Concourse Rehabilitation and Nursing Center, Inc

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification and Abbreviated survey (NY00331425) from 4/6/2024 to 4/12/2024, the resident received inadequate supervision to prevent an accident. This was evident for one (Resident #80) of three residents reviewed for accidents out of 38 total sampled residents. Specifically, the plan of care did not clearly indicate Resident #80 required 2-person assistance with activities of daily living. Subsequently, Resident #80 fell and sustained a left distal femoral neck fracture (thigh bone broken at the knee) when Certified Nursing Assistant #1 rolled the resident on their side during care without a 2nd staff member's assistance. This resulted in actual harm to Resident #80 that was not immediate jeopardy. Finding is: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/6/2024 to 4/12/2024, the facility did not ensure the results of the most recent facility survey were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for 12 of 12 residents (Resident #s 5, 11, 41, 64, 77, 129, 146, 188, 203, 209, 215, and 295) during the Resident Council Meeting. Specifically, there were no observations of posted survey results in the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification and Abbreviated (NY00331425) survey from 4/7/2024 to 4/12/2024, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health immediately or within 2 hours after the allegation was made. This was evident for 2 (Resident #80 and #119) of 38 total sampled residents. Specifically, 1) Resident #80 had a fall resulting in a fracture that was not reported to the New York State Department of Health, and 2) Resident #119 had an unwitnessed fall resulting in a fracture that was not reported to the New York State Department of Health.

Inspectors wroteBased on record review and interviews conducted during a Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that the baseline care plan was developed within 48 hours of a resident's admission and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 10) of 38 total sampled residents. Specifically, the baseline care plan was not completed within 48 hours of Resident #10's admission to the facility and a copy was not provided to Resident #10.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, a comprehensive care plan was not developed and implemented for Resident #24's use of antipsychotic medication.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, 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 #27) of 6 residents reviewed for pressure ulcers out of 38 total sampled residents. Specifically, Resident #27 was observed without on multiple occasions resident #27 was observed without heel float boots, a pressure-relieving device, in accordance with the Physician's Order.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure dental services were provided from an outside resource to meet the needs of the resident. This was evident for 1 (Resident #203) of 38 total sampled residents. Specifically, the facility did not obtain outside dental services for Resident #203 when a tooth extraction was recommended.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 4/7/2024 through 4/12/2024, the facility did not ensure the Binding Arbitration Agreement granted the resident or representative the right to rescind the agreement within 30 calendar days of signing it. This was evident for 1 (Resident #156) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Resident #156 did not grant the resident 30 calendar days to rescind the agreement.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed in the day room, sitting on a wheel chair with a lap tray attached to the resident's body, and the resident was unable to remove it. This was evident for 1 of the 1 resident reviewed for Physical Restraints out of a sample of 39 residents. (Resident # 302). The finding is: The facility policy on Physical Restraint dated 2016 documented the following: Residents being considered for restraints/Device will be evaluated by a team composed of a Licensed Nurse and a rehabilitation therapist and or a social worker. The policy also documented that, prior to instituting a device, a verbal or written order must be obtained from the resident or a designated representative, if at all possible. [...]

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure a care plan was developed for a resident. Specifically, there was no care plan developed for a resident using a laptray. This was evident for 1 resident out of a sample of 39 residents. (Resident # 302) The finding is: The facility policy for Assessment and Care Process/Development dated 11/2018 documented the following that it is the responsibility of the facility to provide care necessary for each resident to reach his/ her highest practicable physical, mental and psychosocial well-being. The policy also documented that a care plan is developed for each resident in order to have a systematic blueprint of the resident's problems and interventions determined to be necessary to achieve the measurable specified and individualized. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident's total plan of care was reviewed by the Physician following readmission. Specifically, The family member of Resident #58 complained to SA that the resident was not walking post fall and was not receiving Physical Therapy/Occupational Therapy. Record reviews revealed that prior to having a fall in the facility and being hospitalized the resident was receiving PT/OT. The Nurse Practitioner (NP#9) assessed the resident upon the resident's readmission, however, the NP did not refer the resident to PT/OT for evaluation. The NP documented that they would confer with the resident's Medical Doctor (MD). There was no documented evidence that the NP conferred with the MD or that the MD evaluated the resident post fall and hospitalization. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a resident who continuously used oxygen was observed on multiple occasions to have oxygen tubing on the floor. (Resident #120)

Inspectors wrote5). Res #43: The Quarterly MDS assessment with an ARD of 6/1/19 was submitted on 8/1/19. 6). Res #48: The Quarterly MDS assessment with an ARD of 6/5/19 was submitted on 8/1/19. 7). Res #3: The Quarterly MDS assessment with an ARD of 5/10/19 was submitted on 8/1/19. Based on record review and interviews during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, Quarterly MDS assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date. Specifically, 57 out of 57 residents reviewed for the Resident Assessment Facility Task had MDS Assessments submitted later than 14 days after completion. [...]