Boro Park Center for Rehabilitation and Healthcare

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 04/20/2024 to 05/06/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, visitors, or legal representatives where individuals wishing to examine survey results do not have to ask to see them. In addition, notices of the availability of such reports were not posted in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located inside a binder placed behind the Security desk, and there were only two notices posted about the availability of the survey results, and the notices which were not in conspicuous locations. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure medications and biologicals were stored in accordance with currently accepted professional principles and expiration date, if applicable. This was evident for 2 of 16 medication storage areas (2 East medication room and 2 [NAME] Unit medical supply room). Specifically, 13 bags of expired intravenous fluids were observed in the medication room on unit 2 East, and 12 bags of expired intravenous fluids were observed in the medical supply closet on 2 West. This was evident for the Medication Storage task.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 4/29/2024 to 05/06/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) expired enteral feeding was observed in the nourishment/supplement room in the kitchen, and 2) there was unlabeled food, degraded, rotted food and expired yogurt in the 5th floor unit refrigerator, and expired ice cream in the freezer. This was evident for the Kitchen Task and Dining Task.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 4/29/2024 to 5/6/2024, the facility did not ensure residents remained free from physical restraints. This was evident for 1 (Resident #151) of 1 resident reviewed for Restraints out of 38 total sampled residents. Specifically, Resident #151's right hand was observed wrapping by a towel to prevent the free movement of the hand and there was no documented evidence of an evaluation or physician's order for use of a restraint.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 04/29/2024 to 05/06/2024, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 1 (Resident #263) of 5 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #263 did not receive bladder/bowel care in a timely manner.

Inspectors wroteBased on observations, record reviews, and interviews, conducted during the Recertification survey from 04/29/2024 to 05/06/2024, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers and to promote healing. This was evident for 2 (Resident #523 and Resident #380) of 7 residents reviewed for Pressure Ulcer out of 38 sampled residents. Specifically, 1) during multiple observations Resident #523 was observed without heel booties in place as ordered and, 2) Resident #380 was observed during wound assessment with loose stool and an uncovered Stage 3 sacral pressure ulcer.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was observed during Kitchen observation. Specifically, 1) expired food was observed in a kitchen refrigerator; and 2) tray line food was not maintained at an acceptable temperature to prevent foodborne illness and were not discarded.

Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not provide the appropriate liability notices were provided to Medicare beneficiaries. Specifically, the facility did not provide residents/representatives with a Notice of Medicare Non-Coverage (NOMNC) at the termination of Medicare Part A benefits within the required timeframes and did not provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) when they were remaining in the facility for care. This was evident for 1 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 38 residents. (Resident #263)

Inspectors wroteBased on record review and interview during a Recertification survey conducted from 4/14/22 to 4/21/22, the facility did ensure that each resident who experiences a significant change in status is comprehensively assessed. Specifically, a Significant Change in Status Assessment was not completed following the start of hospice services. This was evident for 1 of 1 resident reviewed for Hospice and End of Life out of a sample of 38 residents (Resident #245).

Inspectors wroteBased on record reviews and interviews conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure they electronically transmitted encoded, accurate, and complete MDS data to the CMS System within 14 days. This was evident for 1 of 2 residents reviewed for Resident Assessment out of a sample of 38 residents. (Resident #3)

Inspectors wroteBased on record review and interview conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and included the resident's goals, desired outcomes, and preferences were developed. Specifically, care plans were not developed for a resident with a diagnosis of Diabetes Mellitus and a resident prescribed anticoagulant medication. This was evident for 2 of 9 residents reviewed for Nutrition out of a sample of 38 residents. (Resident #120 & Resident #254)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that each resident was offered the opportunity to participate in the review of their comprehensive care plan (CCP). This was evident in 1 of 2 residents reviewed out of a sample of 38 residents (Resident # 46). Specifically, a Resident #46 was not invited to their CCP meetings with the interdisciplinary team (IDT).

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure the services provided met professional standards. This was evident 1 out of 37 sample residents observed for medication administration (Resident # 295). Specifically, 1) the Registered Nurse (RN) prepared medication in advance and left it in the medication cart, 2) the RN did not wait to ensure that a resident took administered medication.

Inspectors wroteBased on record review, observation, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. Specifically, an emergency medication box with expired medication was not removed from a medication storage room. This was evident for 1 of 7 medication storage rooms observed during the Medication Storage and Labeling task. (Unit 5 East Wing).

Inspectors wroteBased on record reviews, observations and interviews conducted during the Recertification survey from 4/14/22 to 4/21/22, the facility did not ensure a resident's drug regimen was free of unnecessary medications. Specifically, there was no documented evidence of behavioral monitoring for a resident with a dementia diagnosis who was prescribed an antipsychotic. This was evident for 1of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident #402).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure the medication error rate was less than five percent (5%). This was evident for 1 of 37 residents observed for medication administration resulting in an error rate of 8.11% (#295). Specifically, 1) Registered Nurse (RN) #1 administered pre-poured prescribed medication to Resident #295 and walked away without observing the resident take their medication, and 2) Resident #295 did not take all prescribed medications and left prescribed medication in a cup on the medication cart.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey, the facility did not ensure infection control practices were maintained. This was evident for 1 of 7 units (7 Floor Unit; Singer #1, #2, and #3). Specifically, Singer #1, #2, and #3 were observed not wearing surgical facemasks while providing Recreational activities to residents in the 7th floor dining room.

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not ensure that all equipment was being maintained in a clean sanitary manner. Specifically, the meat slicing machine was observed after staff cleaning to still have debris. This deficient practice had the potential to affect all residents in the facility. Sanitizing Policy revised 11/2017 documented all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.