Mosholu Parkway Nursing & Rehabilitation Center

Inspectors wroteBased on record review, and interviews conducted during an Abbreviated Survey (NY00373522), the facility did not ensure that all 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 for one (1) out of three (4) residents (Resident #2) sampled. Specifically, Resident #2 was observed sitting on the floor close to their bed with their rolling walker close by. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00370671 and NY00373522), the facility did not ensure that a resident received the necessary care and treatment in a timely manner and in accordance with professional standards of practices. This was evident in two (2) out of five (5) residents (Resident #1 and Residents #2) sampled. Specifically, 1.) on 01/30/2025 at 12 midnight Certified Nursing Assistant #1 observed Resident #1 at the sink in their room holding their right hand under the cold water. According to Certified Nursing Assistant #1, they observed Resident #1's right hand to be a little red but they did not report it to the nurse. At 4:30 AM on 01/30/2025, Certified Nursing Assistant #2 observed Resident #1 at the sink in their room holding their right hand under the cold water. [...]

Inspectors wroteBased on observation, record review and interviews during the abbreviated survey (NY00312367), the facility failed to ensure that a resident was treated with dignity included being free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident in one out of three residents reviewed (Resident #1). Specifically, on 03/09/2023 at approximately 8:39 AM, Physical Therapist #1 observed Resident #1 in their room sitting in the wheelchair with a bed sheet wrapped around their waist and tied to the wheelchair. Registered Nurse Supervisor #1 assessed Resident #1 and there were no visible injuries.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 8/12/2024 to 8/16/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and food service observations. Specifically, 1.) The dairy and meat walk-in refrigerators contained opened cans and undated, unlabeled, expired food items. 2.) There were no thermometers located in the walk-in and ice cream freezers. 3.) The unit refrigerator temperatures were not maintained, and contained spilled, spoiled, undated and unlabeled food items. 4.) During meal service, staff was observed handing resident's food with bare hands.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not ensure that the garbage storage areas were maintained in sanitary condition. This was evident during the Kitchen Observation. Specifically, garbage was not properly contained outside of the facility or disposed of properly. The outside garbage dumpsters were uncovered, and the trash can inside the kitchen was not covered.

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident during the kitchen observation. Specifically, multiple dead cockroaches, water bugs, spiders and silverfish were observed in the food storage room.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically. Enhanced Barrier Precautions were not maintained 1) during wound care, 2) during foley catheter care and 3) during care of a resident with central venous catheter insertion. This was evident in 3 out of 27 sampled residents, (Resident #36,42, and #218).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents' bathing preferences were not honored. This was evident for one of the residents reviewed for Choices out of 27 sampled residents (Resident #76).

Inspectors wroteBased on interviews, observations and record reviews made during the Recertification and Complaint Survey (NY00330894) from 8/12/24 - 8/16/24 the facility did not ensure that all alleged violations including injuries of unknown origin were reported immediately but not later than 2 hours if the event that caused the allegation involved abuse or caused serious bodily injury. Specifically, a resident (Resident #12) sustained a scratch and possible bruise that were not reported to the New York State Department of Health.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification survey from 8/12/24 to 8/16/24, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent a further decrease in range of motion. This was evident for 1 (Resident # 16) of 2 residents reviewed for Position/Mobility out of a sample of 27 residents. Specifically, Resident # 16 had an active Physician order for bilateral hand gauze to both hands to prevent flexion contracture at the digits, to be worn at all times and remove for Activities of Daily Living (ADL) and skin check. Both hands were observed without the hand gauze on multiple occasions.

Inspectors wroteBased on observation, record review, and interview conducted during a Recertification Survey from 08/12/2024 to 08/16/2024 the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and that they were complete and accurately documented for each resident. This was evident for 1 (Resident #42) of 1 resident reviewed for Dialysis out of 27 sampled residents. Specifically, Resident #42 had a right upper chest central venous catheter for hemodialysis, but the documentation showed an AV Fistula.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure handrails were firmly affixed and secured to the wall. This was evident for 1 (Unit #2) of 4 resident units observed during the environmental tour. Specifically, 2 sections of handrails were observed loose and not fully connected to the wall in the hallway of Unit 2.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00330928, and NY00330894) Survey from 08/12/2024 to 08/16/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's needs. This was evident for 2 of 3 residents (Resident #76, and #85) reviewed for care planning out of 27 total sampled residents. Specifically, 1) A comprehensive care plan related to abuse was not developed and implemented for Resident #76 following a resident to resident altercation, and 2) A comprehensive care plan was not developed and implemented to address Resident #85 insulin use.

Inspectors wroteBased on interviews, observations and record reviews made during the Recertification and Complaint Survey (NY00330894) from 8/12/24 to 8/16/24 the facility did not ensure that an alleged of abuse was thoroughly investigated. Specifically, a resident (Resident #12) with a reported injury of unknown origin had only one written statement gathered from staff and no written investigation summary.

Inspectors wroteBased on record reviews and interviews made during the Recertification Survey from 8/12/24 to 8/16/24, the facility did not ensure that a person-centered comprehensive care plan was reviewed and revised to accurately reflect a resident's current status. Specifically, a resident with a new skin break (Resident #12) did not have their Skin Integrity Care Plan updated to reflect the change.

Inspectors wroteBased on interviews, observations and record reviews made during the Recertification and Complaint(NY00326358) survey from 8/12/24 to 8/16/24, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, on 10/18/2023, a resident (Resident #99) eloped from the facility.

Inspectors wroteBased on interviews and record review conducted during the recertification survey from 8/25/22 to 9/1/22, the facility did not ensure resident were provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) at the termination of Medicare Part A benefits. This was evident for 2 (Residents #54 and #94) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 27 residents. Specifically, 1) Resident #54 remained in the facility after being discharged from skilled rehabilitation services and was not provided with a SNFABN; and 2) Resident #94 remained in the facility after being discharged from skilled rehabilitation services and was not provided with a SNFABN.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00275338) Survey, the facility did not ensure that an allegation of abuse involving an injury of unknown origin was reported to the New York State Department of Health (NYSDOH) immediately, but no later than 2 hours, after the allegation was made. This was evident for 1 (Resident #264) of 6 residents investigated for accidents out of 27 sampled residents. Specifically, the facility did not report Resident #264's abrasion to the back of their head, an injury of unknown origin, to the NYSDOH.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00275338) survey, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 1 (Resident #264) of 6 residents investigated for accidents out of 27 sampled residents. Specifically, there was no documented evidence an investigation was conducted when Resident #264 sustained an abrasion to the back of their head.

Inspectors wroteResident #16 Based on observation, record review, and interviews conducted during the rectification survey, the facility did not ensure that Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team (IDT). This was evident for 1 (Resident #16) of 1 resident(s) reviewed for urinary catheter and 1 (Resident #264) of 6 residents reviewed for accidents out of 27 sampled residents. Specifically, (1) the CCP related to bladder incontinence was not revised to address Resident #16's Foley catheter (FC) use; and (2) the CCP related to falls/accidents was not revised following Resident #264's abrasion to the back of their head.

Inspectors wroteBased on observation, record review, and staff interviews conducted during a recertification survey from 8/25/22 to 9/01/22, the facility did not ensure the attending physician documented in the resident's medical record the identified pharmacy irregularity and action taken , if any, to address it. This was evident for 1 (Resident #77) of 5 residents reviewed for unnecessary medication out of 27 sampled residents. Specifically, the Medical Doctor (MD) did not act upon a pharmacy reccomendation for Resident #77 to receive BP monitoring.

Inspectors wroteBased on observation, record review, and staff interviews conducted during a recertification survey from 8/25/22 to 9/01/22, the facility did not ensure a resident was adequately monitored for efficacy and adverse effects while receiving blood pressure (BP) medication. This was evident for 1 (Resident #77) of 5 residents reviewed for unnecessary medication out of 27 sampled residents. Specifically, Resident #77 received Metoprolol Tartrate 25mg daily as per Medical Doctor Order (MDO) without BP monitoring.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey from 8/25/22 to 9/01/22, the facility did not ensure medical records were complete and accurate in accordance with professional standards and practice. This was evident for 2 (Resident #77 and #76) of total sampled residents. Specifically, 1) there was no documented evidence a Health Shake 180 ml was offered to Resident #77 twice daily (BID) as ordered by the Medical Doctor (MD); and, 2) nursing staff documented Resident #76 had a left wrist wanderguard (WG) and Resident #76 was observed on multiple occasions with right ankle WG.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that an incident involving a resident was thoroughly investigated to rule out abuse. Specifically, the facility did not initiate an investigation after a resident was found with a foreign object in his anal cavity (Resident #73). This was evident for 1 of 1 resident reviewed for Abuse (Resident #73).

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure that a Minimum Data Set (MDS) 3.0 was electronically transmitted to Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system and submitted in a timely manner. Specifically, the admission MDS for Resident #1 was not and transmitted within 14 calendar days from MDS completion date. This was evident for 1 of 1 resident reviewed for the Resident Assessment task out a total sample of 27 residents (Resident #1). The finding is: Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set 3.0 (MDS) assessment with an Assessment Reference Date (ARD) date of 6/17/19 had a Care Area Assessment (CAA) completion date of 6/21/19. The MDS was submitted on 7/13/19 which was (8) eight days late. [...]