Independence Care Center for Nursing and Rehabilit

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00362877), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). This was evident in one (1) out of three (3) residents (Residents #3 and #4) sampled. Specifically, on 12/02/2024 at 7:12 AM, Resident #4 stated that Resident #3 threw a chair, and the chair hit them on their back. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00359953), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of two (2) residents (Resident #1) sampled for elopement. Specifically, the facility Elopement Incident Timeline dated 11/08/2024 documented that the surveillance video footage showed at 2:46 PM on 11/07/2024 Resident #1 exited the facility grounds. Resident #1 was wearing a wander guard on their left ankle at the time they left the facility, and the wander guard alarm system did not activate. Facility staff became aware between 3:20 PM and 3:58 PM that Resident #1 was missing from the facility. Resident #1 was located by a facility staff at 10:45 PM on 11/07/2024 walking towards their home. [...]

Inspectors wroteBased on observation, interviews, and record reviews conducted during Abbreviated Survey (NY00348529), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, the facility's surveillance camera recording dated on 07/17/2024 at 4:56pm showed Resident #1 hit Receptionist #1's face and Receptionist #1 retaliated and hit Resident #1 on the top of their head. Resident #1 was assessed by Registered Nurse Supervisors #1 and #2 and there were no visible injuries.

Inspectors wroteBased on staff interviews and record review conducted during an abbreviated survey (NY00348529), the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change. This was evident for 1 out of 4 residents (Resident #1) sampled. Specifically, the facility's surveillance camera recording dated 07/17/2024 showed Resident #1 was involved in an altercation with Receptionist #1. Resident #1 hit Receptionist #1 and Receptionist #1 retaliated and hit Resident #1 on the top of their head. Resident #1's Psychosocial Well-Being Care Plan was not updated to reflect on the abuse incident of 07/17/2024.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00320218), the facility did not ensure that a resident was free from physical abuse by nursing home staff. This was evident for 1 out of 3 residents sampled for abuse (Resident #1). Specifically, on 07/17/23 at 11:37:25 am, Resident #1, who was cognitively intact, reported to the Assistant Director of Nursing they were punched in the nose by Licensed Practical Nurse #1. Review of the facility's surveillance camera dated 07/17/23 at 11:37 am (real time) showed Licensed Practical Nurse #1 exiting Resident #1's room, retrieved their belongings, and exited the nursing unit. Resident #1 was seen crawling on hands and knees on the floor bleeding. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility failed to ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 3 (Residents # 5, #39, and #119) of 3 residents reviewed for baseline care plan out of a total sample of 38 residents. Specifically, 1) Resident #5 did not get a copy of their baseline care plan summary. 2) Resident #39's representative did not receive a copy of the resident's baseline care plan summary, and 3) Resident #119's representative did not receive a copy of the resident's baseline care plan summary.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility did not ensure that a resident's privacy was maintained. This was evident for 1 (Resident #119) of 1 resident reviewed for Privacy out of 38 sampled residents. Specifically, a Respiratory Therapist was observed performing tracheostomy care with the resident's room door opened.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Complaint Survey (NY00331841) from 03/26/2024 through 04/02/2024, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was evident for 5 (Resident #s 39, 82, 108, 109, and 253) of 38 sampled residents. Specifically, 1.) Resident #39 had no care plan in place for antibiotic therapy. 2.) A care plan was not developed to address Resident #108's preference to wear a night gown in the dayroom. 3.) Resident #82 had no care plan for hospice care. 4.) Resident #109 had no care plan developed to address wandering behavior. 5.) Resident #253 had no care in place for ecchymosis on the forehead.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint Survey (NY00327454) from 03/26/2024 through 04/02/2024, the facility did not ensure that each resident's comprehensive care plan was reviewed and revised by the interdisciplinary team following an occurrence of resident-to-resident physical abuse. This was evident for 1 (Resident #35) of 35 total sampled residents. Specifically, the comprehensive care plan was not reviewed and revised for Resident #35 following their involvement in a resident-to-resident altercation.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility did not ensure that an ongoing activities program was provided based on the comprehensive assessment, care plan, and preferences of each resident, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Residents #39) of 3 residents reviewed for Activities out of 38 total sampled residents. Specifically, there was no evidence Resident #39 was engaged in a meaningful activity program on the unit.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 03/26/2024 to 04/02/2024, the facility failed to address an irregularity identified by the pharmacist during Medication Regimen Review. This was evident in 1 (Resident #31) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacist identified a potential medication irregularity during the Medication Regimen Review dated 02/28/2024 and recommended to change the administration time for Montelukast for maximum benefit. The facility did not address the irregularity.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint #NY00331841) from 03/26/2024 through 04/02/2020, the facility failed to ensure that the resident and/or the resident's representative was immediately informed of an accident which results in injury and had the potential for requiring physician intervention. This was evident for 1 (Resident #253) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration on the forehead. There was no documented evidence that the resident's representative was notified of the change in resident's condition.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00331841) from 03/26/2024 through 04/02/2024, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 1 (Resident #253) of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration to the forehead that was not reported to the New York State Department of Health. There was no witness on how Resident #253 sustained the discoloration and the source of injury could not be explained by the resident.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification and Complaint Survey (NY00318593) from 03/26/2024 through 04/02/2024, the facility did not ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #99) of 35 total sampled residents. Specifically, on 03/29/2024, Resident #99's right and left lower extremities were observed with severe edema, dry, and thick scaly skin. There was no documented evidence that the skin condition was evaluated and being treated.

Inspectors wroteBased on observation and interview conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that infection prevention and control program practices were maintained. Specifically, 1) the Licensed Practical Nurse (LPN) failed to practice hand hygiene between glove changes during wound care, and 2)oxygen tubing was observed touching the floor on multiple occasions. This was evident for 1 of 7 residents investigated for Pressure Ulcer/Injury and 1 of 3 residents reviewed for Respiratory care out of a sample of 38 residents. (Resident #4 and Resident #107) The finding is: 1. The facility's policy titled Pressure Ulcer Prevention Management and Treatment Program, reviewed on 10/27/21, documented Standard precautions utilizing barrier protection: [...]

Inspectors wroteF578 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record review completed during a recertification survey 02/23 - 03/02/2022, the facility did not ensure that advance directives were provided. Specifically, there was no evidence that staff assessed a resident's desire regarding advance directives. This was evident for one resident (Resident #420).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that residents' assessments were accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment (1). inaccurately documented that a resident had a diagnosis of Benign Prostate Hypertrophy (BPH), and (2). that a resident had an Indwelling catheter. This was evident for 1 of 3 residents reviewed for Respiratory Care and 1 of 1 resident reviewed for Urinary Catheter out of a sample 38 residents. (Resident #270 and Resident #4)

Inspectors wroteF656 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record reviews completed during a recertification survey 02/23-03/02/2022, the facility did not develop a person-centered care plan for a resident consistent with that resident's medical needs. Specifically, a care plan was not developed to address the use of psychotropics, insulin, antihypertensives or anticoagulants. This was evident in 1 of 4 residents (Resident #140) reviewed for unnecessary medications in a sample of 35.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey 2/23/2022 to 3/2/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives participated in the development of a Comprehensive Care Plan (CCP). Specifically, residents were not afforded the opportunity to participate in the care plan meetings. This was evident for 2 of 2 residents reviewed for Care Plan out of a sample of 38 residents. (Resident #12 and #121)

Inspectors wroteBased on interview and record review conducted during a Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, nursing staff did not administer pain medications as per physician's orders to a resident who complained of pain on several occasions prior to wound dressing change. This was evident for 1 of nine 9 residents reviewed for Pressure Ulcers out of 38 sampled residents. (Resident #150). The finding is: The facility policy titled Pain Assessment Procedure, last updated on 1/21/21 documented the following: [...]

Inspectors wroteBased on staff interviews and record review conducted during the Recertification survey conducted from 2/23/22 to 3/2/22, the facility did not ensure that competent care and services were provided to assure safety and maintain the highest practicable level of mental and physical wellbeing for a resident. Specifically, a Certified Nurse Aide (CNA) did not demonstrate competency and skills in providing care to a resident with pressure ulcers. The CNA cleaned the resident's pressure ulcers during Activities of Daily Living (ADL) care and did not address the resident's concerns regarding pain during care. This was evident for 1 of 9 residents reviewed for Pressure Ulcers out of 38 sampled residents. (Resident #150).

Inspectors wroteBased on interviews, observations and record reviews conducted during a Recertification survey from 2/23/22 to 3/2/22, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the medication room refrigerator on 1 of 5 units during the Medication Storage task. (4th floor)

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, medications were not administered as ordered by the physician: 1). Acetaminophen 500mg was administered instead of instead of Acetaminophen 325mg as ordered and 2). Administration of Artificial tears was omitted leading to a medication error rate of 8%. This was evident for 2 of 25 medication observations conducted during the Medication Administration facility task.

Inspectors wroteBased on observations and staff interviews conducted during a Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure controlled drugs were stored appropriately in locked compartments. Specifically, controlled drugs were observed stored on the medication cart outside of the locked compartments for storage of controlled drugs. This was observed on 1 of 5 units during the Medication Storage Task. (Unit 5)

Inspectors wroteBased on record review and interviews the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility.

Inspectors wroteBased on observations, interview, and record reviews during the recertification survey, the facility did not ensure sufficient nursing staff to provide nursing and related services as determined by resident assessments considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure that cold foods were stored at a temperature of 41 degrees F and below. Specifically, the facility did not ensure that it maintained proper temperatures of Potentially Hazardous Foods (PHF) to prevent food borne illness. After three observations the temperatures of sandwiches on 7/9, 7/15/ and 7/16 which were taken at various times, did not reach the required temperature of 41 degrees F or below. These sandwiches consisted of tuna, ham and cheese, baloney and cheese and turkey and cheese sandwiches. This was evident during the initial and follow-up visits for the Kitchen Task part of the survey. The facility policy and procedure titled Nutrition Service Policy and Procedures Section 7 Review Date 5/17/17 documented: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that the residents received care in a safe, clean, comfortable and homelike environment. Specifically, the facility did not ensure that a safe, functional, sanitary, and comfortable environment is provided for residents, staff and the public. This was evidenced by multiple observations of the overall facility including facility common areas, and nursing stations and staff work areas. The facility policy and procedure titled Maintenance Policy and Procedure Manual Subject: Maintenance Repair request program, Maintenance Repairs Communication and Records: Effective 12/23/2017 documents: The Maintenance Department is responsible for establishing and maintaining work orders and requests, inspections of building, maintenance schedules. [...]

Inspectors wroteBased on record reviews and Interviews the facility did not ensure that residents, or their representatives were invited to Care Plan meeting. Specifically, the facility held Annual Care Conferences for 4 residents and did not invite either the residents or their family members/next of kin to the meeting.

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that infection control guidelines were followed to prevent the spread and development of communicable diseases and infections. Specifically,1) Residents were observed receiving Oxygen by nasal cannula with the oxygen tubing running from the nasal cannula along the floor and resting on the floor to the connection on the oxygen concentrator. Multiple residents receiving oxygen through a ventilator were observed to have oxygen tubing laying on the ground. This included, but was not limited to 2 (two) residents (Resident #1, Resident # 6). 2) Multiple Gastrostomy Tube (GT) poles for hanging tube feeding were observed to be dirty.

Inspectors wroteBased on observation, record review and staff interviews conducted during recertification survey, the facility did not ensure that residents and/or families were informed and provided with written information concerning the right to formulate an advance directive. Specifically, the facility did not document that advance directives were explained to or discussed with family members and a resident's representative. This was evident for 1 of 1 resident reviewed for Advance Directives (Resident #142). The finding is : The facility policy and procedure on advance directives, reviewed 10/2018, documented, Social Work shall provide information concerning resident's rights to make decisions regarding medical care or treatment as soon as possible upon admission. The information will be reviewed with each resident, or with their health care proxy in lieu of capacity, and a copy provided to them. [...]

Inspectors wroteBased on observations, record review and interviews during the recertification survey, the facility did not ensure that drugs and biological's were stored in accordance with Federal and State regulations. Specifically, 1) A multidose vial of Tuberculin Purified protein Derivative (PPD) Tubersol was not labeled with a date of opening by the nursing staff, thus there is no indication as to when it should have been discarded. 2) Twelve multidose vials of Influenza vaccine were found to be outdated in the medication refrigerator located in the nursing supervisors office. The finding is: The facility policy titled, Opened Multidose Vials undated documents, Procedure - 1) The nurse who opens the vial must write the date on the label. 2) When the three (3) month time frame has elapsed, the vial must be disposed of according to the Drug Destruction Policy. [...]