NEW VANDERBILT REHABILITATION AND CARE CENTER, INC
For profit - Corporation
320 Beds
Independent
Data: November 2025
Trust Grade
40/100
#535 of 594 in NY
Photo by New Vanderbilt Rehabilitation and Care Center
Photo by Timms Tyler
Photo by New Vanderbilt Rehabilitation and Care Center
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
New Vanderbilt Rehabilitation and Care Center, Inc. has a Trust Grade of D, indicating below-average performance with some concerns about the care provided. It ranks #535 out of 594 facilities in New York, placing it in the bottom half of all nursing homes in the state, and #8 out of 10 in Richmond County, suggesting limited local options with better ratings. The facility is experiencing a worsening trend, with the number of issues increasing from 16 in 2023 to 21 in 2024. Staffing is a relative strength, with a turnover rate of 39%, slightly below the state average, but the facility has concerning RN coverage, with less than 19% of facilities providing more RN support. While there have been no fines, which is positive, recent inspections revealed issues such as improper food storage practices, residents not receiving the frequency of showers they requested, and ongoing maintenance concerns like a leaking ceiling that has not been adequately addressed. Families should weigh these strengths and weaknesses carefully when considering this facility.
- Trust Score
- D
- In New York
- #535/594
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near New York's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New York facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 10%
No red flags
16 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 16 issues
2024: 21 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below New York average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below New York average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 39%
Near New York avg (46%)
Typical for the industry
The Ugly 37 deficiencies on record
Jul 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 07/09/2024 to 07/16/2024, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #344) of 1 residents reviewed for Dignity out of 39 total sampled residents. Specifically, the facility did not ensure privacy and dignity were provided when a licensed nurse performed blood glucose monitoring.
The findings are:
The facility's policy titled Resident Rights Overview dated 04/2023 documented it is the policy of this facility to protect and promote resident rights. It is the policy of this facility to create an environment that strongly emphasizes individual dignity and self-determination while promoting resident independence and a positive quality of life.
Resident #344 had diagnoses which included Schizophrenia, Depression, and Diabetes Mellitus.
The Minimum Data Set assessment dated [DATE] documented that Resident #344 had intact cognition.
During an observation on 07/09/2024 at 12:39 PM, Licensed Practical Nurse #7 was observed collecting a fingerstick from Resident #344 in the Unit 3 Dining Room in front of other staff and residents while residents were eating lunch.
During an interview on 07/09/2024 at 12:39 PM, Licensed Practical Nurse #7 stated they are instructed to collect the fingerstick from Resident #344 whenever they catch the resident. The Licensed Practical Nurse #7 further stated the fingerstick is usually done in areas where there is privacy.
During an interview on 07/09/2024 at 2:32 PM, the Registered Nurse Supervisor #8 stated Licensed Practical Nurse #7 should have taken Resident #344 to their room for privacy and performed the fingerstick there.
During an interview on 07/16/2024 at 1:50 PM, the Director of Nursing stated resident care is supposed to be provided with privacy, to maintain dignity. The Director of Nursing further stated Licensed Practical Nurse #7 should have taken Resident #344 back to their room for the fingerstick.
10 NYCRR 415.5
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #233 was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular accident, Coronary Artery D...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #233 was admitted to the facility on [DATE] with diagnoses that included Cerebrovascular accident, Coronary Artery Disease, and Non-Alzheimer's dementia.
The admission Minimum Data Set assessment dated [DATE] documented that resident was cognitively intact and that the resident and resident's family participated in the assessment.
The Comprehensive Care Plan titled Advance Directives dated 06/05/2024 stated Resident has the following advance directive orders in place with nine options, however none of the options had been selected and all were unchecked.
There was no documented evidence that advance directives were discussed with the Resident #23 or their designated representative, and no advance directives were noted in the medical record.
On 07/15/24 at 03:06 PM, an interview was conducted with Registered Nurse #3 who stated that when a resident is admitted , the social worker will discuss and determine the resident's advance directives. Registered Nurse #3 also stated that the social worker completes a Medical Orders for Life-Sustaining Treatment form for every admitted resident and that it will be placed in their chart in case of a code. Registered Nurse #3 stated that they will then notify the doctor that the advanced directive order needs to be signed, or the Director of Social Work will get verbal consent from the doctor.
On 07/16/24 at 11:28 AM, an interview was conducted with the Director of Social Work who stated that on admission, the social worker meets with the resident and their family and discusses advance directives. If a choice is made, it is initiated with an order. A Medical Orders for Life-Sustaining Treatment form is created if the resident would like to create one. If the resident does not decide to create a Medical Orders for Life-Sustaining Treatment form, they are documented as being full code by default. stated that this should be documented in the chart and there should be a care plan created for the advance directives. The Director of Social Work also stated that for Resident #233 and Resident #502, there is no Medical Order of Life Sustaining Treatment form and there is no documentation by Social Work about any conversations being conducted about advanced directives.
On 07/16/24 at 11:57 AM, an interview was conducted with the Director of Nursing who stated that when a resident is admitted from a hospital, the admission nurse should check the discharge paperwork to see if the resident came with a Medical Orders for Life-Sustaining Treatment form. If so, they will ask the resident or resident representative if they would like to continue this advance directive and document that in the chart. The Director of Nursing also stated that if they are not admitted with a Medical Orders for Life-Sustaining Treatment form, the admission nurse will explain their advance directive options to them and will document this in their chart. The Director of Nursing further stated that if a resident does not opt to complete a Medical Orders for Life-Sustaining Treatment form, they will be defaulted to being full code and this will be documented in the chart.
10 NYCRR 415.3(e)(1)(ii)
Based on observation, record review, and interviews conducted during the Recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure that residents are provided the option to formulate an advance directive and that advance directives are documented for each resident. This was evident for 2 (Resident #502 and Resident #233) of 6 residents reviewed for Advance Directives out of 39 sampled residents. Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for newly admitted residents.
The findings are:
The policy and procedure titled Advanced Directives reviewed/revised 03/20/2024 documented that residents and/or health care representative will receive education regarding advanced directives on admission, re-admission, annually, with any change in condition, and as requested by the resident and/or healthcare representative.
1. Resident #502 had diagnoses which included Benign Prostate Hyperplasia and Diabetes Mellitus. The admission Minimum Data Set assessment dated [DATE] documented Resident #502 was moderately cognitively intact, was understood and was able to understand others.
A review of the physician orders, hard chart, and electronic medical record on 7/9/2024 reveal no orders for advanced directives and there was no Medical Orders for Life-Sustaining Treatment form located on the chart.
There was no documented evidence in the Social Service notes or assessment that Advanced Directives had been reviewed with Resident #502.
On 07/12/24 at 10:00 AM, Registered Nurse Supervisor #9 was interviewed and stated they were not sure of whose responsibility it is to put in the Medical Orders for Life Sustaining Treatment forms in the chart. Registered Nurse Supervisor #9 also stated that the nurses are supposed to ask on admission about the resident's advanced directives and put a Medical Life Sustaining Orders for Life Sustaining Treatment form on the chart. Registered Nurse Supervisor #9 further stated that they were not sure of why this had not been done for Resident #502.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 7/09/2024 to 7/16/2024, the facility did ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 7/09/2024 to 7/16/2024, the facility did not immediately inform the physician when a resident's blood sugar was below the parameter that needed to be reported. This was evident for 1 (Resident #344) of 1 resident reviewed for Dignity out of 39 total sampled residents. Specifically, Resident #344 had a physician's order to notify the physician when resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result was less than 70 milligrams per deciliter or more than 400 milligrams per deciliter. The licensed nurse failed to notify the physician when Resident #344's finger stick blood sugar was below 70 milligrams per deciliter on 07/09/2024.
The findings are:
The facility's policy titled Diabetic Management dated 01/01/2024 documented the Primary Medical Doctor will be notified when a resident exhibits any signs or symptoms of hypoglycemia, and the current diabetic management regime will be reviewed and revised, and the root cause of hypoglycemia will be identified.
Resident #344 had diagnoses which included Schizophrenia, Depression, and Diabetes Mellitus.
The Minimum Data Set assessment dated [DATE] documented that Resident #344 had intact cognition.
A Comprehensive Care Plan for Diabetes was initiated on 01/04/2018 and revised 6/26/2024 and included interventions of monitor blood glucose level as ordered by the medical doctor and monitor for observable signs and symptoms of hyperglycemia (a condition when the blood sugar was higher than normal) or hypoglycemia (a condition when the blood sugar level was lower than normal).
On 07/09/2024 at 11:30 AM, during a Dining Room observation, Licensed Practical Nurse was observed checking blood glucose for Resident #344.
A physician's order dated 06/02/2024 documented Novolin 100 units per milliliter injection solution, inject subcutaneously every day at 7:30 AM, 11:30 AM, and 4:30 PM when finger stick blood sugar readings are as follows: Between 151 and 200 give 2 units, between 201 and 250 give 4 units, between 251 and 300 give 6 units, between 301 and 350 give 8 units, and between 351 and 400 give 10 units. If greater than 400 or below 70, call the physician.
The electronic Medication Administration Record for 07/9/2024 at 11:30 AM documented a finger stick blood sugar result of 64 milligrams per deciliter.
The nurses and medical progress notes dated 07/09/2024 through 07/10/2024 contained no documented evidence that the physician had been notified as per the order when Resident #344's finger stick blood sugar result was below 70 milligrams per deciliter.
On 07/16/2024 at 11:45 AM, Licensed Practical Nurse #7 was interviewed and stated they have Physician #2's personal cell number and sent a text to the physician with Resident #344's blood sugar result on 07/09/2024.
During an interview on 07/16/2024 at 11:59 AM, Physician #2 stated they did not receive a text from Licensed Practical Nurse #7 on 07/09/2024 and was never notified of Residents #344's low blood sugar on 07/09/2024. The Physician #2 further stated they want to be notified when Resident #344's finger stick blood sugar is below 70.
During an interview on 07/16/2024 at 1:50 PM, the Director of Nursing stated Licensed Practical Nurse #7 should have followed Physician #2's orders and notified the physician and their supervisor when Resident #344's blood sugar was below 70 milligrams per deciliter.
10 NYCRR 415.3(f)(2)(ii)(c)
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · 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 (NY00344855) survey from 7/09/2024 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 (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, on 6/09/24 at 6:51 PM, the Dayroom Attendant sprayed Resident #36 with hand sanitizer when Resident #36 was trying to exit the dayroom.
The findings are:
The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented that residents will be protected from abuse, mistreatment, exploitation, or misappropriation of resident property in accordance with State and Federal Regulations.
Resident #36 was admitted with diagnoses that included Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus.
The Minimum Data Set, dated [DATE] documented that Resident #36 had moderately impaired cognition.
The Comprehensive Care Plan titled Potential for Abuse as evidenced by abusive behavior towards others dated 8/01/2023 and updated 6/10/2024 documented a goal of Resident #36 will not be abused or victimized by others. Interventions included set limits and provide support for inappropriate behavior, encourage resident to voice concerns to staff, and observe for changes in mood/behavior.
The undated Facility Investigation Summary documented that during an investigation for a resident-to-resident altercation incident involving Resident #36 and Resident #102, video surveillance revealed the Dayroom Attendant sprayed Resident #36 with hand sanitizer while Resident #36 was trying to exit the dayroom. This incident occurred just prior to the resident-to-resident altercation. The Dayroom Attendant was immediately removed from the unit, suspended pending the investigation, and terminated as per facility policy upon completion of the investigation.
There was no documentation in the medical record regarding the staff to resident altercation.
A physician's progress note dated 6/12/24 documented Resident #36 was seen and examined at their bedside and no injury was noted.
The Corrective Action Notice to the Dayroom Attendant dated 6/14/24 documented an infraction of abuse, neglect, and mistreatment on 6/9/24 with action of termination.
Video footage of the incident was not retained and was not available for review by the State Surveyor.
On 7/15/2024 at 11:14 AM, the Dayroom Attendant was interviewed and stated they were the only staff in the dayroom with about ten other residents at the time of the incident. The Dayroom Attendant also stated they were sitting in the dayroom and Resident #36 was sitting in their wheelchair and hitting and kicking them, so they used hand sanitizer on Resident #36 to stop the behaviors. The Dayroom Attendant stated that Resident #102 then walked over to Resident #36 and suddenly flipped over the wheelchair with Resident #36 sitting in it. The Dayroom Attendant further stated the next morning the Director of Nursing called them to the office, and they were terminated.
On 07/15/2024 at 4:52 PM, Certified Nursing Assistant #10 was interviewed and stated they were in the hallway when the Dayroom Attendant came out in the hallway to get them. The Certified Nursing Assistant #10 stated they went to the dayroom and saw Resident #36 on the floor and the Dayroom Attendant reported that Resident #102 suddenly flipped Resident #36 over who was sitting in a wheelchair. Certified Nursing Assistant #10 stated they went to go get the nurse and the nurse evaluated Resident #36. Certified Nursing Assistant #10 further stated Resident #36, and Resident #102 have not had previous altercations and they had not observed the Dayroom Attendant abuse any residents.
On 7/12/24 at 6:20 PM, Registered Nurse Supervisor #7 was interviewed and stated that a Certified Nurse Assistant called them and reported Resident #102 grabbed Resident #36 by their legs and flipped them over in their wheelchair. Registered Nurse #7 stated they collected statements from the Certified Nurse Assistants and the Dayroom Attendant who was the only staff witness to the altercation between Resident #36 and Resident #102. Registered Nurse #7 also stated they assessed Resident #36 and there were no injuries observed. Registered Nurse #7 stated the dayroom aide was the only staff member in the room with several other residents at the time of the incident. Registered Nurse #7 stated the Director of Nursing, Administrator, and physician were notified right after the incident occurred. The Registered Nurse #7 further stated they interviewed Resident #36 and Resident #102 who are both confused, and they did not remember anything about the incident.
On 7/16/2024 at 2:04 PM, the Director of Nursing was interviewed and stated they viewed video footage from 6/9/24 to investigate the altercation which occurred in the dayroom between Residents #36 and #102. The Director of Nursing stated that they observed the Dayroom Attendant flicking hand sanitizer which was in a cup at Resident #36 who was trying to exit the dayroom. The Director of Nursing also stated the Dayroom Attendant was sitting on a chair looking at their phone when Resident #102 grabbed the leg of Resident #36's wheelchair and pushed it backwards flipping Resident #36 over. The Director of Nursing stated they interviewed the Dayroom Attendant with the Administrator and the Dayroom Attendant stated they used the sanitizer as a way of redirecting Resident #36. The Director of Nursing further stated the video was not saved and they reported the abuse to the Department of Health once they were made aware of the incident.
On 7/16/24 at 4:45 PM, the Administrator was interviewed and stated it is the facility's responsibility to make sure that each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. The Administrator also stated they watched the video with the Director of Nursing and the Director of Nursing was responsible for the investigation. The Administrator further stated the outcome was that the abuse did happen, and the Dayroom Attendant was terminated.
10 NYCRR 415.4(b)(1)(i)
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · 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 (NY00344855) survey from 7/09/2024 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 (NY00344855) survey from 7/09/2024 to 7/16/2024, 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 2 (Resident #36 and #102) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, a resident-to-resident altercation between Resident #36 and #102 was not reported to the New York State Department of Health within 2 hours of occurrence.
The findings are:
The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented all allegations of abuse must be immediately reported to the Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury.
Resident #36 had diagnoses which included Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus.
The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #36 had moderately impaired cognition.
Resident #102 had diagnoses of Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus.
The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #102 had severely impaired cognition.
An Accident/Incident Report dated 6/09/2024 at 5:55 PM documented as per Dayroom Attendant, Resident #102 flipped over Resident #36 from their wheelchair.
The Department of Health Facility Incident Report Submission dated 6/11/24 documented the facility reported the resident-to-resident altercation between Resident #36 and Resident #102 on 6/10/2024 at 3:57 PM more than 2 hours after the occurrence on 6/09/2024.
On 7/16/2024 at 2:04 PM, the Director of Nursing was interviewed and stated they report abuse within 2 hours if they are made aware immediately. The Director of Nursing further stated the resident-to-resident altercation occurred on a Sunday and they were not in the facility and therefore reported the incident the next day on Monday 6/10/2024. The Director of Nursing stated they were first made aware of the incident on 6/09/2024 at 6:50 PM and the Administrator was informed on 6/09/2024 at 7:03 PM.
On 7/16/24 at 4:45 PM, the Administrator was interviewed and stated the resident-to-resident altercation was reported to the Department of Health within 2 hours of the incident and the Director of Nursing was responsible for the investigation.
10 NYCRR 415.4(b)(2)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 7/09/2024 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 (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 38 total sampled residents. Specifically, the alleged staff-to-resident abuse involving the Dayroom Attendant and Resident #36 was not thoroughly investigated.
The findings are:
The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented the facility will investigate all incidents of alleged and actual abuse, complaints/grievances, misappropriation, and injuries of unknown origin. The investigative process will include statements from staff, witness, residents, interviews with staff, witness, residents, medical record review if applicable, review of employee records. All findings of investigations will be documented. An investigative report will be completed within 5 days and summarize the findings and outcome as well as any corrective action(s). In the event that abuse cannot be ruled out the New York State Department of Health will be notified. Residents/Resident Representative will be informed regarding conclusion of investigation and actions taken.
Resident #36 had diagnoses which included Bipolar Disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus.
The Minimum Data Set assessment dated [DATE] documented that Resident #36 had moderately impaired cognition.
The undated Facility Investigation Summary documented that during an investigation for a resident-to-resident altercation incident involving Resident #36 and another resident video surveillance revealed the Dayroom Attendant sprayed Resident #36 with hand sanitizer while Resident #36 was trying to exit the dayroom. The Dayroom Attendant was immediately removed from the unit, suspended pending the investigation, and terminated as per facility policy upon completion of the investigation.
There was no documented evidence the facility completed a thorough investigation to include interviews and/or witness statements from any staff working at the time the incident occurred. In addition, there were no resident interviews regarding care provided by the accused staff.
On 7/15/2024 at 11:14 AM, the Dayroom Attendant was interviewed and stated they were the only staff in the dayroom with about ten other residents. The Dayroom Attendant also stated that they were sitting down in the dayroom and Resident #36 was sitting in their wheelchair and hitting and kicking them, so they used hand sanitizer on Resident #36 to stop the behaviors. The Dayroom Attendant further stated the next morning the Director of Nursing called them to the office, and they were terminated.
On 7/16/2024 at 2:04 PM the Director of Nursing was interviewed and stated they watched video from the previous evening to investigate the altercation which occurred in the dayroom between Residents #36 and #102. The Director of Nursing observed the Dayroom Attendant flicking hand sanitizer which was in a cup at Resident #36 who was trying to exit the dayroom. The Director of Nursing stated they interviewed the Dayroom Attendant with the Administrator present, and the Dayroom Attendant stated they used the sanitizer as a way of redirecting Resident #36. The Director of Nursing stated the video was not saved and they reported the abuse to the Department of Health once they were made aware of the incident. The Director of Nursing further stated they included the summary of the staff-to-resident abuse in the resident-to-resident Facility Investigation Summary and did not complete a separate investigation with staff statements.
On 7/16/24 at 4:45 PM the Administrator was interviewed and stated they watched the video with the Director of Nursing and observed the Dayroom Attendant flicking hand sanitizer at Resident #36. The Administrator was unable to explain why staff statements were not gathered for this incident and stated the Director of Nursing was responsible for completing the investigation.
10 NYCRR 415.4(b)(3)
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
Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that Comprehens...
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Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Activities of Daily Living was not revised quarterly. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 38 total sampled residents.
The findings are:
The facility's policy and procedure titled Comprehensive Care Plan revised 1/1/2024 documented each resident will have an individualized interdisciplinary plan of care in place.
Resident #143 was admitted to the facility with diagnosis of Cerebrovascular Accident, Hypertension and Hyperlipidemia.
The Quarterly Minimum Data Set assessment was completed on 2/26/2024 and 5/20/2024.
The Care Plan for Activities of Daily Living Functional/Rehabilitation Potential created 11/13/2023 was last revised 12/22/2023.
There was no documented evidence that the Comprehensive Care Plan had been reviewed and revised after the Quarterly assessment on 2/26/2024 and 5/20/2024.
On 7/11/2024 at 11:39 AM, Licensed Practical Nurse #8 stated they are responsible to ensure regular care and treatments are given to the residents on the unit, and they also oversee the nursing staff to ensure residents receive daily care as per their plan of care. Licensed Practical Nurse #8 also stated that the care plans are reviewed and updated by the nurse supervisor.
On 7/16/24 at 11:26 AM, Registered Nurse Supervisor #2 stated that care planning for every resident is done quarterly. The interdisciplinary team will review the resident's plan of care during the care plan meeting and update the care plan after every care plan meeting. Registered Nurse Supervisor #2 also stated that the care plan related to activities of daily living is supposed to be updated by the nurse supervisor. Registered Nurse Supervisor reviewed Resident #143's medical record and stated Resident #143's Activities of Daily Living care plan should have been revised after every care plan meeting.
10 NYCRR 415.11(c)(2)(i-iii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and survey from 7/09/2024 to 7/16/2024, the facility ...
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 survey from 7/09/2024 to 7/16/2024, the facility did not ensure services provided met professional standards. This was evident for 1 (Resident #193) of out of 39 total sampled residents. Specifically, Licensed Practical Nurse #5 was observed administering medications via gastrostomy tube by using the pistol syringe and forcing the medications through the gastrostomy tube.
The findings are:
The facility's policy titled Administering Medications through an Enteral Tube, last revised 1/1/24, documented to administer each medication separately and to administer medication by gravity flow by pouring diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion, then open the clamp and deliver medication slowly.
Resident #193 was admitted to the facility with diagnoses that include Chronic Respiratory Failure and Dry eye Syndrome.
The Quarterly Minimum Data Set, dated [DATE] documented that Resident #193 had a feeding tube.
The Physician's order last renewed 6/24/24 included Acidophilus capsule: give 1 capsule by feeding tube route 2 times per day, multivitamins -minerals: give 5millimeters by feeding tube route once daily, and Vitamin C 500 mg tablet: give 1 tablet by g-tube route 3 times a day.
On 07/12/24 at 08:14 AM, an observation of medication administration was conducted with Licensed Practical Nurse #5.
Licensed Practical Nurse#5 washed their hands and put on gloves, removed medications from the medication cart, then crushed the medications individually and proceeded into the Resident #193's room. Licensed Practical Nurse #5 then placed the medications on top of a clean field on the Resident 190's bedside table and picked up a pistol syringe. Licensed Practical Nurse #5 then put water in the pistol syringe and using the syringe, pushed the water into the tube to check for patency of the tube. Licensed Practical Nurse #5 then continued to push all the other medications into the tube and did not permit the medications to flow into the tube via gravity. Licensed Practical Nurse #5 then put away the pistol syringe and removed their gloves.
On 07/12/24 at 08:34 AM, immediately after the medication administration observation, Licensed Practical Nurse #5 was interviewed and stated that they dilute the medications to ensure that all the medications are administered. Licensed Practical Nurse #5 also said that they were taught both methods for administering medications via a gastrostomy tube, either by gravity or by using the pistol syringe and forcing it through. Licensed Practical Nurse #5 stated that they were taught to use either technique.
On 07/12/24 at 08:34 AM, Registered Nurse Supervisor #2 was interviewed and stated that they when a medication is administered via a gastrostomy tube, the medications can be pushed using the syringe. Registered Nurse Supervisor #2 later stated that they were not quite sure if the medications were to be administered via gravity or pushed.
On 07/16/24 at 01:04 PM, the Director of Nursing was interviewed and stated that the Licensed Staff are in-serviced during orientation, competencies are done on administering medications via gastrostomy tubes, and that the Licensed Practical Nurse #5 was evaluated was on the proper way for the gastrostomy tube medications be administered. The Director of Nursing also stated that the nurses are monitored by the Registered Nursing Supervisors and reeducation is done by the Educator. Registered Nursing Supervisors
do random medication pass observations to ensure that the nurses are using the correct measures. If there is an issue, they would be re- inserviced.
10 NYCRR 415.12
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. This was evident for 1 (Resident #143) 5 residents reviewed for Activities of Daily out of 39 sampled residents. Specifically, Resident #143 was not provided with floor ambulation program as per physical therapy and in accordance with physician's order.
The findings are:
The facility's policy and procedure titled Restorative Nursing Services revised 1/1/2024 documented resident will receive restorative nursing care as needed to help promote optimal safety and independence.
Resident #143 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hypertension, and Hyperlipidemia.
The Quarterly Minimum Data Set, dated [DATE] documented Resident #143 had intact cognition, required supervision for walking 50 feet and walk of 150 feet had not been attempted, and resident used a walker and wheelchair for ambulation.
The New York State Department of Health Complaint Intake received 5/9/2024 documented that Resident #143 can walk to the bathroom, but the staff will not let resident walk or provide any walking exercises.
On 7/10/2024 at 10:20 AM, an interview was conducted with Resident #143 who stated they would like to be out of bed and out of the room more often to decrease further decline in their mobility. Resident #143 also stated they had not been doing any type of walking or ambulating with staff on the unit.
The Physician's Order initiated 1/6/2024, revised 3/3/2024 documented Floor Ambulation Program resident to ambulate 100 feet using rolling walker with closer supervision and wheelchair to follow twice daily.
The Physical Therapy Discharge Summary completed 3/4/2024 documented Resident #143 has reached maximum potential with skilled services and was being discharged from physical therapy. The discharge recommendation for Resident #143 was to continue restorative nursing program/floor maintenance program to maintain current level of performance and in order to prevent decline.
The Physical Medicine and Rehabilitation Evaluation dated 3/13/2024 documented Resident #143 was evaluated for mobility/activities of daily living (ADL) dysfunction. The evaluation also documented resident's prior function was ambulating with rolling walker independently and the recommendation was to proceed with floor ambulation program for Resident #143.
The Comprehensive Care Plan titled Activities of Daily Living/Rehabilitation Potential last revised on 12/22/2023 revealed no documented evidence a floor ambulation program was initiated for Resident #143.
The Certified Nursing Assistant Documentation Record for Resident #143 dated 3/1/2024 to 7/10/2024 revealed task Walk in Corridor task for 150 feet were completed 26 (4/17, 4/18, 4/20, 4/23, 5/5, 5/9, 5/14, 5/15, 5/16, 5/18, 5/20, 5/21, 5/23, 5/25, 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/5, 6/17, 6/24, 6/25, 6/26 and 7/8) out of 132 opportunities for the 7 AM to 3 PM shift, 4 (3/20, 5/18, 6/7, 6/25) out of 132 opportunities for the 3 PM to 11 PM shift, and 5 (3/28, 5/17, 5/26, 5/27, 6/17) out of 132 opportunities for the 11 PM to 7 AM shift.
There was no documented evidence that Resident #143 refused the floor ambulation program.
On 7/11/2024 at 10:44 AM, Certified Nursing Assistant #14 was interviewed and stated Resident #143 is independent but mostly required supervision for their daily care. Resident #143 is able to verbalize their needs and asks for assistance especially when transferring for toileting. Resident #143 is assisted to the toilet by holding and walking with the resident to the toilet. Resident #143 uses a wheelchair to transfer from their room to dining room. Certified Nursing #14 stated they were not aware that Resident #143 was on a floor ambulation program, and so they had never done any ambulation with Resident #143.
On 7/16/2024 at 3:51 PM, Certified Nursing Assistant #15 was interviewed and stated Resident #143 uses a wheelchair in transferring from their room to the dining room. Certified Nursing Assistant #15 also stated they would be notified by the nurse if a resident requires an ambulation program daily. Certified Nursing Assistant #15 further stated they were not made aware of an ambulation program for Resident #143.
On 7/11/2024 at 11:39 AM, Licensed Practical Nurse #8 was interviewed and stated Resident #143 requires supervision for most of their care but does gets out of bed independently at their will and uses a wheelchair to go out of their room. Licensed Practical Nurse #8 also stated that any noncompliance or refusals will be documented in the medical record. Licensed Practical #8 further stated they were not aware that Resident #143 was on a Floor Ambulation Program because the floor ambulation program is usually done on the unit by the Rehab staff.
On 7/11/2024 at 12:30 PM, the Director of Rehabilitation was interviewed and stated that Resident #143 completed Physical Therapy on 3/3/2024 and was discharged to the unit on a Floor Ambulation Program. Resident #143 was able to ambulate 100 feet using the rolling walker and a Floor Ambulation Program was ordered upon discharge to maintain functional ability and to prevent further decline. The Director of Rehabilitation also stated nurses are responsible for picking up the order and implementing the floor ambulation program with the nursing staff. The Director of Rehabilitation further stated that they were not aware that nursing staff did not perform the floor ambulation program for Resident #143
On 7/16/2024 at 11:26 AM, Registered Nurse Supervisor #2 was interviewed and stated the unit nurse is responsible for ensuring that nursing staff is doing the ambulation program with the residents. Registered Nurse Supervisor #2 reviewed Resident #143's medical record and stated that Resident #143 has an order for Floor Ambulation Program, but they did not know why the floor ambulation program was not implemented for Resident #143.
10 NYCRR 415.12(e)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the Recertification/ Complaint Survey from 07/09/2024 to 07/1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the Recertification/ Complaint Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that a resident with indwelling catheter receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bowel function to the extent possible. This was evident for 2 (Residents #20 and #160) of 3 residents reviewed for Catheter care out of a sample of 39 residents. Specifically, the Foley urinary collection bag was improperly positioned compromising the devices' ability to maintain gravity drainage and prevent reflux of urine.
The findings are:
The facility's policy and procedure titled Catheter Care, Urinary with a revision date of 12/2019, documented that the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
1.Resident #20 was admitted to the facility with diagnoses that included Coronary Artery Disease, Neurogenic Bladder, and Cerebrovascular Accident (CVA.
The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident has intact cognitive status (Brief Interview for Mental Status score 15). The Minimum Data Set also documented that Resident #20 is dependent on staff for most activities of daily living including toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and personal hygiene and had an indwelling catheter.
The Comprehensive Care Plan titled Urinary Incontinence-Foley Catheter dated 3/14/24 documented that Resident #20 has alteration in urine elimination, with indwelling catheter in place, with goals that included resident will not experience complications of indwelling catheter as evidenced by no signs or symptoms of urinary infection. Interventions included monitor for signs/symptoms of urinary tract infection, and report abnormal findings to physician.
The Physician's order dated 07/03/2024 documented Foley Catheter Care every shift and as needed.
On 07/09/24 at 12:12 PM, Resident #20 was observed in the dining room, with a Foley catheter bag hanging on the left side of the resident's chair.
On 07/10/24 at 09:21 AM, Resident #120 was observed in bed, and a Foley bag was hanging on the left upper side rail of bed, above the level of Resident #20's bladder. Resident #20 was interviewed and stated that they do not know where the catheter bag was positioned by the staff, and staff comes in to empty and position the bag.
On 07/11/24 at 11:01 AM, Resident #20 was observed in bed, awake, with Foley catheter bag hanging on the left upper side of bed.
On 07/12/24 at 11:00 AM, Resident #20 was observed seated in the reclining chair in the day room, with the Foley catheter placed on top of their thigh. Resident #20 stated that it was their assigned Certified Nursing Assistant that placed it there when they were taken out of bed and brought to the day room.
2.Resident #160 was admitted to the facility with diagnoses that included Neurogenic Bladder, Obstructive Uropathy, and Urinary Tract Infection.
The Quarterly Minimum Data Set, dated [DATE] documented the resident has moderate impairment in cognition; has clear speech, with distinct intelligible words, makes self-understood, and understands others. The Minimum Data Set also documented the resident is totally dependent on staff for toileting hygiene.
The Comprehensive Care Plan titled Urinary Incontinence dated 9/14/2023 documented Resident #160 has Alteration in Elimination related to Urinary incontinence and indwelling catheter with goals that included resident will not experience complications of indwelling catheter as evidenced by no signs or symptoms of urinary infection. Interventions included monitor for signs/symptoms of urinary tract infection, and report abnormal findings to physician.
The Physician's order revised date on 06/19/2024 documented Supra Pubic Catheter-Change every 6 weeks by Urology and as needed; Flush Suprapubic Catheter 30cc every day; Change urinary bag every week.
On 07/09/24 at 11:47 AM, Resident #160 was observed wheeling themself in the hallway and their Foley catheter bag was observed hanging loosely to the left side of Resident's wheelchair. Resident #160 was interviewed and stated that staff assist in emptying and positioning of the bag every shift.
On 07/11/24 at 08:36 AM, Resident #160 was observed in bed sleeping and the Foley catheter bag was hanging on the right upper side rail, above the level of Resident #160's bladder.
On 07/12/24 at 11:03 AM, an interview was conducted with Certified Nursing Assistant #1 who stated that Resident #20's catheter bag was removed from the bed side rail and placed on the resident's thigh while transferring the resident from bed to chair. Certified Nursing Assistant #1 also stated that the catheter bag was to be repositioned properly to the Resident #20's chair, but they were busy doing other things and did not do it.
On 07/12/24 at 11:08 AM, Certified Nursing Assistant #5 was interviewed and stated that they were trained on how to care for resident's Foley catheter, and Resident #160 is assisted with morning care, showers, and with Foley catheter care. Certified Nursing Assistant #5 also stated that the catheter bag is supposed to be placed above the resident's bladder at all times and was not able to explain why the bag was placed on the upper side rail when resident was in bed. Certified Nursing Assistant #5 further stated that resident's Foley bag is removed from the side rail and changed to a leg bag when Resident #160 is taken out of bed.
On 07/12/24 11:35 AM, Registered Nurse Supervisor #1 was interviewed and stated that Certified Nursing Assistants are trained on how to drain the foley catheter drainage bag and to properly position the bag above resident's bladder to ensure free flow of urine. Registered Nurse Supervisor #1 stated that both the Licensed Practical Nurses and Registered Nurses are expected to monitor and ensure that the Certified Nursing Assistants are doing it correctly. Registered Nurse #1 was unable to explain why the Certified Nursing Assistants are not being properly monitored to ensure that they are positioning the bag properly below resident's bladder. Registered Nurse #1 stated that they just checked and noticed that residents' Foley bags were not properly placed, and they will get the staff re-educated.
On 07/15/24 at 10:56 AM, an interview was conducted with the Director of Nursing who stated that staff were given in-service on Foley catheter care when they are newly hired, and if they are reported or observed not be providing proper care, they are sent to the classroom for re-training. The Director of Nursing also stated that Certified Nursing Assistants are supposed to be supervised and monitored by the nurses they work with to ensure proper care is provided to the residents as per their plan of care. The Director of Nursing stated that they are surprised that some the unit nurses and supervisors are not monitoring the certified nursing assistants well to ensure that residents were provided with proper care.
10 NYCRR 415.12(d)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Recertification survey conducted from 7/09/24 to 7/16/24, the f...
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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 survey conducted from 7/09/24 to 7/16/24, the facility did not ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 (Resident #222) of 5 residents reviewed for Unnecessary Medications out of 39 sampled residents. Specifically, the attending physician did not address the consultant pharmacist's recommendations for Resident #222 as documented that they agreed and will do.
The findings include:
The facility's policy titled Consultation Review Policy, last revised 3/1/24, documented all consultation will be reviewed by the Medical Doctor/Nurse Practitioner upon consult completion to ensure that there is no delay in diagnosis, treatment, and service.
Resident #222 was admitted to the facility with diagnoses that include Alzheimer's Disease and Anxiety Disorder.
The Quarterly Minimum Data Set, dated [DATE] documented Resident's 222 cognition as severely impaired-never/rarely made decisions, received 7/7 days of antipsychotics, antipsychotics were received on a routine basis only, and that gradual dose reduction has been documented by a physician as clinically contraindicated on 6/2/24.
The Physician's Order renewed on 6/12/24 documented Divalproex (Valproic acid) extended release 250 mg tablet; extended release 24 hr. Give 1 tablet (250 mg) by oral route 2 times per day.
The Pharmacy Drug Regimen Review dated 5/6/24 documented recommendations that resident is on Depakote, no serum level in chart, recommend 2 weeks after medication started.
The Prescriber's response dated 5/6/24 on the Drug Regimen Review documented agree, will do.
Review of the medical records and laboratory findings from 03/09/24 to 07/15/24, did not reveal any laboratory tests for Depakote levels.
There is no documented evidence that the Depakote levels were ordered.
On 07/15/24 at 10:38 AM, Registered Nurse Supervisor #5 was interviewed and stated that when labs are ordered, the requisition goes directly to the lab via the Electronic Medical Record. The night nurse then writes the names of the residents and the type of labs in the lab log. The technician then comes and documents when the lab is done or if the resident refuses. The Registered Nurse Supervisor #5 also stated that sometimes Resident #222 refuses to have their blood drawn for the labs, but they could not locate any documentation in the medical record that the Depakote level was ordered or that Resident #222 had refused to have it done.
On 07/15/24 at 11:48 AM, Physician #1, who is Resident #222's primary physician, was interviewed and stated that they follow up with the Psychiatrist, since they do not want to adjust any medications or order any labs related to the resident's psychiatric history. Physician #1 also stated that if they check the resident's labs, and it not normal, they will leave it to the Psychiatry, and will go with the Psychiatry's response, since they do not want to do that by themselves. The Physician #1 further stated that although the Psychiatrist does not get a copy of the drug regimen review, they will follow what the Psychiatrist recommends.
On 07/16/24 at 12:41 PM, the Medical Director was interviewed and stated that it is the expectation for the attending physician to get the labs done if they agree with the pharmacist's recommendations. The Medical Director also stated that the responsibility for the resident's care lies with the attending physician as the psychiatrist is a consultant.
On 07/16/24 at 01:10 PM, the Director of Nursing was interviewed and stated that once Pharmacy Consultants makes a recommendation, it would be reviewed by the attending physician who would indicate whether they agree or disagree, then they would sign it, and give the order which would then be carried out by the nurses. The Director of Nursing also stated that the Registered Nurse Supervisors would review to see that orders are placed if the physician stated that they agreed with the recommendation.
10 NYCRR 415.18(c)(2)
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews conducted during the Recertification and Abbreviated (NY00344855) surv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 07/09/2024 to 07/16/2024, the facility did not ensure psychotropic drugs were not given to residents unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #102) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically, Resident #102 displayed worsening of behavioral symptoms and psychotropic medication was increased without Resident #102 being assessed for possible underlying medical cause.
The findings are:
The facility policy titled Role of the Attending Physician at New Vanderbilt Rehab and Care Center dated 05/2023 documented the attending physician will periodically review all medications and monitor both for continued need based on validated diagnosis or problems and for possible adverse drug reactions. The medications review should consider observations and concerns offered by nurses, psychiatrists, consultant pharmacists and others regarding beneficial and possible adverse impacts of medications on the resident.
Resident #102 had diagnoses which included Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus.
The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #102 had severely impaired cognition, had no behavioral symptoms, and antipsychotic medications were received on a routine basis.
A Comprehensive Care Plan titled Behavior Symptoms dated 6/10/2024 had interventions which included notify medical doctor immediately for changes in behavior, provide redirection or distraction to minimize frequency or duration of behavior, and identify pattern of behavior.
On 7/11/2024 at 10:58 AM, Resident #102 was observed sitting by the nurse's station socializing with another resident.
On 7/11/2024 at 11:07 AM, Resident #102 was observed yelling profanity at Registered Nurse Supervisor #5 and asking how they could get out of the nursing home. Registered Nurse #5 was talking in a gentle tone with Resident #102.
On 7/11/2024 at 2:44 PM, Resident #102 was observed walking down the hallway crying out their child's name. Resident #102 then told Registered Nurse #5 that their child was just walking in front of them. Registered Nurse #5 immediately responded in a gentle manner, giving emotional support and redirection.
A Medical progress note dated 7/10/2024 at 11:12 PM documented follow up on agitation, Major Depressive Disorder, and reviewed psychiatry consultation. Resident #102 was seen and examined and was paranoid, confused, and agitated at times. Consider Haldol 2 mg with Benadryl 25 mg as needed every 8 hours for agitation and anxiety. Continue to monitor mood and behavioral changes.
A Nursing behavior progress note dated 7/14/2024 at 6:07 PM documented Resident #102 noted with increased agitation and combative behavior for no apparent reasons. Resident #102 is wandering back and forth on the unit, unable to be redirected by staff. Resident #102 is also verbally aggressive at this time. All efforts to calm resident are non-effective. Resident #102 has received Buspirone 5 mg and Seroquel 50 mg. To be evaluated by Psychiatric Medical Doctor.
A Psychiatric progress note dated 7/14/2024 at 6:33 PM documented follow up note, writer was asked to re-evaluate Resident #102 as they have been acting out, yelling, screaming, disorganized in their thoughts, and behavior was pacing back and forth in the hallways. Resident #102 has a psych history of Schizophrenia paranoid type, Alzheimer's dementia, anxiety disorder, and chronic medical issues. Resident #102 is alert, has fair eye contact, angry, moody, verbally aggressive towards staff and other residents. Resident #102 remains disorganized and paranoid, feels that others are plotting against them and are after them. Resident #102 is needing a lot of redirections. Plan: please consider increasing the Seroquel 50 mg to 4 times daily and continue other psych meds. Will follow up in a week or as needed.
The Medication Administration Record dated 7/01/2024 at 9:00 AM to 7/14/2024 at 5:00 PM, documented Resident #102 received Seroquel 50 mg tablet 3 times per day then on 7/14/2024 at 9:00 PM, documented Resident #102 was started on Seroquel 50 mg tablet 4 times per day for Major Depressive Disorder.
Physician's order dated 5/27/2024 documented Seroquel 50 mg give 1 tablet PO 3 times per day for Major Depressive Disorder.
Physician's order dated 7/14/2024 documented Seroquel 50 mg give 1 tablet PO 4 times per day for Major Depressive Disorder.
There was no documented evidence of a medical workup to rule out underlying medical conditions before Resident #102 was prescribed an increase in their antipsychotic medication.
On 7/15/24 at 3:48 PM, the Psychiatrist was interviewed and stated Resident #102 has Alzheimer's, paranoia, delusions, and depression, and was acting out yesterday evening, calling people names, pacing, getting in other residents' and nurses' faces. The Psychiatrist also stated Resident #102 is on Seroquel which they adjusted a little more yesterday due to their increased behaviors. The plan is to follow up today with Resident #102's increased medication and get feedback from the nurses. The Psychiatrist further stated they will find out whether the Attending Physician had assessed Resident #102 and ordered a urinalysis to rule out any type of infection. The Psychiatrist further stated when residents act out erratically for no reason, who had previously been stable for a few months, they always want to rule out a urinary tract infection or pneumonia.
On 7/15/2024 at 4:52 PM, Certified Nurse Assistant #10 was interviewed and stated Resident #102 has behaviors of yelling but has never hit anyone. Certified Nurse Assistant #10 further stated Resident #102 attends activities and has a group of same-sex residents that they socialize with.
On 7/16/24 at 10:48 AM, Physician #1 was interviewed and stated Resident #102's increased behavior has been on and off for 2 months. Recently their behavior has been better, quieter, and more cooperative. Physician #1 stated Resident #102 was very aggressive and combative 2 months ago. Sometimes Resident #102 is very agitated and sometimes very nice. Resident #102's mental status is up and down. Physician #1 also stated that they rely on the psychiatrist to order any medication adjustments and lab studies that are related to the resident's psychiatric condition.
On 7/16/24 at 1:57 PM, the Director of Nursing was interviewed and stated it is always encouraged to rule out a medical condition when a resident has increased behaviors. The Director of Nursing also stated that staff reported this is not new behavior for Resident #102 as they have flare ups in behavior on occasion.
10 NYCRR 415.12(l)(2)(i)
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Resident #143 was not provided with floor ambulation program, but documentation reflected that resident was provided with a floor ambulation program. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 39 sampled residents.
The findings are:
The facility's policy and procedure titled Restorative Nursing Services revised 1/1/2024 documented resident will receive restorative nursing care as needed to help promote optimal safety and independence.
Resident #143 was admitted to the facility with diagnosis that included Cerebrovascular Accident and Hypertension.
The Quarterly Minimum Data Set, dated [DATE] documented Resident #143 had intact cognition, required supervision for walking 50 feet and walk of 150 feet had not been attempted, and resident used a walker and wheelchair for ambulation.
The New York State Department of Health Complaint Intake received 5/9/2024 documented that Resident #143 can walk to the bathroom, but the staff will not let resident walk or provide any walking exercises.
On 7/10/2024 at 10:20 AM, an interview was conducted with Resident #143 who stated they would like to be out of bed and out of the room more often to decrease further decline in their mobility. Resident #143 also stated they had not been doing any type of walking or ambulating with staff on the unit.
The Physical Therapy Discharge Summary completed 3/4/2024 documented Resident #143 has reached maximum potential with skilled services and was being discharged from physical therapy. The discharge recommendation for Resident #143 was to continue restorative nursing program/floor maintenance program to maintain current level of performance and in order to prevent decline.
The Physician's Order initiated 1/6/2024, revised 3/3/2024 documented Floor Ambulation Program resident to ambulate 100 feet using rolling walker with closer supervision and wheelchair to follow twice daily.
The Comprehensive Care Plan titled Activities of Daily Living/Rehabilitation Potential last revised on 12/22/2023 revealed no documented evidence a floor ambulation program was initiated for Resident #143.
The Certified Nursing Assistant Documentation Record for Resident #143 dated 3/1/2024 to 7/10/2024 revealed task Walk in Corridor task for 150 feet were completed 26 (4/17, 4/18, 4/20, 4/23, 5/5, 5/9, 5/14, 5/15, 5/16, 5/18, 5/20, 5/21, 5/23, 5/25, 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/5, 6/17, 6/24, 6/25, 6/26 and 7/8) out of 132 opportunities for the 7 AM to 3 PM shift, 4 (3/20, 5/18, 6/7, 6/25) out of 132 opportunities for the 3 PM to 11 PM shift, and 5 (3/28, 5/17, 5/26, 5/27, 6/17) out of 132 opportunities for the 11 PM to 7 AM shift.
On 7/11/2024 at 10:44 AM, Certified Nursing Assistant #14 was interviewed and stated Resident #143 is independent but mostly required supervision for their daily care. Resident #143 is able to verbalize their needs and asks for assistance especially when transferring for toileting. Resident #143 is assisted to the toilet by holding and walking with the resident to the toilet. Resident #143 uses a wheelchair to transfer from their room to dining room. Certified Nursing #14 stated they were not aware that Resident #143 was on a floor ambulation program, and so they had never done any ambulation with Resident #143. Certified Nursing Assistant #14 was not able to explain why walk in corridor was being documented in their task record when they had never walked Resident #143.
On 7/16/2024 at 3:51 PM, Certified Nursing Assistant #15 was interviewed and stated Resident #143 uses a wheelchair in transferring from their room to the dining room. Certified Nursing Assistant #15 also stated they would be notified by the nurse if a resident requires an ambulation program daily. Certified Nursing Assistant #15 further stated they were not made aware of an ambulation program for Resident #143. Certified Nursing Assistant #15 stated they did not know why walk in corridor was being documented in their task record when they had not walked Resident #143.
On 7/16/2024 at 12:28 PM, the Director of Nursing was interviewed and stated that care should be accurately documented in the medical record and staff should only document tasks that have actually been performed.
10 NYCRR 415.22(a)(1-4)
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
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #63 had diagnoses which included Cerebrovascular accident and hemiparesis.
The Quarterly Minimum Data Set assessment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #63 had diagnoses which included Cerebrovascular accident and hemiparesis.
The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #63 was cognitively intact, required moderate assistance with bathing and personal hygiene, and that there was no rejection of care.
The Significant Change Minimum Data Set assessment dated [DATE] documented that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath.
During an interview on 07/09/24 at 12:03 PM, Resident #63 stated that they received showers on Tuesdays and Saturdays. Resident #63 stated that they would like to take showers more often but if they request to shower on an alternate day, they are told by the Certified Nursing Assistants to wait until their designated shower day.
During an interview on 07/15/24 at 09:46 AM, Certified Nursing Assistant #7 stated that Resident #63 is scheduled for showers during the event shift and that they work the day shift, so they do not assist with this resident's showers. Certified Nursing Assistant #7 stated that Resident #63 has not requested a shower during the day shift but requests a bed bath one to two times per week and they are able to accommodate this.
3. Resident #39 had diagnoses which included Renal Failure, Diabetes Mellitus, and Anxiety.
The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #39 was cognitively intact, required dependent-level assistance for bathing, tub/shower transfer, putting on and removing footwear, and lower body dressing. Resident #39 required moderate assistance for upper body dressing and personal hygiene.
The Annual Minimum Data Set assessment dated [DATE] stated that it was very important to choose between a tub bath, shower, bed bath or sponge bath.
During an interview on 07/09/24 at 11:33 AM, Resident #39 stated that their shower days are Wednesday and Saturday, but that they attend dialysis every Wednesday, so they are only able to shower on Saturdays. Resident #39 stated that they would like to shower three days per week, on days that they are not attending dialysis.
During an interview on 07/12/24 at 09:13 AM, Resident #39 stated that they clean themselves in bed by mixing their own solution which they put on a rag because they do not feel like the staff cleans them thoroughly. Resident #39 also stated that they are rushed in and out of the shower by the Certified Nursing Assistant on their shower day and that there are times when the Certified Nursing Assistant is unable to wash their hair on their shower day because they are too busy.
During an interview on 07/15/24 at 09:38 AM, Certified Nursing Assistant #7 stated that Resident #39 is scheduled for showers on Wednesday and Saturday. They stated that a bed bath is given on Wednesday instead of a shower due to the resident going to dialysis on Wednesdays. Certified Nursing Assistant #7 stated that they will wash the resident's body completely but that the resident sometimes wants to clean themself in addition to that, and Certified Nursing Assistant #7 will give the resident a washcloth to do so. Certified Nursing Assistant #7 stated that the nurse on the floor creates the shower schedule and that depending on how many other showers are scheduled for that day, they may be able to accommodate shower requests for non-scheduled shower days.
During an interview on 07/15/24 at 02:57 PM, Registered Nurse #3 stated that showers are given twice a week based on the posted shower schedule which designates assigned shower days based on room number. Registered Nurse #3 stated that the schedule that is currently followed for the 2nd floor residents was created with day and room assignments prior to Registered Nurse #3 being assigned to the floor, but that they can edit it if needed. Resident Nurse #3 also stated that they have only had one or two requests for showers on alternate shower days by residents on the floor, and if the resident's assigned Certified Nursing Assistant has extra time, they will usually comply with extra shower requests unless they are chaotically busy and short staffed. Registered Nurse #3 stated that the social worker and Director of Nursing would be required to approve requests for a resident to be regularly scheduled for more than two showers per week, or to change the day of the scheduled two showers.
During an interview on 07/16/24 at 11:28 AM, the Director of Social Work stated that residents are showered twice a week and that if residents want to change their shower day, the social service department would work with the nurses on the floor to assist with the resident's request. The Director of Social Work stated that they were unaware if anyone asks residents about their shower frequency preference or bathing preference and that that would likely be something the nursing department would do.
During an interview on 07/16/24 at 11:45 AM, the Director of Nursing stated that showers are scheduled at least twice a week, or more if that is the resident's preference. The Director of Nursing stated that residents are told that they will get showers twice a week during their admission but that nurses on the floor should be telling residents that they can take showers more frequently than that if they would like.
10 NYCRR 415.5(b)(1-3)
Based on interview and record review conducted during the Recertification and Complaint survey (NY00335874) from 7/9/24 to 07/16/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living, and 2 (Resident #39 and #63) of 2 residents reviewed for Choices. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #143, Resident #39's, and Resident #63's wishes.
The findings are:
The facility's policy and procedure titled Shower and Bath reviewed 2/2022 documented facility to cleanse and refresh the residents through showering and scheduled for two showers per choice weekly and as needed.
1. Resident #143 was admitted to the facility with diagnosis of Cerebrovascular Accident and Hypertension.
The Quarterly Minimum Data Set, dated [DATE] documented resident had severely impaired cognition and required partial/moderate assistance for shower.
The New York State Department of Health Complaint Intake (NY00335874) received 5/9/2024 documented that Resident #143's hygiene is poor, and they do not get their hair washed.
During an interview on 7/10/2024 at 10:20 AM, Resident #143 stated they were showered once last week but they would like twice a week as per their shower schedule.
The Comprehensive Care Plan for Activities of Daily Living/Rehabilitation Potential revised 12/22/2023 documented that resident's bathing type is shower.
The Certified Nursing Assistant Documentation Record from 6/1/2024 to 7/10/2024 revealed Resident #143 was showered 3 (6/6/2024, 6/13/2024, and 6/25/2024) days out of 9 days in June 2024 and 2 (7/2/2024, 7/9/2024) days out of 3 days from 7/1/2024 to 7/10/2024.
The review of Resident #143's medical record from 6/1/2024 to 7/10/2024 revealed resident refused shower once on 7/5/2024; therefore, bed bath was rendered instead.
There was no documented evidence that Resident #143 refused shower on other scheduled days.
On 7/11/2024 at 10:44 AM, Certified Nursing Assistant #14 was interviewed and stated that Resident #143 requires assistance and is scheduled to shower twice a week. Certified Nursing Assistant #14 also stated that Resident #143 is able to verbalize their needs and they did not recall Resident #143 ever refusing a shower.
On 7/11/2024 at 11:39 AM, Licensed Practical Nurse #8 stated that all residents on the unit have a shower schedule and are showered twice a week. Licensed Practical Nurse #8 also stated that any refusal of care or treatment is documented in the resident's medical record and Resident #143 had refused a shower on 7/5/2024. Licensed Practical Nurse#8 further stated that they do not recall Resident #143 refusing any showers last month.
On 7/16/2024 at 11:26 AM, Registered Nurse Supervisor #2 stated the unit nurse is responsible for ensuring that nursing staff is providing showers as per the schedule and document if it is not being done. Registered Nurse Supervisor #2 also stated they were not aware that Resident #143 was not getting shower consistently on their shower days.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 07/11/24 at 11:24 AM, brown marks were observed on the ceiling of room [ROOM NUMBER]. A basin was observed on top of the a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 07/11/24 at 11:24 AM, brown marks were observed on the ceiling of room [ROOM NUMBER]. A basin was observed on top of the air conditioning unit, positioned under some of the brown marks on the ceiling.
On 07/11/24 at 11:24 AM, the resident who resides in room [ROOM NUMBER], was interviewed and stated that the ceiling had been leaking for a while on and off, most recently on 07/10/2024, and that it had been an ongoing issue. They were unable to identify an approximate date when it began. The resident also stated that all of the staff on the floor were aware of the issue,
On 07/15/24 at 11:00 AM, the resident who resides in room [ROOM NUMBER] was re-interviewed and stated that maintenance had examined the leak on 07/12/2024 and told them that it was resolved. [NAME] marks on the ceiling remained present.
On 07/15/24 at 2:48 PM, room [ROOM NUMBER] was observed with a ceiling actively leaking, with drops collecting in the basin placed on top of the air conditioning unit. [NAME] marks were observed on the ceiling where leak was occurring.
On 07/16/24 at 09:31 AM, the basin in room [ROOM NUMBER] was observed to have two white cloths in it that were saturated in water.
5. On 07/10/2024 at 12:39 PM, the following observations were made on Unit 8 in room [ROOM NUMBER]:
a) Paint on the ceiling and walls were mismatched,
b) Stains and scuffmarks observed on walls,
c) Radiator paint was chipped,
d) Nightstand door was broken,
e) Sink ledges were dusty,
f) Brownish stains observed on remote control,
g) Scuffmarks observed on dresser,
h) Stains observed on floor, and
i) Privacy curtain improperly hung with hooks missing,
On 07/12/24 at 10:29 AM, Registered Nurse Supervisor #3 was interviewed and stated that the facility was aware of the leak in room [ROOM NUMBER], and that the leak is coming from the air conditioning unit in the room on the 3rd floor above room [ROOM NUMBER]. Registered Nurse #3 also stated that maintenance was aware of the leak and was working on fixing it.
On 07/15/2024 at 09:46 AM, Certified Nursing Assistant #7 was interviewed and stated that on 07/12/2024, maintenance fixed the leak in Resident #63's ceiling. Certified Nursing Assistant #7 also stated that maintenance requests are managed via a computer ticketing system.
On 07/16/24 at 12:20 PM, Housekeeper #1 was interviewed and stated that privacy curtains are cleaned when the Director of Housekeeping tells the housekeepers to clean them. The housekeeper will remove the curtain, wash them, and rehang them. Housekeeper #1 also stated that the housekeepers are not responsible for identifying when curtains need to be cleaned or fixed and that it would be up to the nurse on the floor to notify the Director of Housekeeping of concerns. Housekeeper #1 further stated that concerns like leaks would be handled by the maintenance department.
On 07/16/24 at 12:30 PM, the Director of Housekeeping was interviewed and stated that they make daily rounds of the units to identify concerns, but that if there is a specific concern, nurses will let them know, and that housekeepers are not responsible for notifying the head of housekeeping of these concerns. The Director of Housekeeping stated that there may be torn curtains on Unit 2 but that they were not sure, and that if privacy curtains are torn, it is their responsibility to order new ones.
On 07/16/24 at 12:42 PM, the Director of Maintenance was interviewed and stated that they make daily rounds on the units to identify any maintenance related concerns. The Director of Maintenance also stated that they were aware of the leak in room [ROOM NUMBER] and that it needs to be repaired. The Director of Maintenance further stated that there are only four other people working on the maintenance team so they cannot immediately repair things like this but try their best to get it done as quickly as possible.
10 NYCRR 415.5 (h)(2)
Based on observation, record review, and interview conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to the residents. Specifically, maintenance services necessary to maintain a sanitary, orderly and comfortable interior were not provided to the residents. This was evident for 4 of 9 resident units (Unit 5, Unit 6, Unit 7, Unit 2, and Unit 8) during environmental observations. Specifically, 1) on Unit 5 a wooden closet was observed with scuff marks and scratches, and the lock on the closet was broken, 2) on Unit 6 name plaques were missing, there mismatched and scuffed paint on walls, scratched furniture, cracked armrests and missing parts on wheelchairs, rusted and scratched lockers, and black substance on shower room floor grout, 3) on Unit 7 there was mismatched paint, scuff marks in dining room and throughout unit, and scratched furniture, 4) on Unit 2 an active leak was observed in the ceiling of a resident's room, 2), and on Unit 8, mismatched pain, stained walls, chipped radiator, broken nightstand, scuffed walls, dusty furniture, and improperly hung privacy curtains were observed.
The findings are:
The facility's policy titled Safe, Clean, Comfortable, and Home-like Environment revised on 02/20/2023 stated that it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights to the extent possible. The policy also documented that this included but was not limited to the provision of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
The New York State Department of Health Complaint Intake #NY00337577 dated 4/1/2024 documented the facility is dirty and there is broken furniture throughout the facility.
1. On 7/9/2024 at 10:58 AM and on 7/10/2024 at 9:05 AM, on Unit 5 in room [ROOM NUMBER] A, the wooden closet was observed with scuffs marks and scratches, and the lock on the closet was broken.During multiple observations from 7/9/24 to 7/16/24 the following were noted:
2) On Unit 6
a) Rooms 615/616/618-Name plaques were missing near bedroom doors leaving square area of mismatched, scuffed paint,
b) Lock on 618A wooden closet was broken,
c) a black-colored substance was noted along the floor/wall edge in shower room (lower side of unit),
d) Resident #36's wheelchair armrests cracked and missing foam from right arm rest,
e) Resident #102's left push handle grip missing and plastic part at end of left anti bar missing on wheelchair,
f) Metal lockers and cabinet rusted and scratched (located in side hallway on unit), and
g) Chipped paint, mismatched paint, scuff marks, and scratched furniture were observed throughout unit.
3) On Unit 7
a) Large chunk of paint peeled off lower door of dining/day room,
b) Mismatched/scuffed paint throughout dining/day room,
c) room [ROOM NUMBER] Large rectangular area of mismatched paint,
d) room [ROOM NUMBER] About 8 chipped paint on wall by nightstand bed A,
e) room [ROOM NUMBER] Large piece of the top layer of counter below sink was missing, wooden closet had scratches, and large square area of mismatched paint missing,
f) Large area of mismatched paint near elevator, and
g) Chipped paint, mismatched paint, scuff marks, and scratched furniture throughout unit.
On 7/12/2024 at 11:10 AM, [NAME] #1 was interviewed and stated staff reports broken furniture in the maintenance book which is located at the nurse's station. Then we either fix the furniture or throw it out.
On 7/16/2024 at 1:42 PM, the Director of Nursing was interviewed and stated we do weekly rounds with Administrator, Maintenance, and Housekeeping Director. The Director of Nursing stated they are putting together work orders for maintenance and housekeeping issues that need to be addressed and setting aside broken furniture in the facility alcove to be removed from the facility.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not assure that menus are developed/prepared/followed to meet resident choices including their nutritional, religious, cultural/ethnic needs. Specifically, 1) Resident #37 requested an ice cream during lunch service but was denied because of kosher dietary requirements, 2) Resident #143's alternative menu selection for lunch meal was not followed, and 3) Resident #58 stated the menus are developed with strict kosher dietary requirements and did not accommodating their cultural preferences.
The findings are:
The facility's policy and procedure titled Menus reviewed on 1/1/2024 documented menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs. Menu items and available snack reflect religious, cultural, and ethnic preferences of the residents and inputs from resident is considered in menu planning.
1.Resident #37 was admitted to the facility with diagnosis of Depression, Respiratory Failure and Hypertension.
The Annual Minimum Data Set, dated [DATE] documented that Resident #37 has intact cognition.
On 7/9/2024 at 12:29 PM, Resident #37 was observed eating a hamburger provided for a special barbecue event on the unit. Recreation Staff was observed calling the kitchen for a soda and ice cream as per Resident #37's request. Resident #37 was informed that thy would not be permitted to have ice-cream as dairy is not allowed to be served for this meal because meats were served for this event. Resident #37 was visibly upset and stated they do not follow a kosher diet.
2. Resident #143 was admitted to the facility with diagnosis of Cerebrovascular Accident, Hypertension and Hyperlipidemia.
The Quarterly Minimum Data Set, dated [DATE] documented resident has severely impaired cognition.
The New York State Department of Health Complaint Intake received 5/9/2024 documented that food is unpalatable, and Resident #143 does not get their choice.
On 7/11/2024 at 10:44 AM, Certified Nursing Assistant #14 stated that Resident #143 did not like today's lunch option, so they ordered cheeseburger from the alternative menu.
On 7/11/2024 at 12:01 PM, Certified Nursing Assistant CNA #14 was observed calling the kitchen for the missing cheese for the cheeseburger.
On 7/11/2024 12:03 PM, Resident #143's hamburger was observed without cheese.
The review of alternative menu selected on 7/11/2024 for Resident #143 documented cheeseburger was ordered for Resident #143's lunch meal.
3. Resident #58 was admitted to the facility with diagnosis of Hypertension, Hyperlipidemia, and Chronic Obstructive Pulmonary Disease.
The Quarterly Minimum Data Set, dated [DATE] documented cognition is intact.
On 7/9/2024 at 11:50 AM, Resident #58 was interviewed and stated they have been residing in the facility for 4 years and are currently an active member of the Resident Council. Resident #58 also stated that the facility's regular menu strictly adheres to Kosher dietary law and so there is no cooked food served on Saturdays. Resident #58 further stated that the alternative menu is very limited, and they are forced to order alternative option daily. In addition, when the facility has special events, they are always challenged when ordering non-kosher foods such as cheeseburgers. Resident #58 stated that they are aware that this facility follows kosher law, however they are not kosher and feel that all residents' food choices are not accommodated.
On 7/12/2024 at 11:00 AM, the Director of Activity stated that the Super Bowl Party is a pre-planned event with the menu items selected by residents and were approved for the event. On Super Bowl Day, some items were not ordered for the residents because the Rabbi did not approve them. The Director of Activity also stated that the residents complained and eventually the food items were ordered, however, a number of residents expressed dissatisfaction about the situation.
On 7/16/2024 at 9:22 AM, the Food Service Director was interviewed and stated that the kitchen follows kosher dietary law, and so dairy and meat are not served together for all meals, and there is no raw meat cooked in the kitchen on Saturdays. The menus reflect these laws. The Food Service Director also stated that residents can always order alternative menu options such as battered fish, hamburger, baked chicken, spaghetti/sauce, meatballs, and cheeseburgers. These menu options are also offered for Saturday meals because some residents may not like the main option which is a salad. These foods can be cooked on Friday and can be reheated for the next day. The Food Service Director further stated the cheeseburger cannot be prepared together since it is a kosher kitchen therefore, hamburger and cheese are served separately for any request. The Food Service Director stated they are doing everything to accommodate residents' requests but they are also following the kosher dietary laws.
10 NYCRR 415.14(c)1-3
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interviews conducted during the recertification survey from 7/09/2024 through 7/16/2024, the facility did not ensure a Quality Assurance and Performance Improv...
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Based on observation, record review, and interviews conducted during the recertification survey from 7/09/2024 through 7/16/2024, the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents. Specifically, there were 7 repeated deficiencies from the last survey conducted on 5/22/2023. (Refer to: F600, F609, F640, F655, F657, F758, and F880) for further information.
The findings include but are not limited to:
The facility policy titled QAPI Plan, dated January 01, 2024, documented the system to monitor care and services will continuously draw data from multiple sources. These feedback systems will actively incorporate input from staff, residents, families, and others, as appropriate. Performance indicators will be used to monitor a wide range of processes and outcomes and will include a review of findings against benchmarks and/or targets that have been established to identify potential opportunities for improvement and corrective action. The system also maintains a system that will track and monitor adverse events that will be investigated every time they occur. Action plans will be implemented to prevent recurrence.
1.
Refer to F550 and F561 re: resident rights.
2.
Refer to F578 re: Advance directives.
3.
Refer to F580 re: notification.
4.
Refer to F584 re: the environment.
5.
Refer to F610 re: investigation of allegations.
6.
Refer to F658 re: professional standards.
7.
Refer to F676 and F677 re: activities of daily living.
8.
Refer to F685 re: communication/maintaining hearing.
9.
Refer to F690 re: catheter care.
10.
Refer to F756 re: drug regimen review.
11.
Refer to F803 and F812 re: food and nutrition services.
12.
Refer to F814 re: garbage disposal.
13.
Refer to F842 re: resident records.
14.
Refer to F865 re: QAPI.
15.
Refer to R0610, R0830, and R1022 re: criminal history record check.
16.
Refer to I210 re: signage for COVID vaccine availability.
16. Refer to F600, F609, F640, F655, F657, F758, and F880 re: repeat deficiencies.
On 07/16/24 at 4:05 PM, the Administrator was interviewed and stated when any deviation from expected performance, or a negative trend occurs the findings are brought to the attention of the Quality Assurance committee. Staff report quality concerns to the Quality Assurance committee through their chain of command, the compliance officer, or the hotline. The facility works on issues that trigger and issues that the department feels need improvements. Also, weekly rounds are done with the department heads and the findings are reported to the Quality Assurance and Performance Improvement Committee. The nursing team and department heads will give a report on whether the corrective actions are effective, and if improvement is occurring. Monthly Quality Assurance and Performance Improvement committee meetings have been implemented in order to fix the issues. They compare month to month from the monthly progress reports from the departments. They meet as a team and discuss the inputs and ideas on how to change and correct the deficiencies. The Administrator stated at the time of the last survey, the facility submitted a plan of correction, and they continue to work on Quality Assurance and Performance Improvement and provide in-service training for the staff. The Administrator stated the facility performs competencies on staff and measure improvements and are working on recruiting staff with enticements such as bonuses. The Administrator stated the facility tracks performance by bringing it up to the team and move on if effective, if not effective then they continue to do Quality Assurance and Performance Improvement until compliance. The Minimum Data Set assessments are being worked on and Abuse issues are being worked on also. The Administrator further stated the Director of Nursing is new at the facility and started a month ago and they took over as Administrator late last year.
10 NYCRR 415.27
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #167 was admitted to the facility with diagnoses that included an Unstageable pressure ulcer, Diabetes Mellitus, Alz...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #167 was admitted to the facility with diagnoses that included an Unstageable pressure ulcer, Diabetes Mellitus, Alzheimer's disease, and Malnutrition.
The admission Minimum Data Set assessment dated [DATE] documented Resident #167's cognition as moderately impaired, and that the resident was at risk of developing pressure ulcers and had one Stage 3 pressure ulcer that was present upon admission/reentry to facility.
The Nursing Progress Note dated 07/8/24 documented that Resident #167 had a sacral ulcer which measured 2.5 cm x 4cm x 0.1 cm, 100% granulation, scant serous exudate. Treatment was documented as: cleanse area with NSS, pat dry, apply calcium alginate, cover with foam dressing daily & PRN.
The Physician's Order renewed 7/09/2024 documented cleanse with normal saline solution, pat dry, apply calcium alginate, and cover with foam dressing daily.
On 07/15/2024 at 10:42 AM, a wound care observation was conducted with Licensed Practical Nurse #4. Licensed Practical Nurse #4 entered the room of Resident #167 wearing a gown and gloves, with a tray containing wound care supplies that they placed on Resident #167's overbed table. Licensed Practical Nurse #4 performed hand hygiene and donned gloves. Licensed Practical Nurse #4 removed the dressing from Resident #167's sacral region and disposed of it in the trashcan positioned next to the bed. Licensed Practical Nurse #4 removed and disposed of their gloves in the trashcan and walked to the sink in Resident #167's room to perform hand hygiene. Licensed Practical Nurse #4 asked Certified Nursing Assistant #6 to kick the trashcan at the bedside over to the sink, which Certified Nursing Assistant #6 did. Licensed Practical Nurse #4 completed hand hygiene and kicked the trashcan back to the resident's bedside. Licensed Practical Nurse #4 donned gloves and picked up a piece of dry gauze from a multipackage of gauze and poured saline onto it. Licensed Practical Nurse #4 then rubbed the wet gauze horizontally across the wound to clean it. Licensed Practical Nurse #4 then disposed of the gauze in the bedside trash can, picked up a piece of calcium alginate, and placed it on gauze, then applied it to the wound before applying a foam dressing. Licensed Practical Nurse #4 returned to the sink and completed hand hygiene. Licensed Practical Nurse #4 took the multipack of gauze from the resident's bedside table and returned it to the medication cart positioned outside of Resident #167's room.
Licensed Practical Nurse #4 did not sanitize the bedside table or place a drape on the table before placing supplies down, did not clean the wound from inner to outer aspects, did not perform hand hygiene after cleaning the wound, and did not maintain infection control standards when returning the opened multipack of gauze to the medication cart.
On 07/15/2024 at 02:34 PM, an interview was conducted with Licensed Practical Nurse #4 who stated that they forgot to use the drape because they were nervous. Licensed Practical Nurse #4 also stated that they typically use single-use gauze for wound care but used the multipackage of gauze during Resident #167's observation because they were nervous. Licensed Practical Nurse #4 further stated that they have been observed doing wound care in an in-service earlier this year, and also completed an infection control in-service earlier this year.
On 07/15/2024 at 02:49 PM, an interview was conducted with Registered Nurse Supervisor #3 who stated that they have done wound care twice since beginning employment at the facility around seven months ago. Registered Nurse Supervisor #3 also stated that the Wound Care Nurse is responsible for monitoring the wounds and reporting concerns during their weekly wound care rounds. Registered Nurse #3 failed to identify the steps for performing wound care appropriately, including the need to perform hand hygiene after cleaning a wound and before performing the ordered treatment.
On 07/16/2024 at 09:52 AM, an interview was conducted with the Staff Educator who stated wound care observations are conducted upon hire and then yearly for all staff providing wound care in the facility. The Staff Educator stated that it was their responsibility to conduct the observation upon hire, and that the Wound Care Nurse conducts the yearly in-service wound care observations. If a staff member is identified as needing an additional in-service, the Staff Educator stated that they would do that with the assistance of the Wound Care Nurse. When asked about hand hygiene during wound care, the Staff Educator stated that after cleaning the wound and before applying treatment, they would remove the soiled gloves and put on new ones but failed to identify the need to perform hand hygiene after removing the soiled gloves.
On 07/16/2024 at 10:08 AM, an interview was conducted with the Wound Care Nurse who stated that they do an initial skin check on admitted patients, and weekly wound rounds with the doctors. They will also assist the Licensed Practical Nurses on the floor with complex wound care, such as wounds requiring wound vac treatment. When asked for the steps on providing wound care, the Wound Care Nurse failed to identify the need to perform hand hygiene after cleaning a wound and before performing the ordered treatment. The Wound Care Nurse stated that most wound care competencies are completed by the Staff Educator and that they try to do some but have not been able to complete many due to their current workload.
On 07/16/24 at 11:49 AM, an interview was conducted with the Director of Nursing who was able to accurately outline how wound care should be completed while maintaining infection control standards. The Director of Nursing stated that the Staff Educator was responsible for completing the upon-hire and annual wound care competencies for staff members providing wound care. 3. Resident #193 was admitted to the facility with diagnoses that include Chronic Respiratory Failure and Dry eye Syndrome.
The Quarterly Minimum Data Set, dated [DATE] documented that Resident #193 had a feeding tube.
The Physician's Orders last renewed 6/24/24, documented Artificial tears 1.4% eye drops, apply 1.4 drops by eye route in each eye 2 times per day.
On 07/12/24 at 08:14 AM, an observation of medication administration was completed with Licensed Practical Nurse #5.
Licensed Practical Nurse #5 entered Resident #193's room, washed their hands, and put on a pair of gloves. Licensed Practical Nurse #5 then administered the medications via the gastrostomy tube. Licensed Practical Nurse #5 then removed their gloves, donned a clean pair of gloves and proceeded to instill eye drops to both of Resident #193's eyes. Licensed Practical Nurse #5 did not perform hand hygiene between glove changes.
On 07/12/24 at 08:34 AM, immediately after the medication administration observation for Resident #193, Licensed Practical Nurse #5 was interviewed and stated that they were taught to wash their hands between glove changes, but that they did not clean their hands after they changed their gloves to administer the eye drops. Licensed Practical Nurse #5 also stated that they were nervous and forgot to wash their hands after taking off the gloves when they administered medications via the gastrostomy tube.
On 07/16/24 at 01:04 PM, the Director of Nursing was interviewed and stated that the staff is taught to wash their hands after every glove changes. The Licensed Staff are in-serviced during orientation, competencies are also done yearly, and Licensed Practical Nurse #5 was evaluated and knew the correct way to do glove changes. The Director of Nursing said that the nurses are monitored by the Registered Nursing Supervisors and reeducation is done by the Educator. The Registered Nursing Supervisors do random medication pass observations to ensure that the nurses are using the correct measures. If there is an issue, they would be re-in-serviced.
10 NYCRR 415.19(b)(4)
Based on observation, and interviews conducted during the Recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) Registered Nurse Supervisor #8 failed to practice hand hygiene and glove changes during wound care, 2), Licensed Practical Nurse #4 failed to practice appropriate infection control during wound care treatment, and 3). Licensed Practical Nurse #5 did not perform hand hygiene during Medication Administration for a resident with a gastrostomy tube This was evident for 2 (Resident #189 and Resident #167) of 7 residents reviewed for Pressure Ulcer/Injury and 1 resident (Resident #193) observed during Medication Administration out of 39 sampled residents.
The findings are:
The facility policy titled Pressure Sore Prevention Program & Wound Care Management reviewed June 2024 documented that for residents with existing pressure sores, treatment, evaluation and monitoring are needed to prevent the progression of existing wounds, the development of new breakdown and complications such as infections.
The facility's policy titled Infection Prevention and Control Program with revised date of 06/09/2024 documented the facility will require staff to perform hand hygiene as indicated by Centers for Disease Control guidelines.
1. Resident #189 had diagnoses of Stage 4 pressure ulcer of sacral region, Paraplegia, and Peripheral vascular disease.
The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #189 had intact cognition and Stage 4 pressure ulcers.
The Physician's Orders renewed on 06/02/2024 documented cleanse sacral ulcer with normal saline solution, pat dry, Skin Prep to outer wound edges, apply Silvasorb, and Calcium Silver Alginate Sheet to wound bed, cover with Silicone Border dressing every day and as needed.
On 07/15/2024 at 10:51 AM, wound care observation was conducted for Resident #189 with Registered Nurse Supervisor #8 performing wound care. Registered Nurse Supervisor #8 entered the room, placed the supplies, and washed their hands. Registered Nurse Supervisor #8 then donned gloves and removed Resident #189's soiled dressing from the wound on their sacrum. Registered Nurse Supervisor #8 then changed their gloves without washing their hands and cleansed the wound, applied the treatment, and placed the clean dressing on the wound. Registered Nurse Supervisor #8 then removed their gloves and performed hand hygiene.
Registered Nurse Supervisor #8 did not change their gloves or wash their hands after removing the soiled dressing, cleaning the wound, and before applying the treatment and clean dressing.
On 07/15/23 at 11:40 AM, Registered Nurse Supervisor #8 was interviewed and stated they were instructed to wash their hands during dressing change or use hand sanitizer if soap is not available. Registered Nurse Supervisor #8 further stated they used sanitizing wipes instead of washing their hands. However, surveyor did not observe the Registered Nurse Supervisor #8 using hand sanitizer wipes when performing wound care.
On 07/16/2024 at 1:55 PM, the Director of Nursing who is also serving as the Infection Preventionist was interviewed and stated that hand hygiene is supposed to be performed in between changing gloves when performing wound care. The Director of Nursing further stated the Registered Nurse Supervisor #8 was supposed to change gloves and wash their hands after removing the soiled dressing, then again after cleaning the wound, and also before applying the treatment and clean dressing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that food was stored, prepared, distributed and served in...
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Based on observations and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, 1) dairy walk-in refrigerator contained undated, unlabeled food items. 2) dry storage room was not maintained at appropriate temperature condition and was observed with expired items, and 3) cold food items were not held at the proper temperatures during tray line service. This was observed during the Kitchen Observation.
The findings are:
The facility's policy and procedure titled Food Safety and Sanitation dated 1/18/2024 documented all local, state federal standards and regulations will be followed to assure a safe and sanitary food and nutrition service department.
On 7/9/2024 from 9:36 AM to 10:10 AM, the initial observation of the kitchen was conducted with the Food Service Director. The following were observed: 1. Dairy walk-in refrigerator contained a pan of leftover scrambled eggs and another pan with boiled eggs that were covered with aluminum foil without a date or a label. 2. The basement dry storage room storing non-perishable foods was observed and was humid with no ventilation and hot in temperature. Three bottles of unopened of salsa were observed with manufacturing label indicating to store in a cool place and to refrigerate after opening. The temperature of the dry storage room was checked immediately with the Maintenance Director and thermometer registered at 87.7 degrees Fahrenheit. Additionally, there were 2 bottles of sweet Chili sauce on the shelf with a manufacturing label documenting best by date of 6/12/2024.
On 7/9/2024 at 2:11 PM, Dietary Chef stated they are responsible for ensuring all prepared foods are labeled and dated. The Dietary Chef also stated that the items found were left-over foods from the breakfast line today and was probably put away by staff on the breakfast tray line. The Dietary Chef further stated that the items should have been labeled with dates, but it was missed.
On 7/10/2024 at 11:12 AM, a tray line observation was conducted with the Food Service Director and the temperature checks revealed the following: cheese sandwich was 59 degrees Fahrenheit, plate of lettuce/tomato at 64 degrees Fahrenheit, and tuna fish sandwich at 63.5 degrees Fahrenheit.
On 7/16/2024 at 9:33 AM, the Director of Maintenance was interviewed and stated that there are no windows or a ventilation system in the dry storage room, so the temperature tested higher than the ideal room temperature. The Director of Maintenance also stated that the temperature of the dry storage room seems to be higher due to the hot summer weather. The ideal temperature for food storage room should be below 75 degrees Fahrenheit.
On 7/16/2024 at 9:22 AM, the Food Service Director was interviewed and stated that any left-over, prepared foods should be covered and labeled with dates before storing in the refrigerator/freezer. The dry storage room is also checked routinely for any expired items. The Food Service Director also stated that sandwiches are made daily in the kitchen around 9:30 AM daily and placed in the freezer for 2 hours. The sandwiches stored in the freezer are taken out right before lunch service and kept on ice to maintain proper internal temperature below 41 degrees Fahrenheit. The Food Service Director also stated that the freezer was not working properly on 7/10/24.
10 NYCRR 415.14(h)
MINOR
(C)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, during the recertification survey from 07/09/2024 to 07/16/2024 the facility did no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, during the recertification survey from 07/09/2024 to 07/16/2024 the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System Assessment Submission and Processing system in a timely manner. Specifically, admission, annual, and quarterly assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 53 of 53 residents reviewed for the Resident Assessment facility task.
The findings include but are not limited to:
The facility policy and procedure titled Resident Assessment Using Minimum Data Set reviewed 01/01/2024 documented that the facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. The Minimum Data Set assessments will be completed and submitted in accordance with regulatory time frames. The Minimum Data Set Assessments will be transmitted to CMS within 14 days after completion by the Minimum Data Set Coordinator/designee.
The Centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual Dated October documented that Assessment Completion refers to the date that all information needed has been collected and recorded and staff have signed and dated the assessment is complete. The manual also documented that Assessment Transmission refers to the electronic transmission of submission files to the Quality Improvement Evaluation System Assessment Submission and Processing system using the Medicare Data Communication Network. The Centers for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0 Manual also documented that the Minimum Data Set completion date must be no later than 14 days after the Assessment Reference Date for all non-admission assessments. The Minimum Data Set completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date.
1. Resident #202 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of 05/04/2024 was completed and signed on 05/18/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 51 days late.
2. Resident #1 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of 04/30/2024 was completed and signed on 05/7/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 48 days late.
3. Resident #136 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of 05/08/2024 was completed and signed on 05/16/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 39 days late.
4. Resident #167 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of 05/07/2024 was completed and signed on 05/14/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 41 days late.
5. Resident #5 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of 04/16/2024 was completed and signed on 04/22/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 63 days late.
6. Resident #59 was initially admitted to the facility on [DATE]. The Quarterly assessment with an Assessment Reference Date of05/10/2024 was completed and signed on 05/17/2024 and submitted/transmitted on 07/08/2024. The assessment was submitted/transmitted 38 days late.
On 07/16/2024 at 10:31 AM, the Minimum Data Set/Rehabilitation Department head was interviewed and stated that their job responsibilities include overseeing the Minimum Data Set Secretary, who submits the Minimum Data Set assessment books. The Minimum Data Set/Rehabilitation Department head also stated that the Minimum Data Set assessment books were being submitted late because some of the interdisciplinary team members who conducted the assessments were completing the documentation of their assessments late. The Minimum Data Set/Rehabilitation Department head further stated that the Minimum Data Set system can show that the assessment was completed timely even though all members of the interdisciplinary team may not have completed their assessments.
On 07/16/2024 at 10:37 AM, the Minimum Data Set Secretary was interviewed and stated that their job responsibilities include submitting the Minimum Data Set assessment books in the electronic medical record after they are completed. The Minimum Data Set Secretary also stated that once a Minimum Data Set book is completed, the Minimum Data Set/Rehabilitation Department head would move it to the ready to submit category in the electronic medical record. The Minimum Data Set Secretary further stated that they check the ready to submit section daily, and if an assessment was submitted late, it would be because it was not marked as ready to submit by the Minimum Data Set/Rehabilitation Department head.
On 07/16/2024 at 11:13 AM, the Administrator was interviewed and stated that they are not certain who is signing the Minimum Data Set assessment books but that it would be someone in the Minimum Data Set department overseen by Minimum Data Set/Rehabilitation Department head. The Administrator also stated that they are aware that assessments are being submitted late and that the Minimum Data Set/Rehabilitation Department head has been discussing this with the involved interdisciplinary departments.
On 07/16/2024 at 11:38 AM, the Director of Social Work was interviewed and stated that the social work department is heavily strained due to staffing issues and that assessments are sometimes submitted late due to these staffing issues.
MINOR
(C)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation, record review and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure garbage and refuse was disposed of properly...
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Based on observation, record review and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure garbage and refuse was disposed of properly. Specifically, the garbage compactor door was observed ajar, and multiple flies were observed flying on top of garbage inside the compactor.
The findings are:
The facility's policy and procedure titled Proper Kitchen Trash Disposal dated 1/8/2024 documented all kitchen waste is disposed properly to the compactor.
During an observation of the kitchen on 7/12/2024 from 10:02 AM to 10:16 AM, the Dietary Worker brought the garbage to the garbage disposal area located outside of the building. The garbage compactor was observed to be open and there were multiple flies flying on top of the garbage piles inside the compactor.
On 7/12/2024 at 10:25 AM, the Dietary Worker #1 was interviewed and stated the compactor door should have been kept closed to keep garbage inside the compactor.
On 7/16/2024 at 9:22 AM, the Food Service Director was interviewed and stated the compactor is used by housekeeping and food service staff. The Food Service Director also stated that all staff are expected to keep the compactor door closed after each use.
On 7/16/2024 at 9:33 AM, the Director of Housekeeping was interviewed and stated that staff should not have left the compactor door open on 7/12/2024. The Director of Housekeeping also stated that they are working with the Food Service Director to ensure that all staff are educated on the garbage disposal process.
10 NYCRR 415.14 (h)
May 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0570
(Tag F0570)
Could have caused harm · This affected 1 resident
Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure a surety bond was purchased to secure all personal funds of resid...
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Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure a surety bond was purchased to secure all personal funds of residents deposited with the facility. This was evident for 160 residents with personal funds accounts (PFA) out of 249 residents. Specifically, the facility's PFA for 160 residents exceeded the facility's surety bond amount.
The findings are:
The facility policy titled Resident Funds dated 9/13 documented that the facility's policy to ensure the safeguard of resident funds and ensure fund are accessible as appropriate in accordance with applicable regulations.
The resident's personal funds surety bond effective date from 11/14/22 to expire date to 11/14/23 documented the facility obtained a surety bond for $350,000.
The facility resident balances as of 5/24/23 documented a total balance of $361,013.10.
The facility did not ensure a surety bond was obtained to cover the total value of residents' funds held by the facility.
On 05/26/23 at 11:46 AM, the Director of Account Receivable (DAR) was interviewed and stated that the trial balance sheet that was provided to the surveyor, was the updated information of all residents' funds currently in the facility. DAR further stated that the facility has a controller officer that knows the details of the surety bond.
On 05/30/23 at 11:23 AM, the Controller was interviewed and stated that trial balance sheet is not updated because there are residents on the list who were discharged . The Controller stated that the facility purchased the surety bonds to ensure that they are enough to cover the total residents' funds. The controller stated that the total funds amount was increased but the surety bond should still be enough to cover the increased amount of the funds.
On 05/30/23 at 3:03 PM, the Administrator called and stated that Resident #232's security deposit of $15,000 should have been deducted from the total balance of residents' funds $361,013.10. Therefore, the updated total balance of residents' funds is $346,013.10. Administrator further stated Resident #232 is currently still residing in the facility but private paid; therefore, it should be excluded from total funds of residents with Medicaid/Medicare program.
415.26(h)(5)(v)
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the recertification and complaint survey (NY00309251) from 5/22/23 ...
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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 complaint survey (NY00309251) from 5/22/23 to 5/26/23, the facility did not ensure that each resident was free from abuse. This was evident for 1 (Resident #143) of 4 residents reviewed for abuse out of 39 total sampled residents. Specifically, on 01/24/23 Resident #143 was slapped on the buttocks by Certified Nursing Assistant (CNA) #3 while being assisted with ADL care.
The findings include:
The facility's current Policy and Procedure, titled Abuse Prevention Policy and Procedure stated that the facility prohibits all forms of abuse. Physical abuse is hitting, slapping, pinching, and kicking and control of behavior with corporal punishment. All prospective employees will be screened prior to employment to rule out any history of abuse, neglect or mistreatment or resident. All employees would be trained on abuse prevention policy. All incidents will be investigated. The facility will report all incident or violations where abuse, neglect, mistreatment of misappropriation of property is suspected to New York State Department of Health (NYSDOH) according to protocol.
Resident #143 had diagnoses of hypertension and cerebral palsy.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #143 's cognitive status was intact.
On 05/23/23 at 10:53 AM, Resident #143 was interviewed and stated that CNA #3 slapped them on the buttocks while giving the resident a bed bath. Resident#143 stated that the staff member cursed at them first. CNA #3 was handling Resident #143 rough during Activities of Daily Living (ADL) care and Resident #143 asked the CNA to stop. Resident#143 stated that CNA#3 got angry and hit their buttocks. Resident #143 reported the incident to their sister who then reported it to the facility Administration.
The facility's Incident Report documented that on 01/24/23 at approximately 9:30 AM, the Assistant Administrator received a call from Resident #143's sister stating the resident reported being slapped on the buttocks by CNA #3.
Resident #143's statement dated 01/24/23 documented CNA #3 slapped their buttocks during care after the resident asked CNA #3 to stop handling them rough during ADL care.
Resident #20's statement dated 01/24/23 documented Resident #20 was the roommate of Resident #143 and witnessed CNA #3 being rude to Resident #143 on 1/24/23. Resident #20 heard CNA #3 slap Resident #143.
The Facility's investigation determined that there is a reason to believe that the alleged abuse has occurred. The Risk Management team determined there was a negative interaction between the resident and CNA #3, and CNA #3 hit Resident #143 as they alleged on 01/24/23. CNA #3 admitted during an interview that the occurrence took place in Resident #143's bedroom around 9 AM, and they hit Resident #143 during the occurrence.
On 05/25/23 at 11:45 AM, CNA #3 was interviewed and stated Resident #143 was disrespectful and insulting CNA #3 every day. CNA #3 stated they touched the resident lightly on the leg. CNA #3 stated they were trying help calm the resident down. CNA #3 stated they did not abuse the resident. The resident is making up the abuse. CNA # 3 stated they did not report the incident to their supervisor because it was nothing. It was not abuse.
On 05/25/23 at 11:50 AM, Registered Nurse (RN) #5, the unit charge nurse, stated they were informed by the Assistant Administrator that Resident #143's sister stated Resident #143 reported they were hit. CNA #3, the assigned CNA, admitted they hit Resident #143. CNA #3 stated they asked Resident #143 to turn over so they can provide ADL care. Resident #143 can be resistant to care. CNA #3 was initially suspended, and they were terminated within twenty-four hours. RN #5 stated that abuse prevention trainings are provided every 3 months and as needed. The trainer explains what is abuse and the different types of abuse. All staff are trained on abuse prevention and how to deal with difficult residents. RN #5 stated they round often to ensure the CNAs are doing their job and to ensure residents are safe. RN #5 stated that when patients are difficult, we provide two persons to assist.
On 05/25/23 at 11:55 AM, the Assistant Administrator stated that Resident #143's sister reported that the resident was slapped on the buttocks by a staff member. The Assistant Administrator stated that they went to the unit right away to investigate the incident. The Assistant Administrator stated CNA #3 admitted to putting their hands on the resident. CNA #3 stated that they lightly touched the resident's leg. CNA #3 was suspended pending investigation. The Assistant Administrator further stated that all staff received training on abuse prevention every two to three months and as needed. The CNA #3 received training on abuse prior to and after the incident. CNA #3 was terminated once the facility concluded the allegation was substantiated.
On 05/25/23 at 03:07 PM, the Director of Nursing (DNS) stated at the time of the incident, she was told that a CNA slapped Resident #143. An investigation was started, and CNA #3 was interviewed and confirmed what happened. The CNA #3 stated that they put their hands on the resident. The facility explained that it was not acceptable and determined that abuse occurred. The facility terminated CNA #3. All staff received training on abuse prior to the incident, and all staff were re-trained on abuse prevention after the incident.
10 NYCRR 415.4(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the fac...
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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 5/22/23 to 5/26/23, the facility did not ensure each resident remained free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was evident for 1 (Resident #126) out of 1 resident reviewed for Physical Restraint out of a sample of 39 residents. Specifically, Resident #126, a resident with severely impaired cognition, was observed with bilateral full side rails in place, and there was no assessment, physician's order for the bilateral full side rails (SR), or medical justification. In addition, there was no assessment for the half-side rails that were ordered.
The findings are:
The facility policy titled Restraints last updated on 12/2009 documented restraints may be used for medical, emergent and in an extreme situation to protect the residents from injury. The policy also documented that all restraints must have a physician order with medical rationale for the use of restraint, and there must be specific instructions on how to release them. The restraint policy further documented that a restraint assessment will also be completed prior to the use of physical restraints.
Resident #126 had diagnoses which include Restlessness and agitation, Dependence on respirator [ventilator] status, and Seizure Disorder.
The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #126 had severely impaired cognition and required total assistance of one person for transfers and toilet use. The MDS also documented that bed rails were not used for this resident.
On 05/22/23, from 9:55 AM to 01:55 PM, Resident #126 was observed in bed, alert and awake with padded bilateral full side rails in place. Resident #126 appeared confused and could not communicate verbally.
On 05/25/23, from 10:33 AM to 02:55 PM, Resident #126 was again observed in bed, alert and awake with padded bilateral full side rails in use. The resident occasionally moved their legs and arms involuntarily.
The Comprehensive Care Plan titled behavior symptoms dated 06/27/21, revised on 04/07/23 documented the following: Two half (2 1/2 ) Side rails up while in bed to promote and maintain bed boundaries. Interventions include but not limited to: Allow time to de-escalate and re-approach if agitated, identify pattern of behavior (specify):throwing objects, pacing, Redirect negative behaviors.
The Physician's Order initiated 7/27/22 and last renewed 5/1/23 documented an order for two half (1/2) Side Rails (SR) up while in bed to promote and maintain bed boundaries and to be used as enablers.
There was no physician's order for bilateral full side rails.
There was no documented evidence in the medical record that a SR assessment for half or full side rails was completed for Resident #126. There was no documented evidence in the medical record that they facility tried any alternative measures prior to use of SR, and no rehab assessment was completed. There was no medical justification in the medical record indicating what medical symptoms the half or full side rails were being used to treat. There was no evidence of ongoing re-evaluation for the continued use of the half side rails ordered.
During an interview on 05/25/23 at 03:13 PM, the Certified Nursing Assistant (CNA #5) stated Resident #126 had full side rails for over a year. CNA #5 also stated Resident #126 used to have half SR when they resided in a different room on the west side, but Resident #126 liked to come out of bed. That is why the full SRs were started. CNA #5 stated they monitor the resident one-to-one (1:1) because Resident #126 likes to move around, and they remove their peg tube.
During an interview on 05/25/23 at 03:16 PM, the Registered Nurse (RN #7) stated Resident #126 is on 1:1 observation and always likes to get out of bed despite the full side rails. RN #7 stated Resident #126 is monitored closely, and there has not been any falls in a few years. RN #7 stated the Rehab department is responsible for restraint assessments.
During an interview on 05/26/23 at 03:50 PM, the Rehab Supervisor (RS) stated that thy were not aware that Resident #126 was on full side rails until they were asked by nursing on 5/25/23 to conduct an assessment for the need for full side rails. The RS stated nursing usually informs rehab about what type of bed rails the resident needs. The RS stated that after reviewing Resident #126's record and communicating with the interdisciplinary team (IDT), they concluded that Resident #126 would continue to use full side rails due to their behaviors. The resident needed to use full side rails because of behaviors we cannot control. The resident also has a personal aide, and the CNA does 1:1 observation to ensure safety.
During an interview on 05/25/23 at 03:51 PM, the Assistant Director of Nursing (ADON) stated that they cannot determine when Resident #126 began having the full side rails. The ADON stated the Interdisciplinary Team (IDT) decides if a resident needs a restraint, such as full side rails. They also stated that they reviewed Resident's #126 medical records found no assessment for the full side rails. As a result, they called rehab to complete an assessment today, and decided Resident #126 needed full side rails and obtained an order from the physician.
During an interview on 05/25/23 at 04:08 PM, the Director of Nursing (DON) stated that they were not aware that the resident used full side rails. DON also stated that a side rail assessment must be completed when using side rails of any kind. The DON stated they must get an order for the SR, create a CCP, and notify the family about the SR use. The DON stated they reviewed the records and found no record indicating who put the side rail on for Resident #126.
During an interview on 05/26/23 at 2:46 PM, the Medical Doctor (MD) stated that rehab just recommended Resident #126 have four side rails, and the resident has involuntary movement at times and sometimes hits the side rails, so the padding serves as protection for the resident. The MD also stated that the use of the bed rail is not considered a restraint but as protection for the resident.
415.4(a)(2-7)
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #18 had diagnoses of bipolar disorder and spinal stenosis.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #18 had diagnoses of bipolar disorder and spinal stenosis.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderately impaired cognition and no known behavior.
A Nursing Note dated 2/17/23 documented at 4:40 PM, Resident #18 came out of the dayroom crying that another resident hit them in the face. Cold compress applied and next of kin were made aware. The aggressor was immediately removed from dayroom.
The Medical Doctor (MD) Note dated 2/17/23 documented Resident #18 reported another resident hit them in the face earlier today. The aggressor was sent to the hospital. Resident #18 had mild tenderness to the left eyebrow.
A Report of Investigation dated 2/17/23 documented Resident #18 was sitting next to another resident in the dayroom when the other resident hit Resident #18 in the face. The residents were immediately separated, and Resident #18 reported what happened to the nurse. Resident #18 was referred to the psychiatrist and psychologist, and supervision should be provided at all times.
The Accident/Incident report dated 2/17/23 documented Resident #18 was hit in the face by another resident and emotional support and cold compress was given with good effect. Residents involved should not be kept in close proximity to each other.
There was no documented evidence the facility reported the incident involving Resident #18 to the NYSDOH.
On 05/26/23 at 04:32 PM, the Director of Nursing (DNS) was interviewed and stated the incident involving Resident #18 being hit in the face by another resident was a reportable incident. It was a mishap that it was not reported to the NYSDOH. The facility does report resident to resident altercations and abuse allegations must be reported right away.
On 05/26/23 at 05:10 PM, the Administrator was interviewed and stated resident-to-resident altercations are reportable to the NYSDOH. The Administrator stated they thought they reported the incident involving Resident #18.
10 NYCRR 415.4(b)
Based on record review and interviews conducted during a recertification /complaint survey (NY 00309251) from 5/22/23 to 5/26/23, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but no later than 2 hours after the allegation was made. This was evident for 2 (Resident #143 and #18) of 39 sampled residents. Specifically, 1) Resident #143 reported an allegation of abuse and the facility did not report the allegation to the NYSDOH timely, and 2) the facility did not report a resident-to-resident altercation that resulted in pain to NYSDOH involving Resident #18.
The findings are:
The facility policy titled Abuse Prevention Policy and Procedure stated that All incidents will be investigated. The facility will report all incident or violations where abuse, neglect, mistreatment of misappropriation of property is suspected to NYSDOH according to protocol.
1) Resident #143 had diagnoses which included atrial fibrillation and hypertension.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #143 's cognitive status was intact.
The facility's Incident Report documented that on 01/24/23 at approximately 9:30 AM, the Assistant Administrator received a call from Resident #143's sister who stated the resident reported that a Certified Nursing Assistant (CNA) slapped their buttocks while rendering care.
The Nursing Home Facility Incident Report Submission record documented the incident was reported on 01/24/23 at 05:20 PM.
There was no documented evidence the facility reported Resident #143's allegation of abuse to the NYSDOH within 2 hours of occurrence.
On 05/25/23 at 11:55 AM, the Assistant Administrator was interviewed and stated that allegations of abuse are supposed to be reported to the NYSDOH within 24 hours. The allegation of abuse is investigated first before the NYSDOH is contacted.
On 05/25/23 at 03:07 PM, the Director of Nursing (DON) was interviewed and stated the Administrator is responsible for reporting allegations of abuse to the NYSDOH. Reports of abuse are required within 5 days of the occurrence. The police were not called after Resident #143 made an allegation of abuse against a CNA.
On 05/25/23 03:31 PM, the Administrator was interviewed and stated Resident #143's allegation of abuse was reported on 01/24/23 at 05:20 PM. Resident abuse is reported to the NYSDOH within five days. All abuse allegations are supposed to be reported within 24 hours. If there is immediate injury, it is reported immediately. The Administrator further stated local law enforcement was contacted to inform them of the situation on 01/24/23, but the Administrator did not have a record of that report.
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 05/22/23 to 05/26/23 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 05/22/23 to 05/26/23 the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, The MDS assessments did not accurately document that four side rails were used with a resident. This was evident for 1 of 1 resident reviewed for Physical Restraints out of a of 39 sample residents. (Resident #126).
The findings are:
Resident #126 had diagnoses which include Restlessness and agitation, Dependence on respirator [ventilator] status, and Seizure Disorder.
The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #126 had severely impaired cognition and required total assistance of one person for transfers and toilet use. The MDS also documented that bed rails were not used.
On 05/22/23, from 9:55 AM to 01:55 PM, Resident #126 was observed in bed, alert and awake with padded bilateral full side rails in place. Resident #126 appeared confused and could not communicate verbally.
On 05/25/23, from 10:33 AM to 02:55 PM, Resident #126 was again observed in bed, alert and awake with padded bilateral full side rails in use. The resident occasionally moved their legs and arms involuntarily.
A review of Physician's Order dated 7/27/22 renewed 5/1/23 documented the following: Two half (2 1/2 ) Side rails up while in bed to promote and maintain bed boundaries as well and enablers.
There was no documented evidence that the said rails use was captured on the most recent MDS assessment of 5/15/23.
During an interview on 05/26/23 at 03:13 PM, the MDS Assessor stated that they see the resident, review the orders, and interview staff to complete the MDS assessment. Any device being utilized should be included in the MDS. If the resident is using full side rails and is unable to release them, they could be considered a restraint. The MDS Assessor stated that it could be that the resident did not have the side rails up when they completed the assessment, and there was no physician's order for full side rails. The MDS Assessor stated that they reviewed the MDS and modified it.
On 05/26/23 at 3:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the side rails are not used as a restraint. The DON also stated that they were fully aware that full side rails could be a restraint, if necessary, assessments were not completed, and alternate measures didn't work. The DON concluded by saying that the MDS will be modified.
415.11
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not develop and implement a Baseline Care Plan (BCP) within 48 hours of admission. This was evident for 1(Resident #546) out of 1 resident reviewed for Care Planning out of a sample of 35 residents. Specifically, Baseline Care Plan was initiated but not completed within 48 hours of admission, and residents and their representatives were not provided with a written summary of the baseline care plan.
The findings are:
The policy and procedure titled Baseline Care Plans dated 3/16/22 documented that it is the facility's policy to develop and implement a Baseline Care Plan (BCP) to each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.
Resident #546 was admitted to the facility on [DATE] with diagnoses of Chronic Gout, End Stage Renal Disease, and Hyperlipidemia.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #546 was cognitively intact, and the resident and family participated in the assessment and goal setting.
During the interview on 5/22/23 at 1:46 PM, Resident #546 stated that they were admitted to the facility for short-term placement. Resident #546 was not provided a copy of their BCP or invited to an interdisciplinary care plan meeting upon admission.
The review of the medical record dated from 1/18/23 to 5/22/23 revealed there was no documented evidence that the BCP was developed for Resident #546.
On 5/25/23 at 11:43 AM, the Director of Social Work (DSW) was interviewed and stated Resident #546's BCP was created initially on 1/18/23 but it was never completed nor given to the resident. DSW provided the hard copy of Resident #546's BCP (created date of 1/18/23, completed date of 5/25/23) to the surveyor. DSW further stated It may have been missed because the resident was transferred to the hospital shortly after being admitted and returned later to the facility. DSW stated that it was an oversight and acknowledged that BCP should have been completed/provided to the resident during the admission process.
415.11 (c)
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** 2) Resident #547 was admitted to the facility with diagnosis of Chronic Atrial Fibrillation, Coronary Artery Disease, and Hypert...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #547 was admitted to the facility with diagnosis of Chronic Atrial Fibrillation, Coronary Artery Disease, and Hypertension.
The Minimum Data Set 3.0(MDS) assessment dated [DATE] documented resident received 7 days of anticoagulant.
The medical order initiated 4/28/23, renewed 3/19/23 documented Resident #547 to receive Eliquis 5 mg tablet every 12 hours.
A review of the Medication Administration Record of May 2023 documented that resident received Eliquis 1 tablet (5 mg) every 12 hours at 9AM and 9 PM during the month of May 2023.
Review of the Comprehensive Care Plan (CCP) initiated 4/28/23, revised 5/22/23 revealed there was no documented evidence that care plan for anticoagulant use was developed.
During an interview on 5/25/23 at 10:36 AM, RN Supervisor (RNS #4) stated that Resident #547 has been on Eliquis since admission, and they were not aware that there was no care plan developed for anticoagulant use. RNS #4 acknowledged that it should have been developed when the care plan was created initially.
During an interview on 5/26/23 at 12:31 PM, Director of Nursing (DON) stated that they were not aware that there was no care plan developed for anticoagulant for Resident #547.
415.11(c)(1)
Based on record reviews and interviews conducted during the recertification survey from 05/22/23 to 05/26/23, the facility did not ensure that comprehensive care plans (CCP) were developed. This was evident for 2 (Resident #60 and #547) of 39 sampled residents. Specifically, a dialysis care plan was not developed for Resident #60, and an anticogulant care plan was not developed for Resident #547.
The findings are:
1) Resident #60 had diagnoses of chronic kidney disease and type 2 diabetes.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #60 was cognitively intact, received dialysis, and received a therapeutic and mechanically altered diet.
On 05/25/23 at 10:01 AM, Resident #60 was interviewed and stated they are scheduled for testing for a kidney transplant today and desires a more liberal diet and meal planning.
Medical Doctor Orders (MDO) last renewed 5/7/23 documented Resident #60 was ordered to receive a no concentrated sweets/no added salt diet, non-carb ProSource 30cc twice daily, Nepro supplement 8 oz twice daily, hemodialysis 3 times weekly, hold meds when out to dialysis, left Arteriovenous Graft (AVG) arm precautions, no blood pressure on left arm, Renvela 800mg 3 times daily with meals, and monitor vitals post/pre dialysis. Resident #60 has an appointment with the Kidney Clinic 5/25/23.
Nursing Notes from 4/27/23 to 5/24/23 documented Resident #60's pre and post dialysis weights and vitals.
There was no documented evidence a CCP related to dialysis was developed and implemented for Resident #60.
On 05/26/23 at 12:11 PM, CNA #8 was interviewed and stated Resident #60 gets a regular or chopped diet. There are no other dietary restrictions. Resident #60 goes to dialysis 3 times weekly.
On 05/26/23 at 12:27 PM, the Inservice Coordinator/Covering Registered Nurse (RN) Supervisor was interviewed and stated the RN Supervisor is responsible for initiating CCPs based on resident need. The Intake Coordinator reviewed Resident #60's medical record and was unable to locate a CCP related to dialysis treatment. There should be a CCP to address the resident's dialysis needs
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident for 1 (Resident #35) of 1 resident reviewed for Infection Control, out of a sample of 38 residents. Specifically, there was no documented evidence that a Pulmonary consult that was ordered for a resident (Resident #35), with Respiratory Syncytial Virus (RSV), was done.
The findings are:
The facility's policy titled Consultation Request and Report, dated January 2022, documented that the purpose is to ensure that all consults ordered by the Attending Physician, will be done in a timely manner.
Resident #35 was admitted to the facility with diagnoses that include Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease (COPD) and Non-Alzheimer's Dementia.
The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The resident required extensive assistance of 1 person for bed mobility, transfers, an toilet use. The MDS documented Resident #35 had no pain and no isolation or quarantine
The Comprehensive Care Plan (CCP) titled Respiratory Disorders: COPD/Oxygen use /RSV, created 11/27/17, documented Resident #35 was at risk for respiratory distress due to the diagnosis of COPD, and the resident was prescribed albuterol via nebulizer. The goals included that Resident #35 would not experience complications of COPD such as respiratory failure or dysrhythmias. Interventions included to monitor respiratory status -oxygen saturation, lung sounds, cyanosis, use of accessory muscles, shortness of breath, etc.
A nursing note dated 12/12/22 documented Resident #35 was tested for COVID-19, RSV, and Influenza.
The laboratory findings dated 12/12/22 documented the resident tested positive for RSV.
The Physician's Orders dated 12/12/22 documented orders for Residesnt #35 to be tested for RSV.
The Physician's Order dated 12/13/22 documented a Pulmonology consult was ordered because the resident tested positive for RSV.
A Nurse Practitioner's (NP) progress note dated 12/13/22 documented the labs were reviewed, and the resident tested positive for RSV. The resident was currently stable, on medication for cough, and received symptom management. A Pulmonology consult ordered.
An NP progress note dated 12/19/22 documented Resident #35 was seen for a follow-up visit and tested positive for RSV last week. NP also documented that upon assessment the resident continued to have a cough, and Guaifenesin was re-ordered. The resident was RSV+ and required symptom management with Guaifenesin 100 milligrams (mg)/5 milliliters (ml), 10ml 3 x daily x 5 days.
A Medical Doctor's (MD) note dated 12/20/22, documented that the patient was seen and examined at bedside after being positive for RSV last week and that the resident (#35) continued complaining of cough, but stateed that overall, felt well. MD also documented the assessment and plan: Cough, and to continue with Guaifenesin as needed. Monitor for improvement. COPD was stable, and the plan was to continue current management.
There was no documented evidence that the Pulmonary consult was done,
On 05/24/23 at 02:46 PM, the Licensed Practical Nurse (LPN) #3 was interviewed and stated that when a consult is ordered, it is picked up by the RN or the Supervisor. The LPNs are not allowed to pick up the orders for consults. LPN #3 stated they were not aware a Pulmonology consult was ordered for Resident #35.
On 05/23 at 11:13AM, Registered Nurse (RN) #5 was interviewed and stated that they are the charge nurse for the unit and worked at the time Resident #35 had RSV. RN #5 said that the the resident did not follow-up with the Pulmonologist, and it was missed. RN #5 also stated that when they get a consult order, the RN enters the order. Then, the order is printed out and put inside the folder for the respective consultant in the Staffing Office. There is no reconciliation in the electronic medical record for the consult orders, and only the RN prints out the consults.
On 05/24/23 at 02:50 PM, the Nurse Practitioner (NP) #2 was interviewed and stated that they saw Resident #35 on 12/12/22 and 12/19/22. NP #2 said that RSV, initially a pediatric illness, was very new to adults, and it was not a concerns. NP #2 stated they ordered a Pulmonary Consult for Resident #35 due to RSV, however, they did not pursue it since the resident was better. NP #2 stated that they did not document that they were not going to pursue the consult, nor did they notify the nurse that a Pulmonary consult was not needed.
On 05/24/23 at 03:14 PM, the DON was interviewed and stated that consult orders are filled out on the unit. Then, the consult order is printed out and put in the nursing office so the consultants pick up the consultation order in the office and do the consults. The DON said that only the RN or the RNS pick up the consult orders. The DON also said that the nursing secretary oversees that the consults are done, whether weekly or daily. The Nursing Care Coordinator (NCC) who oversees the units daily should be checking to see if they are followed-up. The DON said that they don't know how it was missed.
415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents received adequate supervision to prevent accidents and hazards. This was evident for 1 (Resident #107) of 5 residents reviewed for Accidents/Hazards out of 39 total sampled residents. Specifically, Resident #107, a resident with a history of holding their own smoking materials against facility policy, did not receive adequate supervision to prevent the resident from smoking in their room.
The findings are:
The facility policy titled Non-Smoking Facility Revised 9/5/2020, documented the facility will provide appropriate safety education, including location of the designated smoking area. Residents who identified as smokers will keep all smoking materials/paraphernalia with the Recreation Department to ensure safe storage of materials.
Resident #107 had a diagnosis of diabetes mellitus and pulmonary embolism.
The Minimum Data Set 3.0 (MDS) dated documented Resident #107 had mild cognitive impairments.
On 05/26/23 at 10:55 AM, Resident #107 was interviewed and stated they have been in the facility for a couple of months and someone they know brought cigarettes to them. Resident #107 admitted to the nursing staff that they were smoking in their room. The staff didn't know until Resident #107 alerted them because Resident #107 felt guilty about it. The nursing staff did not perform room search. Resident #107 did give their cigarettes and lighting materials to the nursing staff.
An Activities Note dated 3/26/23 documented Resident #107 was unsure about smoking and refused to sign the smoking agreement.
A Social Work (SW) Note dated 3/27/23 documented Resident #107 was educated regarding the facility smoking policy. The note did not document Resident #107's smoking status.
The Smoking Contract dated 5/1/23 documented Resident #107 signed in agreement that the facility has the right to search their room with or without their presence if smoking materials have been found and Resident #107 will be evaluated to determine their ability to smoke.
The Comprehensive Care Plan (CCP) related to smoking initiated 5/1/23 documented Resident #107 is a known smoker and will smoke in the designated area. The CCP was updated on 5/1/23 that Resident #107 signed the smoking contract. On 5/8/23 the CCP documented Resident #107 refused to give the Recreation smoke monitor their smoking materials.
The SW Note dated 5/8/23 documented Resident #107 refused to give their smoking materials to the recreation staff. Resident #107 was not an everyday smoker.
The CCP was not updated with new interventions after the resident refused to have the facility hold their smoking matierials.
A Smoking assessment dated [DATE] documented Resident #107 becomes aggressive when redirected about smoking hours, will give/sell cigarettes to others, attempts to hide or hold their own lighter and cigarettes, and, at times, does not use an ashtray.
There were no CCP interventions to address Resident #107's behavior of giving/selling cigarettes to others or attempts to hold their own smoking materials.
A Nursing Note dated 5/25/23 at 9:45 PM documented a strong smell of smoke was coming from Resident #107's room and the nursing supervisor found the resident sitting by the window smoking marijuana. The resident admitted to smoking cigarettes and denied smoking marijuana although a strong smell of marijuana was present. Nursing staff conducted a room search on 5/26/23 and confiscated Resident #107's lighter.
The SW Note dated 5/26/23 documented Resident #107 received counseling re: facility smoking policy and discharge planning was explored.
On 05/26/23 at 10:39 AM, Registered Nurse (RN) #6 was interviewed and stated they are per diem and do not usually work on this unit. RN #6 thinks there might be smokers on the unit but is not sure. Recreation obtains the resident's smoking status upon admission and instructs the residents to give over their cigarettes and smoking materials. RN #6 did not have a list of smokers and stated the only way nursing becomes aware a resident is a smoker is when the resident discloses this information to them. Recreation keeps a list of smokers. RN #6 does not know if there are any noncompliant smokers in the facility. The nursing staff are informed if a resident is smoking outside of the designated smoking times. Residents are not supposed to hold onto their lighters and cigarettes. RN #6 does not know of any residents that hold their own cigarettes or lighting materials. If a resident is noncompliant with smoking rules, the staff must do a room check followed by a CCP meeting with the interdisciplinary team (IDT). RN #6 then check the 24-hour Report to review information endorsed by the previous nursing shift and stated they are reading for the first time that Resident #107 was found smoking in their room last night. RN #6 stated this had not been endorsed to them when they started their shift. There was a strong smell of smoke, and the Director of Nursing (DNS) approached the resident. Resident #107 was reminded of the smoking contract. There is no documentation that the resident's room was searched. Frequent rounds on Resident #107 were done after they were found smoking in their room.
On 05/26/23 at 11:28 AM, the Director of SW (DSW) was interviewed and stated SWs ask residents about their smoking status upon admission to the facility. If a resident says they smoke, the SW informs Recreation and Recreation educates the resident re: the facility smoking policy. Recreation has the resident sign a contract and has the resident hand over their smoking materials. The IDT determines if the resident is safe to smoke. SW counsels and reeducates residents re: handing over smoking paraphernalia. If there is continued noncompliance with smoking rules, SWs provide education and explore discharge planning with a resident if this is not an appropriate space for them. The smoking hours changed recently because the weather is better, and the residents can smoke outside more. Recreation verbally let residents know via word of mouth that smoking hours were changed. The DSW stated it was reported to them this morning that Resident #107 was found smoking in their room. The DSW counseled Resident #107 who admitted smoking. No room check was performed. Resident #107 was told not to smoke in their room. The DSW stated they think Resident #107 ordered the cigarettes and Resident #107 said it was a mistake and would not happen again.
On 05/26/23 at 03:35 PM, the Director of Recreation (DOR) was interviewed and stated the facility previously allowed smoking and then switched to being a non-smoking facility in April 2023. A meeting was held with the Resident Council in January 2023 re: the change in smoking status for the facility. There was no mailing to the families. And no notices were handed out to residents regarding the facility's change in smoking status. The facility stopped admitting residents that were smokers. Administration was supposed to meet with residents to give a new smoke policy and it just didn't happen. The grandfathered-in residents are accommodated. Some residents are admitted as non-smokers but see other residents smoking and then decide that they want to smoke. The new admissions are allowed to smoke. Residents are asked to sign the smoking contract. Once violated, the resident is supposed to be discharged elsewhere. The facility has not discharged any residents related to their smoking noncompliance. Non-compliant smokers account for 8 out of 20 smokers. When these issues are brought up in morning report with the other disciplines, the DOR is not provided with guidance on how to address the current smoking population. Recreation keeps a smoking list on their cart and on the DOR's computer. All charge nurses are made aware of smokers during morning report. They get a list when it changes. In the event there is a noncompliant smoker, the IDT approaches the resident, reeducates them on the smoking policy and lets the nursing staff know. This is documented in the Activities progress notes and on the CCP. There have not been any CCP meetings held with the noncompliant smokers. Noncompliant smoking was addressed with the Resident Council. The IDT responded to Resident #107, counseled the resident, and discussed discharge placement. Resident #107 came in as a nonsmoker, was assessed after noncompliance where she was in possession of cigarettes and was determined to be a safe smoker. Resident #107 stated they understand the policy but then the resident smoked again last night. The resident is awarded a smoking contract and safe smoking status even though they already violated the policy. The CCP related to smoking is updated when there is noncompliance but the interventions for complaint and noncompliant smokers stay the same.
415.12(h)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 resident (Resident #18) reviewed for Pain Management out of 38 total sampled residents. Specifically, Resident #18 received opiod pain medications and treatment without ongoing monitoring of the efficacy of the pain management.
The findings are:
The policy titled Pain Management dated 7/2022 documented the nurse should document the pain scale reported by the resdient and a pain scale after interventions were rendered.
Resident #18 had diagnoses of bipolar disorder and spinal stenosis.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderate cognitive impairment, received opioid medication 7 out of 7 days prior to the assessment, and reported they had no pain at time of the assessment.
The Comprehensive Care Plan (CCP) related to pain management initiated 12/10/21 documented Resident #18 had lower back pain and interventions included monitoring side effects of pain medication, ongoing assessment of pain, and monitoring resident's behavior.
Nursing Pain assessment dated [DATE] documented Resident #18 had no pain in the previous 5 days and no indicators of pain were present.
The Medical Doctor Orders (MDO) renewed 5/18/23 documented Resident #18 was ordered to receive Tylenol 650 mg every 6 hours as needed (PRN), Lidocaine patch to left knee and lumbar spine, Methadone (an opioid) for chronic pain, Morphine (an opioid) extended release 60mg every 12 hours. There was no documented order for pain monitoring.
The Medication Administration Record (MAR) for May 2023 documented Resident #18 received Tylenol 650 mg every 6 hours 11 out of 27 opportunities from 5/2/23 to 5/23/23. There was no documented pain scale to monitor efficacy of Tylenol 650 mg every 6 hours.
Pain Monitoring for Resident #18 documented the following:
5/2/23 at 10:02 PM Pain = 6, Back
5/5/23 at 2:52 AM Pain = 4, Back
5/18/23 at 12:54 AM Pain = 4, Headache
5/19/23 at 12:04 AM Pain = 6, Back
There was no documented evidence Resident #18 received ongoing monitoring for efficacy of the pain management.
On 05/25/23 at 11:57 AM, Resident #18 was interviewed and stated their pain is well-controlled with pain medications.
On 05/26/23 at 10:05 AM, Certified Nursing Assistant (CNA) #7 was interviewed and stated Resident #18 has pain in their knees and lower back. The nurse applies a patch for the pain. When Resident #18 complains of pain, CNA #7 tells the nurse, and the nurse gives the resident medication for the pain.
On 05/26/23 at 10:15 AM, Registered Nurse (RN) #5, Supervisor of Resident #18's unit, was interviewed and stated Resident #18 expresses chronic pain in their back and leg. RN #5 assesses the resident's pain by asking where the pain is, assessing the area, and reporting to the Medical Doctor. The nurses use a verbal pain scale from 1- 10 to assess a resident's level of pain, documents this in the MAR and then administer PRN pain medications. After 30 minutes, the nurse follows up with the resident and documents another pain scale in the MAR. After reviewing Resident #18's medical record, RN #5 stated the nurses have not been documenting a pain scale before and after administering pain medication to Resident #18. The pain scale should be documented under the comments section and clinical monitoring, but it is not there. The nurse should have requested for the resident to have an evaluation by the MD for the pain. Resident #18 should have been referred for a pain management consultation. The Licensed Practical Nurse (LPN) is responsible for documenting the pain scale and RN #5 is responsible for ensuring the LPN does the pain scale accordingly. RN #5 stated they did not review Resident #18's medical record and did not know they were missing a pain scale. There is no MD Order for pain scale or monitoring to be done for Resident #18. RN #5 stated Resident #18's medical record did not prompt the nurses to document a pain scale and RN #5 made a revision to ensure the nurses would be prompted to document a pain scale going forward.
On 05/26/23 at 12:45 PM, Resident #18's MD was interviewed and stated Resident #18 has opioid dependence but not opioid abuse. The MD did not initiate Resident #18's use of morphine for their back pain. Resident #18 was admitted to the facility on morphine. Resident #18 has not had any pain management consults. Tylenol is needed as a PRN medication to manage breakthrough pain. Resident #18's pain is chronic and muscular in nature. Even with the morphine, Resident #18 complains of back pain. The MD speaks with the Resident #18 and the nurses about Resident #18's pain. The MD does not know what the nurses do to assess or monitor Resident #18's pain. The MD stated they usually try to titrate opioid use down when a resident's pain is better controlled. Resident #18's complaints of pain have been less frequent, and Resident #18 could benefit from a pain management consult.
415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that if bed rails are used, correct installation, use, and maintenance was maintained. This was evident for 1 (Resident #126) resident reviewed for Physical restraint out of a sample of 39 residents. Specifically, Resident #126 had full side rails in use without (1) An assessment for risk for entrapment from bed rails prior to installation; (2) review of the risks and benefits of bed rails with Resident #126's representative to obtain informed consent prior to installation, and (3) An evaluation to ensure the bed's dimensions are appropriate for Resident #126's size and weight.
The findings are:
The facility policy titled Side Rail Use dated 2017 documented that resident will be assessed for functional status on admission, readmission and quarterly. Partial side rails will only be used by a resident to assist with his or her bed mobility. Full side rails are only be used when a resident has a movement disorder and unable to control their movement disorder.
The policy further documented the following procedures: Initial assessment of side rails to be completed by the Interdisciplinary team (IDT), this includes nursing, rehab, and social service. The resident or significant others will be notified and educated about the side rails, the maintenance worker will conduct appropriate measurement and maintain monitoring of the risk of entrapment.
Resident #126 had diagnoses which include Restlessness and agitation, Dependence on respirator [ventilator] status, and Seizure Disorder.
The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #126 had severely impaired cognition and required total assistance of one person for transfers and toilet use. The MDS also documented that bed rails were not used for this resident.
On 05/22/23, from 9:55 AM to 01:55 PM, Resident #126 was observed in bed, alert and awake with padded bilateral full side rails in place. Resident #126 appeared confused and could not communicate verbally.
On 05/25/23, from 10:33 AM to 02:55 PM, Resident #126 was again observed in bed, alert and awake with padded bilateral full side rails in use. The resident occasionally moved their legs and arms involuntarily.
There was no physician's order for the use of bilateral full side rails.
There was no documented evidence in the medical record that a side rails assessment was completed for Resident #126, and no evidence that the facility had tried alternative measures before using full side rails. There was no evidence documented in the medical records that the resident representative was contacted to obtain informed consent prior to installation of side rails. There was no documented evidence the resident was assessed for risk for entrapment or the bed was evaluated to determine the bed dimensions were appropriate for Resident #126 prior to the bed rail installation.
During an interview on 05/25/23 at 03:13 PM, the Certified Nursing Assistant (CNA #5) stated Resident #126 had full side rails for over a year. CNA #5 also stated Resident #126 used to have half SR when they resided in a different room on the west side, but Resident #126 liked to come out of bed. That is why the full SRs were started. CNA #5 stated they monitor the resident one-to-one (1:1) because Resident #126 likes to move around, and they remove their peg tube.
During an interview on 05/25/23 at 03:51 PM, the Assistant Director of Nursing (ADON) stated that they cannot determine when Resident #126 began having the full side rails. The ADON stated the Interdisciplinary Team (IDT) decides if a resident needs a restraint, such as full side rails. They also stated that they reviewed Resident's #126 medical records found no assessment for the full side rails. As a result, they called rehab to complete an assessment today, and decided Resident #126 needed full side rails and obtained an order from the physician.
During an interview on 05/25/23 at 04:08 PM, the Director of Nursing (DON) stated that they were not aware that the resident used full side rails. DON also stated that a side rail assessment must be completed when using side rails of any kind. The DON stated they must get an order for the SR, create a CCP, and notify the family about the SR use. The DON stated they reviewed the records and found no record indicating who put the side rail on for Resident #126.
During an interview on 05/26/23 at 09:52 AM, the Director of Maintenance stated that the nursing or rehab department would verbally inform them about what type of SR is needed. They stated that sometimes the nursing will inform them of the size, such as length and weight. They also stated that they do not communicate with the physician and do not have access to the medical records, and they don't any documentation as to what type of bed they installed. The Maintenance director concluded by saying that the resident #126 has been on full SR since they began working in the facility, and they are the only resident with full SR in the building.
During an interview on 05/26/23 at 03:50 PM, the Rehab Supervisor (RS) stated that thy were not aware that Resident #126 was on full side rails until they were asked by nursing on 5/25/23 to conduct an assessment for the need for full side rails. The RS also stated that they were fully aware that full side rails could be a restraint, if necessary, assessments were not completed and alternate measures were not explored. They stated that the nursing usually will inform the rehab what type of bed rails resident needs. They concluded that Resident #126 would continue to use full side rails due to their behaviors. The resident needed to use full side rails because of behaviors we cannot control. The resident also has a personal aide, and the CNA does 1:1 observation to ensure safety.
415.12(h)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the fac...
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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 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet their needs. This was evident for 1 (Resident #446) of 39 total sampled residents. Specifically, a resident was prescribed Allopurinol once a day and nurses were administering twice a day.
The findings are:
The facility Policy on Medication Administration dated September 2021, documented: The RN shall write verbal and telephone orders and shall read the order back to the ordering Physician or Authorized Practioner for confirmation of accuracy. Also documented Verify the medication selected matches the order and label. and The Licensed Nurse shall verify active medication orders prior to administration and ensure that the intent of the order is carried out.
Resident #446 was admitted [DATE] with diagnoses which include Gout due to renal impairment, Bipolar disorder, and Major depressive disorder.
The Physician's Orders dated 5/05/23 documented the following medication order:
Allopurinol 100 mg (milligrams) tablet: give 1 tablet (100 mg) by oral route once daily.
The Medication Administration Record (MAR) for May 2023 documented Resident #446 received Allopurinol 100 mg at 9:00 am and 5:00 pm from 5/05/23 to 5/22/23.
The Nurse Practioner (NP) Progress Note dated 5/24/23 documented Registered Nurse (RN) reported that Allopurinol 100 mg tablet was transcribed as daily but administered twice a day (BID).
On 5/25/23 at 10:01 AM, the Registered Nurse (RN #3) was interviewed and stated Resident #446's hospital discharge instructions documented Allopurinol as BID but I transcribed the order as once daily in the Electronic Medical Record (EMR). I am not sure how that could have happened and also how medications are reconciled. I probably clicked on every day (QD) by mistake on the physician order and scheduled correctly as BID in the MAR.
On 5/26/23 at 3:03 PM, the NP #9 was interviewed, and stated I was at the facility when Resident #446 was admitted . I spent time with the resident and reviewed the hospital discharge medication list. I ordered the Allopurinol to be administered once a day. My focus was that resident was on too many medications.
On 5/26/22 at 3:46 PM, the Director of Nursing (DON) was interviewed and stated I questioned the nurse who transcribed the order, and he/she said the Allopurinol order is supposed to be BID as documented in the hospital discharge paperwork. I informed the nurse that he/she clicked once daily in Sigma. This was a transcription error from day 1. There is a system in place where every order gets rechecked by 3 nurses. The 3 nurses that checked that order were all given warnings for not picking this error up.
415.18(a-d).
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
Infection Control
(Tag F0880)
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 during the Recertification and Complaint Survey (NY00308839), from 05/22/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility failed to establish and maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases. Specifically, the facility did not follow their policy and procedures to maintain Contact precautions on a resident (Resident#35). with Respiratory Syncytial Virus (RSV). This was evident for 1 of 1 resident reviewed for Infection Control, out of a sample of 38 residents.
The findings are:
The facility's policy titled Guidelines for Isolation Precautions: preventing transmission of infectious agents in healthcare settings dated May 2020, documented that the purpose is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for residents, visitors, and employees. The policy also documented that example of infections requiring contact precautions include RSV.
Resident#35 was admitted to the facility with diagnoses that include Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease (COPD) and Non-Alzheimer's Dementia.
The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognition is moderately impaired, needs extensive assistance of 1 person's physical assistance for bed mobility, transfers, toilet use, supervision with set up for eating. MDS also documented no pain, no isolation or quarantine
The Physician's Orders dated 12/12/22 documented an order for Resident #35 to be tested for RSV.
The Physician's Order dated 12/13/22 documented an order for a Pulmonology consult for positive RSV.
The laboratory findings documented 12/12/22 Flu Panel ordered with results documented Resp Syn Virus Result: Detected, Abnormal results.
The Comprehensive Care Plan (CCP) titled Respiratory Disorders: COPD/Oxygen use /Resp Syn Virus, created 11/27/17. Resident is at risk for respiratory distress due to diagnosis of COPD. Prescribed albuterol for nebulizer. Goals include that Resident#35 will not experience complications of COPD such as respiratory failure or dysrhythmias. Interventions include to monitor respiratory status -oxygen saturation, lung sounds, cyanosis, use of accessory muscles, shortness of breath, etc.
A nursing note dated 12/12/22 documented PCR/COVID/RSV/FLU, ready for pickup.
A Nurse Practitioner's (NP) progress notes dated 12/13/22 documented labs reviewed member tested positive for RSV. Currently stable, on medication for cough, symptom management. Pulmonology consult ordered.
An NP progress notes dated 12/19/22 documented member was seen for follow up visit and tested positive for RSV last week. NP also documented that upon assessment member continues to have cough, Guaifenesin re-ordered, RSV+ symptom management, Guaifenesin 100mg/5ml, 10ml 3 x daily x 5 days.
A Medical Doctor's (MD) note documented that the patient was seen and examined at bedside after being positive for RSV last week and that the resident (#35) continues complaining of cough, but states that overall, feels well. MD also documented the assessment and plan: Cough, and to continue with Guaifenesin as needed. monitor for improvement COPD: Stable Continue current management.
There was no documented evidence that the resident was placed on Contact precautions for RSV as per the facility's policy.
On 05/23 at 11:13AM, Registered Nurse(RN)#5 was interviewed and stated that they are the charge nurse for the unit and worked at the time the resident #35 had RSV. RN#5 said that when there is morning discussion with the interdisciplinary team members, it would be disseminated as to what type of precautions may be used if a resident is diagnosed and needs Contact Precautions. The NP would bring it up on the morning report and notify who needs to be on Contact Precautions. The Infection Control (IC) nurse would go around and notify the Staff on which residents are on Contact Precautions. RN#5 said that they were not aware that a resident with RSV had to be on Contact Precautions.RN#5 also said that are educated periodically on IC policies and procedures.
On 05/24/23 at 08:33 AM, the Infection Control Preventionist (ICP) was interviewed and stated that they were not the ICP at the time Resident#35 was confirmed with RSV. The ICP stated that they do have a policy that includes that a resident with RSV should be placed on Contact Precautions.
On 05/24/23 at 02:46 PM, Licensed Practical Nurse (LPN) #3 was interviewed and stated they were not made aware that the RSV is classified for Contact Precautions, and that the resident was not on Contact Precautions at any time in the month of December for such.
On 05/24/23 at 02:50 PM, NP#2 was interviewed and is said that they are one of the NP, and that they saw Resident #35 on 12/12/23, and then on the 19th. NP also said that based on their experience with RSV, it was initially a pediatric illness and that its very new to the Adults, and it was not a concern. The NP also said that they are made aware of the policies of the facility, as it relates to IC. The NP stated that they did order a Pulmonary Consult for Resident #35 due to RSV, however they did not pursue it since the resident was better. The NP also said that they did not document that they were not going to pursue the Consult, nor did they notify the nurse.
On 05/24/23 at 03:14 PM, the Director of Nursing (DON) was interviewed and stated that in reference to RSV, this is something new that was added in the last year, and that Staff is aware, since it is part of the training for Contact Precautions. The DON also said that they (Staff) would need more training, since it was initially a pediatric illness, and not commonly seen with the Adults, and that when the Staff is made aware, signage at the resident's door would be placed, would be discussed when the nurse gives report to the Staff. The IC keeps a list of everyone on the line listings and keeps track of the Infections. The DON said that they were not aware that Resident #35 was on any line listings.
415.12(k)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents, staff, and the public were provided with...
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Based on observation, record review, and interviews conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents, staff, and the public were provided with a safe, sanitary, and comfortable environment. This was evident for 2 (Elevator 1 and 3) of the 3 elevators. Specifically, Elevator 1 and Elevator 3 were observed with detached ceiling panels and dust buildup.
The findings are:
On 05/25/23 at 10:00 AM, Elevators #1 and #3 were observed with ceiling panels that were warped with multiple screws missing. Ceiling panels in each elevator were detached from the ceiling where screws were missing and the panels were observed hanging off of and separated from the ceiling. The wooden molding on the ceiling of Elevator 1 and Elevator 3 bordered the panels and was observed with splintered peeling wooden strips. The center of the ceiling in Elevator 1 and Elevator 3 had a raised dome with ornate metal casing that was covered with dust and grime. One side of the ventilation panel on the ceiling of Elevator 3 was not screwed in, was detached, and was hanging from the ceiling.
On 05/26/23 at 09:40 AM, the Director of Maintenance was interviewed and stated they have observed the issues with the ceiling panels for Elevator 1 and Elevator 3. They tried nailing the panels into the ceiling but they are old and warped because of a former leak on the roof. The leak was fixed but the panels started becoming detached. The screw on the ventilation panel cannot be easily tightened because of the water damage from the leak. The facility is planning to renovate and make improvements. The splintering wood will also be replaced, and it will be a brand-new elevator.
415.29
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) Resident #546 was admitted to the facility on [DATE] with diagnoses of Chronic Gout, End Stage Renal Disease, and Hyperlipide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #546 was admitted to the facility on [DATE] with diagnoses of Chronic Gout, End Stage Renal Disease, and Hyperlipidemia.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #546 was cognitively intact, and the resident and family participated in the assessment and goal setting.
During the interview on 5/22/23 at 1:46 PM, Resident #546 stated that they were admitted to the facility for short-term placement. Resident #546 was not provided a copy of their BCP or invited to an interdisciplinary care plan meeting upon admission.
The review of the medical record dated from 1/18/23 to 5/22/23 revealed there was no documented evidence that Resident #546 was invited to attend the CCP meeting upon admission.
On 5/25/23 at 11:43 AM, the Director of Social Work (DSW) was interviewed and stated Resident #546's BCP was created initially on 1/18/23 but it was never completed nor given to the resident. There was no initial care plan meeting for Resident #546 because the resident was transferred to the hospital shortly after being admitted and returned later to the facility. DSW stated that it was an oversight and there should have been a care plan meeting with the resident/family when resident returned to the facility from the hospital. DSW further stated that resident/resident's family were recently invited to a quarterly care plan meeting and only the family representative attended the meeting held via telephone on 5/18/23 as per medical record. However, DSW was not able to explain why Resident #546 did not attend the meeting.
Surveyor: [NAME]
3.) Resident #97 had a diagnosis of Type 2 diabetes mellitus and Osteomyelitis.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #97 had intact cognition.
On 5/26/23 at 10:59 AM, Resident #97 was interviewed and stated, The facility caught me smoking when I first got here, and since then, I have been compliant. Resident #97 further stated that the staff did not meet with them as a team.
Activity Notes dated note dated 3/9/23, 3/15/23, 5/5/23, 5/6/23, and 5/8/23 documented Resident #97 was noncompliant with smoking paraphernalia and was observed smoking out of pocket. Resident #97 was reeducated regarding the facility smoking policy.
The Smoking Contract dated 8/11/22 documented Resident #97 signed an agreement that they may not retain cigarettes, or other smoking materials such as lighters, matches or other sources of ignition. Smoking materials would be stored in a locked area by the staff. The contract further documented, the facility has the right to search their room with or without their presence if smoking materials have been found.
The Comprehensive Care Plan (CCP) related to smoking initiated 8/8/2022 documented Resident #97 will understand and accept the facility policy on smoking. Interventions included to review the smoking policy with resident and family upon admission, readmission, and as needed. On 5/8/23 the CCP documented Resident #97 remained noncompliant during supervised smoking times, and all departments were aware of the concerns and will continue to monitor and document as needed.
The Resident Smoking List dated 4/03/23, 4/04/23, 4/05/23, 4/08/23, 4/09/23, 4/25/23, and 4/26/23 documented in the comments and observations column that Resident #97 smoked out of pocket during supervised smoking times.
A Smoking assessment dated [DATE] documented Resident #97 becomes aggressive when redirected about smoking hours, will give/sell cigarettes to others, attempts to hide or hold their own lighter and cigarettes, and, at times, does not use an ashtray.
There was no documented evidence the facility addressed Resident #97's noncompliance with the smoking policy and limited accessibility of smoking paraphernalia with revised care plan interventions.
On 5/25/2023 at 12:08 PM the Recreation Director (RD) was interviewed and stated Resident #97 is noncompliant with the smoking policy. Resident #97 pulls their cigarettes and lighter out of their pocket during supervised smoking times. Resident #97 becomes verbally aggressive and swears when staff reviews the smoking rules with them. Also, Resident #97 will not give their smoking paraphernalia to the staff to hold. At morning report, the Director of Nursing (DON), Administrator, and staff are all made aware of these incidents. The RD further added that Resident's room has not been searched.
On 05/26/23 at 11:28 AM, the Director of SW (DSW) was interviewed and stated SWs ask residents about their smoking status upon admission to the facility. If a resident says they smoke, the SW informs Recreation and Recreation educates the resident re: the facility smoking policy. Recreation has the resident sign a contract and has the resident hand over their smoking materials. The IDT determines if the resident is safe to smoke. SW counsels and reeducates residents re: handing over smoking paraphernalia. If there is continued noncompliance with smoking rules, SWs provide education and explore discharge planning with a resident if this is not an appropriate space for them.
On 05/26/23 at 03:35 PM, the Director of Recreation (DOR) was further interviewed and stated the grandfathered-in residents are asked to sign the smoking contract. Once violated, the resident is supposed to be discharged elsewhere. The facility has not discharged any residents related to their smoking noncompliance. Non-compliant smokers account for 8 out of 20 smokers. When these issues are brought up in morning report with the other disciplines, the DOR is not provided with guidance on how to address the current smoking population. Recreation keeps a smoking list on their cart and on the DOR's computer. All charge nurses are made aware of smokers during morning report. They get a list when it changes. In the event there is a noncompliant smoker, the IDT approaches the resident, reeducates them on the smoking policy and lets the nursing staff know. This is documented in the Activities progress notes and on the CCP. There have not been any CCP meetings held with the noncompliant smokers. Noncompliant smoking was addressed with the Resident Council. The CCP related to smoking is updated when there is noncompliance, but the interventions for complaint and noncompliant smokers stays the same.
415.11(c)(2)(i-iii)
Based on observations, record reviews, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure resident Comprehensive Care Plan (CCP) was reviewed and revised upon each assessment. This was evident for 3 (Resident #60, #546, and #97) of 39 total sampled residents. Specifically, 1) Resident #60 did not have their CCP related to fluid restriction revised upon change in fluid restriction, 2) Resident #546 was not invited to their CCP meeting, and 3) Resident #97 did not have their CCP related to smoking revised upon noncompliance with facility smoking policy.
The findings are:
The policy and procedure titled Interdisciplinary Care Plan Conference dated 1/20 documented that the facility to hold an interdisciplinary care planning conference to identify resident needs and establish goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents.
1) Resident #60 had diagnoses of chronic kidney disease and type 2 diabetes.
The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #60 was cognitively intact, received dialysis, and received a therapeutic and mechanically altered diet.
On 05/25/23 at 10:01 AM, Resident #60 was interviewed and stated they are scheduled for testing for a kidney transplant today and desires a more liberal diet and meal planning.
Medical Doctor Orders (MDO) last renewed 5/7/23 documented Resident #60 was ordered to receive a no concentrated sweets/no added salt diet, non-carb ProSource 30cc twice daily, Nepro supplement 8 oz twice daily, hemodialysis 3 times weekly, hold meds when out to dialysis, left Arteriovenous Graft (AVG) arm precautions, no blood pressure on left arm, Renvela 800mg 3 times daily with meals, and monitor vitals post/pre dialysis. Resident #60 has an appointment with the Kidney Clinic 5/25/23.
Comprehensive Care Plan (CCP) related to nutritional status initiated 1/9/23 and last reviewed 4/18/23 documented interventions to address Resident #60's nutritional status included accommodate food preferences, assess efficacy of diet quarterly, offer supplements, pre and post dialysis weights, provide oral supplements as ordered. Labs will yield clinically acceptable limits for chronic kidney disease.
CCP related to ADL tasks initiated 8/25/18 documented Resident #60 was on a fluid restriction of 1000 ccs per day.
CCP related to renal/dialysis fluid restriction 1000 cc/day initiated 3/20/20 and last reviewed 3/13/23 documented Resident continues with 1000 cc per day of fluid restriction. Interventions included 720 cc/day from dietary and 280 cc/day from nursing. Meds to be given with 110 cc/morning and evening shift and 60 cc per night shift. Monitor for edema and shortness of breath.
A Dietary Note dated 3/9/23 documented the dialysis dietician recommended to discontinue Resident #60's renal diet and fluid restriction as resident is requesting extra foods and fluids and is noncompliant with diet. Medical Doctor (MD) made aware.
Th Certified Nursing Assistant (CNA) Accountability for 5/2023 documented Resident #60 was on 1000 cc fluid restriction.
On 05/26/23 at 12:11 PM, CNA #8 was interviewed and stated Resident #60 gets a regular or chopped diet. There are no other dietary restrictions. Resident #60 goes to dialysis 3 times weekly.
On 05/26/23 at 12:14 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated Resident #60 receives a renal diet and is on a fluid restriction of 1000ccs per day. This is documented in the record. The CNA Accountability has it. There is supposed to be a MDO for it. The Registered Nurse (RN) Supervisor and the Dietician are responsible for placing the diet and fluid restriction orders for s resident. LPN #2 was unable to find the MDO for Resident #60 to have 1000ccs fluid restriction. The CCP for ADLs has the fluid restriction. Nursing must monitor fluid intake. LPN #2 stated Resident #60 does not drink much when given medication and LPN #2 does not document the resident fluid intake. Nursing staff document the fluid the resident is given during meals like the Nepro supplement. That is the routine for all dialysis patients. The resident is alert and would not take more than allowed on their fluid restriction. All the regular nurses know Resident #60 is on fluid restriction. If a regular nurse is not assigned, the resident will let the nurse know.
On 05/26/23 at 12:27 PM, the Inservice Coordinator/Covering RN Supervisor was interviewed and stated Resident #60 is supposed to have a MDO for fluid restriction.
On 05/26/23 at 03:07 PM, the Registered Dietician/Food Service Director was interviewed and stated resident #60 was taken off fluid restriction some time ago. The resident used to get upset and angry and would act out because of the fluid restriction. It was changed because the nephrologist said Resident #60 was noncompliant and the dietician discontinued the fluid restriction. The CCP related to ADLs and Dialysis fluid restriction should have been updated to reflect the changes.
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 during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive as...
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Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in timely. Specifically, Annual assessments were not transmitted within 14 days of the care plan completion date and Quarterly assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date. This is evident for 3 of 3 residents reviewed for the Resident Assessment facility task (Resident #s 68, 99 and 147).
The findings are but not limited to:
The facility's policy and procedure entitled Minimum Data Set dated 1/19 documented that a standardized, comprehensive assessment (Minimum Data Set) will be conducted for each resident.
1) Resident #68 had a quarterly assessment with assessment reference date of 4/4/23 and completion date of 4/11/23. The assessment was submitted late on 5/24/23.
2) Resident #99 had a quarterly assessment with assessment reference date of 4/11/23 and completion date of 5/2/23. The assessment was submitted late on 5/24/23.
3) Resident #147 had an annual assessment with an assessment reference date of 4/11/23 and completion date of 4/18/23. The assessment was submitted late on 5/23/23.
On 5/26/23 at 11:39 AM, MDS Assessor was interviewed and stated some residents' assessments on unit 7 were submitted late because they did not submit them in a timely manner. MDS Assessor acknowledged that it was their mistake and that they were all submitted late recently.
On 5/30/23 at 3:01 PM, MDS Coordinator was interviewed and stated that they had a staffing shortage issue during that month because one of the staff went out on a medical leave. MDS Coordinator stated that the staff member is back on duty and the department is now fully staffed. MDS Coordinator further stated that it will not be an issue going forward.
415.11
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most New York facilities.
- • 39% turnover. Below New York's 48% average. Good staff retention means consistent care.
Concerns
- • 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is New Vanderbilt Rehabilitation And, Inc's CMS Rating?
CMS assigns NEW VANDERBILT REHABILITATION AND CARE CENTER, INC an overall rating of 1 out of 5 stars, which is considered much 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 New Vanderbilt Rehabilitation And, Inc Staffed?
CMS rates NEW VANDERBILT REHABILITATION AND CARE CENTER, INC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 39%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at New Vanderbilt Rehabilitation And, Inc?
State health inspectors documented 37 deficiencies at NEW VANDERBILT REHABILITATION AND CARE CENTER, INC during 2023 to 2024. These included: 34 with potential for harm and 3 minor or isolated issues.
Who Owns and Operates New Vanderbilt Rehabilitation And, Inc?
NEW VANDERBILT REHABILITATION AND CARE CENTER, INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 320 certified beds and approximately 268 residents (about 84% occupancy), it is a large facility located in STATEN ISLAND, New York.
How Does New Vanderbilt Rehabilitation And, Inc Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, NEW VANDERBILT REHABILITATION AND CARE CENTER, INC's overall rating (1 stars) is below the state average of 3.0, staff turnover (39%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting New Vanderbilt Rehabilitation And, Inc?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 below-average staffing rating.
Is New Vanderbilt Rehabilitation And, Inc Safe?
Based on CMS inspection data, NEW VANDERBILT REHABILITATION AND CARE CENTER, INC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at New Vanderbilt Rehabilitation And, Inc Stick Around?
NEW VANDERBILT REHABILITATION AND CARE CENTER, INC has a staff turnover rate of 39%, which is about average for New York nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was New Vanderbilt Rehabilitation And, Inc Ever Fined?
NEW VANDERBILT REHABILITATION AND CARE CENTER, INC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is New Vanderbilt Rehabilitation And, Inc on Any Federal Watch List?
NEW VANDERBILT REHABILITATION AND CARE CENTER, INC 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.