Long Island State Veterans Home

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure it implemented a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #260) of two residents observed for Medication Administration. Specifically, on 3/6/2025, during the medication pass observation for Resident #260, Licensed Practical Nurse #1 did not rinse the resident's mouth after administering a Symbicort inhaler (a medication that helps reduce inflammation and keep airways open; the inhaler contains a steroid medication that increases the risk of oral fungal infection) as per the physician's orders. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for one (Resident #25) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #25's Significant Change Minimum Data Set (MDS) assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 35 days after the completion of the assessment. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 8/28/2023 and completed on 9/1/2023 facility did not ensure each resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect the current needs of the resident. This was identified for one (Resident #288) of five residents reviewed for unnecessary medications and one (Resident #163) of two residents reviewed for vision/hearing. Specifically, 1) Resident #288's behavioral and activities care plans were not updated to reflect behaviors the resident exhibited and precautionary measures to be taken when the resident attended activity programs; and 2) Resident #163's communication care plan was not updated to reflect the current status of the resident's use of the hearing aid or a hearing amplifier device.

Inspectors wroteBased on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00263584) completed on 7/1/2021, the facility failed to ensure resident rights to be free from abuse for two of two residents reviewed for abuse (Resident #23 and Resident #157). Specifically, Resident #23 who was identified with aggressive behavior, pushed a wandering resident (Resident #157) when Resident #157 grabbed and shook Resident #23's arm. Resident #157 fell to the floor and sustained two lacerations to the back of the head. Subsequently Resident #157 was sent to the hospital with a change in mental status and the two lacerations to the back of the head required five staples. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00263584) completed on 7/1/2021, the facility did not ensure that all alleged violations involving abuse are reported immediately but not later than 24 hours after the allegation is made for 2 of 2 residents reviewed for abuse. Specifically, the facility did not report a Resident to Resident physical altercation between Resident #23 and Resident #157 on 8/30/2020 until 9/4/2020 (a 5-day delay) and another altercation between Resident #23 and Resident # 157 on 8/31/2020 until 9/4/2020 (a 4-day delay). The finding is: The Facility's Freedom from Abuse, Mistreatment, Neglect, and Exploitation policy dated 4/1/91 and last revised on 11/2018 documented that the facility will immediately report alleged violations of abuse to the New York State Department of Health (NYSDOH). [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00263584) completed on 7/1/2021, the facility did not ensure that further potential abuse was prevented while the investigation was in progress for 2 of 2 residents reviewed for abuse (Resident #157 and Resident #23). Specifically, Resident #157 and Resident #23 had a physical altercation on 8/30/2020. Resident #157 was sent to the hospital for evaluation and returned on 8/31/2020. The facility investigation was not thorough to ensure interventions to prevent reoccurrence remained appropriate and effective. Subsequently, on 8/31/2020 Resident #157 and Resident #23 had a second physical altercation. The finding is: [...]

Inspectors wroteBased on observation, record review, staff interviews during the Recertification Survey completed on 7/1/2021, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed to meet the resident's current needs. This was identified for 1 (Resident #101) of 2 residents reviewed for Pressure Ulcers (PU). Specifically, Resident #101 was identified with a Stage II PU to the Sacrum on 12/30/2020. There was no documented evidence that a CCP was developed until 1/27/2021 when the PU deteriorated to a Deep Tissue Injury (DTI). The finding is: Resident #101 was admitted with diagnoses that included Coronary Artery Disease, Hypertension, and Peripheral Vascular Disease. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had one Stage II PU. [...]

Inspectors wroteBased on observations, interviews and record review during the Recertification Survey completed on 7/01/2021, the facility did not ensure that each residents' Comprehensive Care Plan (CCP) was reviewed and revised to address the residents' current care needs. This is identified for one (Resident #137) of 3 residents reviewed for accommodation of needs. Specifically, Resident #137 did not have a CCP reviewed and revised to address the resident's need for a specialized call bell. The finding is: The Policy and Procedure entitled Comprehensive Care Plan effective 11/2/93 documented the facility will develop a person-centered care plan for each resident to ensure that appropriate care is provided to the resident. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 7/1/2021, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for 1 (Resident # 631) of 3 residents reviewed for skin conditions, and 1 (Resident # 264) of 4 residents reviewed for Accidents. Specifically, Resident #264 was observed with Zinc Oxide 20% cream on the over-the-bed table within Resident # 264's room and Resident #631 was observed with Zinc Oxide 20% cream on the window sill in Resident #631's room. There were no staff members present in either Resident #264 or Resident #631's room at the time of the observations.

Inspectors wroteBased on observations and staff interviews during the Recertification Survey completed on 7/1/2021, the facility did not dispose of refuse and garbage properly. Specifically, the facility did not ensure that the area surrounding the garbage compactor was kept clean and free of debris. This was identified on two separate observations; during the initial tour of the kitchen on 6/24/2021, and a subsequent visit to the garbage storage area five days later on 6/29/2021. The finding is: During the initial kitchen tour on 6/24/2021 at 11:30 AM, the area surrounding the garbage compactor was observed to be littered with 3 pairs of used blue surgical gloves and 2 opened institutional size #10 food cans. The General Manager of Food Service was present during the tour and acknowledged the presence of blue gloves and empty cans on the ground near the garbage compactor. [...]