Bensonhurst Center for Rehabilitation & Healthcare

Inspectors wroteBased on record review and interview, conducted during the Recertification survey from 01/26/2025 to 01/13/2025, the facility did not ensure a resident or the resident's representative(s) were notified of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This was evident for 1 (Resident #6) of 2 resident reviewed for Hospitalization, and 1 (Resident #12) of 1 resident reviewed for Discharge out of a sample of 38 residents. Specifically, the facility did not provide written notices of discharge at least 30 days prior to the discharge, and did not send written notices of transfer or discharge to the residents, their representatives, and a representative of the Office of the State Long-Term Care Ombudsman.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey from 01/26/2025 to 01/31/2025 the facility did not ensure residents' person-centered comprehensive care plans were developed and implemented to meet residents' needs. This was evident for 1 (Resident #238) out of 6 sampled residents investigated for Activities of Daily Living out of 38 sampled residents. Specifically, a care plan to address Activities of Daily Living was not developed and implemented for Resident #238 who required substantial assistance with grooming and personal care. The finding is: The facility policy titled Care Plans - Comprehensive with a revision date of 03/20/2024 stated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 01/26/2025 to 01/31/2025, the facility did not ensure that residents or their designated representative were afforded the opportunity to participate in their care planning process. This was evident for 1 (Resident #38) of 1 resident reviewed for Care Planning out of 38 total sampled residents. Specifically, there was no documented evidence that Resident #38 or their representative were given the opportunity to participate in the review and revision of their care plan.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 01/26/2025 to 01/31/2025, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #11) of 5 residents reviewed for Pressure Ulcers out of 38 total sampled residents. Specifically, Resident #11 was observed without a bunny boot, (a pressure-relieving device) on multiple occasions in accordance with the Physician's Order.

Inspectors wroteBased on record review and interviews and conducted during the Recertification Survey and Complaint Survey (NY00331691) from 01/26/2025 to 01/31/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on record review and interviews conducted during the Recertification/ Complaint Survey from 2/14/2023 to 2/22/2023, the facility did not ensure, to the extent practicable, that residents/resident representatives were involved in developing the comprehensive care plan and making decisions about their care. This was evident for 1 of 2 residents reviewed for Participation in Care Planning out of a sample of 38 residents (Resident # 139). Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meetings with the interdisciplinary team.

Inspectors wroteBased on record review, observation, and interviews conducted during the Recertification/ Complaint Survey from 2/14/2023 to 2/22/2023, the facility did not ensure that a resident's MDS assessment accurately reflect the resident status. This was evident for 1 out of 3 residents investigated for Dialysis (Resident #64), and 1 out of 3 residents investigated for Discharge Resident #193), out of an investigative sample of 38 residents (residents #193 and resident #64). Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that 1) A resident ( # 193) who was discharged to an acute hospital was coded as being discharged to the community; 2) A resident (# 64) who was receiving dialysis services was coded as not receiving dialysis.

Inspectors wroteBased on observation and staff interviews during recertification survey, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, hand hygiene was not performed prior to handling food, and the meat slicer was not properly cleaned after use. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observations and interviews, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comvortable interior were provided. Specifically, 6 dirty wheelchairs, dusty and dirty AC units, scratched and chipped furniture, unpatched holes in the wall, torn privacy curtains, and chipped floor tiles were observed on resident units. This was evident for 2 of 6 units observed for the Environment (Units #4 and #5).

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not ensure that medications and biologicals drugs were stored, labeled, and discarded in accordance with currently accepted professional principles. Specifically, (1) antibiotic eye ointment was not removed from the medication cart after the order was discontinued, (2) Enema set and Enema Mineral Lubricant were not discarded after the manufacturers expiration date. This was evident during the observation conducted for the medication cart and room (a cart on the 8th floor and medication storage room on the 4th floor). This was evident for 2 out of 6 floors assessed for medication storage and labeling facility task.

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect during care. Specifically, the Licensed Practical Nurse (LPN) entered a resident room without knocking during medication administration. This was evident of 1 out of 2 residents observed (Resident #408) during medication pass, out of a total investigation sample of 39 residents.

Inspectors wroteBased on interview and record review during the recertification survey, the facility did not provide the appropriate liability notice to a medicare beneficiary. Specifically, the facility did not provide a resident/resident representative with the Skill Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare part A benefits were terminated. This was evident for 1 of 3 residents reviewed for Beneficiary Protection Notification (Resident #122). The finding is: Resident #122 was a resident who received Medicare Part A skilled services and remained in the facility. The minimum data set 3.0 (MDS) documented that the resident had Moderately impaired cognition. The SNFABN Beneficiary Notification Review form for Resident #122 documented Medicare Part A skilled services began on 11/1/2019, and the last covered day of part A service was 12/17/19. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that each resident was provided with personal privacy during care. Specifically, the Licensed Practical Nurse (LPN) administered medications via peg tube without closing the door. This was evident of 1 out of 2 residents observed (Resident # 29) during medication pass, out of a total investigation sample of 39 residents.

Inspectors wroteBased on staff interview and record review conducted during a Recertification and abbreviated survey, the facility did not ensure that each portion of the MDS assessment accurately reflected the resident's status. Specifically, the most recent MDS did not accurately documented that 1 resident was receiving enteral feeding and another resident had a fall. This was evident for 2 of 12 residents reviewed for Resident Assessment out of a total sample of 39 residents (resident #99 and resident #191).

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing,and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, a comprehensive care plan was not developed for a resident on anticoagulant medication. This was evident for 1 of 1 residents reviewed for Anticoagulant Side Effects out of 38 sampled residents (Resident # 365). The finding is: The facility policy # 1.01 revised 5/20/19 documented a care plan is developed for each resident in order to have a systematic blueprint. Care plans include a list of the residents problems, measurable goals for each problem, and itemized interventions to achieve goals. [...]

Inspectors wroteBased on observation, record reviews, and staff interviews during the Recertification Survey, the facility did not ensure that each resident's care was supervised by a physician. Specifically, a resident with a left toe wounds status and treatment was not addressed or reviewed by the physician. This was evident for 1 of 1 resident reviewed for Non-Pressure Skin Conditions (Resident #118) out of 39 sampled residents. The finding is: Resident #118 was [AGE] years old admitted to the facility 2/11/20. The residents diagnoses included Type 2 Diabetes with Diabetic Chronic Kidney Disease (DM), Hypertension, Unspecified Protein Calorie Malnutrition, Atherosclerotic Heart Disease, Unspecified A-Fib, Subacute Osteomyelitis, End Stage Renal Disease (ESRD), and Unspecified Fall. [...]