22 at 11:30 AM, Resident #189 was interviewed and stated they have been in the facility for the past 3 months but have not been given any written summary of the care plan.
The Meeting Attendance Sheet dated 08/26/22 documented that resident participated in initial care plan meeting held on 8/26/22.
There was no documented evidence that Resident #189 was given a written summary of the baseline care plan.
On 10/28/22 at 09:09 AM, Registered Nurse Supervisor (RNS) #2 was interviewed. RNS #2 stated that the Baseline Care Plan is done for the resident within 48 hours of admission, and the initial care plan meeting is held between 14 and 21 days of admission; the team members discuss and explain plan of care to the resident and the family members. RNS #2 stated that the Social Worker is responsible for giving the written summary of the plan of care to the resident.
On 10/28/22 at 09:18 AM, an interview was conducted with Social Worker (SW) #2. SW #2 stated that they are not sure when the written summary of the baseline care plan is given to the resident. SW #2 also stated they could not locate any documentation that a copy of the baseline care plan was given to the resident.
On 10/27/22 at 12:21 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the Interdisciplinary team members meet with the residents/resident family to discuss the baseline care plan. The ADON also stated that the written summary of the initial plan of care is to be given by the Social Services to the resident/resident family after the discussion of the baseline care plan. The ADON further stated that they were not aware that Social Services had not reached out to the family to explain the plan or provided residents with a written summary of the plan of care.
On 10/27/22 at 12:26 PM, an interview was conducted with the Director of Social Service (DSS) The DSS stated that the baseline care plan is done within 48 hours of resident's admission and the written summary given to the resident and the family right after completion within that 48 hour period. The DSS also stated that they are sure that all the residents were given the written summary of their initial care plan within 48 hours. The DSS stated that they do not have a signed copy of the baseline care plan that was provided to any residents or family members.
415.11(c)
Based on record review and staff interviews conducted during a Recertification/Complaint Survey from 10/25/22 to 10/31/22, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 3 of 8 residents reviewed for Baseline Care Plan out of 38 sampled residents. (Residents #30, #111 & #189).
The findings are:
The facility policy titled Baseline Care Plan effective 11/2017 and reviewed 11/2019 documented that a copy of the written summary of the Baseline Care Plan completed within 48 hours of admission must be given to the resident/resident representative. Same copy will be kept in the resident's medical record.
1. Resident #30 was admitted on [DATE] with diagnoses that included Central Cord syndrome, Injury at C4, and Pressure Ulcer of sacrum.
The admission Minimum Data Set (MDS) assessment dated [DATE] that resident had intact cognition, required extensive of two staff for bed mobility and transfer, and extensive assistance of one staff for all other Activities of Daily Living. The MDS assessment also documented that the resident participated in the assessment and that no family or significant other participated in the assessment.
On 10/25/22 at 02:06 PM, Resident #30 was interviewed and stated that they were not given any paperwork by the facility following admission and did not have a meeting with any staff members.
A baseline care plan initiated on 7/28/22 was signed off on by the Registered Nurse on 7/28/22 and by the Recreation Therapist, Physician, Physical Therapist and Dietician on 7/29/22.
There was no documented evidence that Resident #30 had been provided with a copy of the baseline care plan (BCP).
On 10/31/22 at 02:53 PM, an interview was conducted with Registered Nurse Supervisor (RNS) #5 who stated that the resident did not ask for a copy of the baseline care plan so a copy was not provided. RNS #5 also stated that baseline care plans are done on admission by the admitting Registered Nurse and they were not sure who was responsible for providing the resident with a copy of the BCP and would have to ask.
On 10/31/22 at 03:02 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that the BCP is completed within 48 hours and a copy is given to the resident. The ADON also stated that Social Services provides the resident with a copy of it but they were not sure where this was documented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's policy and procedure titled Care Plans-Comprehensive with a revised date of 02/01/2018 documented that assessm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's policy and procedure titled Care Plans-Comprehensive with a revised date of 02/01/2018 documented that assessments of residents are ongoing and care plans are revised as information about the resident condition changes. The policy further documented that the CCP development will include the participation of the resident and the resident representative. An explanation will be included in a resident medical record if the resident's and their representative's participation is determined not practicable for the development of the resident's care plan. The CCP will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Resident # 9 was initially admitted to the facility with diagnoses including Peripheral Vascular Disease, Renal insufficiency, and Non-Alzheimer's Dementia.
The Quarterly Minimum data set (MDS) assessment dated [DATE] identified Resident # 9 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3.
Progress notes dated 01/2021 through 12/2021 contained no documented evidence that Resident # 9's representative was invited to participate in the care plan meeting. There was no documented evidence of care plan meeting notes and/or attendance records.
Progress notes dated 01/2022 through 10/27/2022 contained no documented evidence that Resident # 9's representative was invited to the care plan meeting. There was no documented evidence of care plan meeting notes and attendance records.
On 10/25/2022 at 11:37 AM, Resident #9's spouse stated during an interview that they were not invited to any care plan meetings.
On 10/28/2022 at 11:20 AM, the Director of Social Services stated they were still looking for the care plan meeting notes and the attendance record.
On 10/31/2022 at 10:49 AM, Social Worker (SW) #1 stated that the resident and the resident's family representative are invited in person or over the phone. SW #1 also stated that the notes and attendance records are entered into the computer on the same day of the care plan meeting. SW #1 further stated that no care plan meeting notes are in the chart for Resident #9.
On 10/31/2022 at 11:57 AM, the Director of Social Service (DSS) was interviewed over the phone. The DSS stated that they were unable to find the notes. The DSS also stated that there was a care plan meeting for Resident #9, but they needed help finding notes or attendance records for 2022. The DSS further stated that the resident and their representatives are not invited to the quarterly care plan meeting as this is the facility policy.
On 10/31/2022 at 1:51 PM, the Director of Nursing (DON) was interviewed and stated that Resident #9's family representative should be invited to care plan meetings. The DON also stated that the Social Worker is responsible for documenting the care plan meeting and the attendance record in the progress notes.
415.11(c)(1)
Based on observation, record review, and interviews conducted during the Recertification survey from 10/25/2022 through 10/31/2022, the facility did not ensure that (1) residents' Comprehensive Care Plans (CCP) were reviewed and revised after each assessment, and (2) each resident or resident representative was offered the opportunity to participate in the review of their CCP. Specifically, (1) care plans for anticoagulant use, vision, Parkinson's Disease were not revised for Resident #88 and care plans for pain and Osteoarthritis were not revised quarterly for Resident #161, and (2) Resident #9 representative was not invited to participate in the residents' care plan meetings. This was evident of 1 of 5 residents reviewed for Unnecessary Medication, 1 of 4 residents reviewed for Pain Management and 1 of 2 residents reviewed for Abuse out of a sample of 38 residents. (Resident #88, #161 and #9)
The findings are:
The facility policy and procedure titled Care Plans-Comprehensive revised 02/01/2018 documented that the Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans at least quarterly. The policy also documented that the facility would assess a resident using the quarterly review instrument not less frequently than once every three months and update the comprehensive care plan.
1. Resident #88 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Parkinson's Disease, Hypertension and Unspecified Cataract.
The Physician's Order dated 10/4/22 documented resident was prescribed Carbidopa-Levodopa ER 25-100mg PO four times daily for Parkinson's and Aspirin 81mg daily.
Quarterly Minimum Data Set (MDS) Assessments were completed on 6/4/22 and 9/3/22.
The Comprehensive Care Plan (CCP) titled Anticoagulant Therapy dated 5/27/20 was last revised on 6/4/22.
The CCP titled Parkinson's Disease dated 5/27/20 was last revised on 6/4/22.
The CCP titled Vision dated 5/27/20 was last revised on 6/4/22.
There was no documented evidence that the comprehensive care plans had been reviewed and revised after the MDS assessments on 6/4/22 and 9/3/22.
Resident #161 was admitted with diagnoses that included Alzheimer's Disease, Anxiety Disorder, and Unspecified Osteoarthritis.
Quarterly MDS assessments were completed on 12/16/21, 3/12/21, 6/11/21, 7/17/21 and an Annual MDS assessment was completed on 9/30/22.
The Comprehensive Care Plan (CCP) titled Pain was created on 9/23/01 and was not revised until 10/27/22.
The CCP titled Osteoarthritis created on 9/23/21 had not been revised.
There was no documented evidence that comprehensive care plans had been reviewed and revised after each assessment.
On 10/31/22 at 11:40 AM, an interview was conducted with Registered Nurse Supervisor (RNS) #5. RNS #5 stated that care plans are revised every three months and are usually done after the MDS assessment has been completed. RNS #5 also stated that they had reviewed and revised other care plans for both residents but must have gotten distracted and overlooked completing the other care plans.
On 10/31/22 at 12:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that care plans should be revised following any MDS assessment including annually and quarterly. The ADON also stated that CCP's should be revised with applicable interventions if there are any significant changes with the resident and as needed. The ADON stated that tools utilized to help supervisors remain up to date with care plan review are the mini QA sessions and morning rounds sessions which is communicated to all staff on a daily basis. The ADON further stated that the MDS department also meets with RN managers weekly to make sure that MDS and CCP are in sync and done in a timely manner.
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 observation and staff interview conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that food was stored, prepared, distributed and served in ac...
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Based on observation and staff interview conducted during the Recertification survey from 10/25/22 to 10/31/22, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, (1) prepared and frozen foods were not labeled, dated appropriately, and (2) cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below. This was observed during the Kitchen Task.
The findings are:
The undated facility policy and procedure titled Storing Leftovers: timeframe for storing leftovers and prepared perishables documented leftovers and prepared perishables must be labeled and dated as to date of preparation. Both leftover foods and prepared perishables should not be kept longer than 48 hours. The policy also documented that any food that is left over in the original container in which it was delivered that has an expiration date will be discarded as to the date indicated by the manufacturer and not within 48 hours.
During an initial tour of the main kitchen on 10/25/22 at 9:27 AM, with the Food Service Director (FSD) present, food items in the freezer were observed. The freezer contained two packages of franks and an unopened package of meat which was undated and unlabeled. There was a full-size steam table pan containing sliced beef cuts in a dark brown sauce covered and dated 10/14/22.
Further observations of the walk-in fridges were made. The dairy walk-in fridge was observed with two half-size deep steam pans; one pan contained cold cut slices covered and dated 10/20/22 and the other pan contained different cold cut slices covered and dated 10/15/22. In addition, an unlabeled, undated red bag was observed stored inside the dairy walk-in fridge. The red bag contained left over fried fish, chopped pieces of raw fish, and other unidentifiable items which belonged to staff. The cook's walk-in fridge was observed with an unidentifiable brown puree item in a half-size deep steam pan covered and dated 10/23/22. Raw cuts of chicken pieces mixed in batter were covered and dated 10/23/22.
During an observation of the kitchen on 10/27/22 at 11:19 AM, the FSD was observed calibrating a thermometer in the kitchen to test food items on the tray line. The FSD removed cold sandwiches from the cook's walk-in fridge. Temperature checks of the food items revealed that the bologna sandwich measured 46 degrees F, and a cream-cheese/jelly sandwich measured 52 degrees F.
On 10/25/22 at 9:55 AM, the Dietary [NAME] (DC) was interviewed. The DC stated that the item observed in the cook's walk-in fridge dated 10/23/22, was a beef puree meat used for residents. The DC also stated that the package was opened/stored in the fridge on 10/23/22 so it will need to be used and discarded by tomorrow (10/26/22).
On 10/25/22 at 9:57 AM, the Food Service Director (FSD) was interviewed. The FSD stated that cold cuts found in the dairy fridge were bologna which was sliced and stored in the fridge on 10/20/22 and the salami cold cuts were stored on 10/15/22. The FSD also stated both cold cuts are to be used or discarded by end of today. The FSD stated that the item stored in the freezer dated 10/14/22 was a beef stew prepared by mistake, so it was stored for later use.
On 10/28/22 at 1:16 PM, the FSD was interviewed and acknowledged the food items observed were not labeled or dated properly. The FSD stated the cook's walk-in fridge contained sandwiches that measured above the proper temperature because the fridge is frequently opened and used during the mealtimes. Therefore, the temperatures of the sandwiches were above normal. The FSD also stated that the FSD already started to correct the identified areas and staff will be provided with in-service to address these issues.
415.14(h)
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 27% annual turnover. Excellent stability, 21 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), $87,741 in fines. Review inspection reports carefully.
- • 28 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $87,741 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
- • Grade F (7/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Sapphire Center For Rehab & Nursing's CMS Rating?
CMS assigns SAPPHIRE CENTER FOR REHAB & NURSING 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 Sapphire Center For Rehab & Nursing Staffed?
CMS rates SAPPHIRE CENTER FOR REHAB & NURSING's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 27%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sapphire Center For Rehab & Nursing?
State health inspectors documented 28 deficiencies at SAPPHIRE CENTER FOR REHAB & NURSING during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 24 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Sapphire Center For Rehab & Nursing?
SAPPHIRE CENTER FOR REHAB & NURSING 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 SAPPHIRE CARE GROUP, a chain that manages multiple nursing homes. With 227 certified beds and approximately 220 residents (about 97% occupancy), it is a large facility located in FLUSHING, New York.
How Does Sapphire Center For Rehab & Nursing Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, SAPPHIRE CENTER FOR REHAB & NURSING's overall rating (2 stars) is below the state average of 3.1, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Sapphire Center For Rehab & Nursing?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Sapphire Center For Rehab & Nursing Safe?
Based on CMS inspection data, SAPPHIRE CENTER FOR REHAB & NURSING has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Sapphire Center For Rehab & Nursing Stick Around?
Staff at SAPPHIRE CENTER FOR REHAB & NURSING tend to stick around. With a turnover rate of 27%, the facility is 19 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.
Was Sapphire Center For Rehab & Nursing Ever Fined?
SAPPHIRE CENTER FOR REHAB & NURSING has been fined $87,741 across 1 penalty action. This is above the New York average of $33,956. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Sapphire Center For Rehab & Nursing on Any Federal Watch List?
SAPPHIRE CENTER FOR REHAB & NURSING 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.