New Carlton Rehab and Nursing Center, LLC

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident for 1 (4th floor) of 4 resident units. Specifically, 1.) multiple rooms on the 4th floor were observed with mismatched paint on the floor, 2.) the shared bathroom, opposite room [ROOM NUMBER], had broken and missing tiles under the sink, and dusty walls and fans, 3.) the baseboard on the unit dining room was not attached to the wall, 4.) the dry wall in multiple rooms were cracked and some with missing paint, and 5.) a hole was observed on the dry wall stuffed with a copper colored steel wool.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the kitchen task. Specifically, there were multiple expired food items in the kitchen dry storage room.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that the garbage storage area were maintained in a sanitary condition. This was evident during the Kitchen and Environmental observation. Specifically, garbage was not properly contained outside of the facility. The garbage dumpster and trash bins were not covered to prevent the harborage and feeding of pests.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure a safe functional environment for the staff. This was evident during the kitchen observation. Specifically, accumulation of dusts were observed on different parts of the kitchen, floor tiles were observed with cracks, and the dry wall in the dry storage room had cracks and holes.

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, 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 environmental observation. Specifically, 1.) vermin droppings were noted on the boxes and top of cans in the kitchen dry storage room, 2.) a cockroach was observed crawling in a resident's room and on the metal frame of the overhead grease trap hood over the cooking stove in the kitchen, 3.) flies were observed in the kitchen and on the 2nd floor unit hallway.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint Survey (NY00338835) from 07/09/2024 to 07/16/2024, the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident in 1 (Resident #121) of 25 total sampled residents. Specifically, on 04/07/2024, Registered Nurse #3 received a report that Resident #121 alleged that Certified Nursing Assistant #6 roughed them up in the bathroom. Registered Nurse #3 did not initiate an investigation and did not put measures in place to ensure that further potential abuse does not occur. The investigation was initiated by the Director of Nursing on 04/08/2024. Additionally, there was no documented evidence that Resident #121 was immediately assessed to identify any potential injury as a result of the allegation.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint Survey (NY00338835) from 07/09/2024 to 07/16/2024, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency in accordance with State law through established procedures. This was evident in 1 (Resident #121) of 25 total sampled residents. Specifically, on 04/07/2024, the facility received a report that Resident #121 alleged that Certified Nursing Assistant #6 roughed them up in the bathroom. The facility did not report the allegation to the New York State Department of Health.

Inspectors wroteBased on record review, and interview during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 3 of 28 investigated sampled residents (Resident #101, Resident #116 and Resident #122). Specifically, (1). the MDS for Resident #122 did not accurately reflect the resident's behavior of refusing medication, and the antipsychotic medication review was not completed even though the resident received antipsychotic medication daily. (2) The MDS assessment for Resident #101 did not accurately reflect the resident's level of assistance required for feeding and toileting. (3)The MDS assessment for Resident #116 did not reflect the resident was recieving dialysis.

Inspectors wroteBased on observation and interview, during the Recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically 1) food items were observed unlabeled and undated in a cook prep fridge and meat freezer, 2) employee lunch food items were observed in the cook prep fridge, 3) food items were observed with freezer burn and falling out of packaging in the freezer, and 4) food boxes were observed crushed, opened, and water marked in the freezer. This was observed during the Kitchen Observation Facility Task.

Inspectors wroteBased on observations, record review and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, an oxygen tubing was observed touching the floor on several occasions and the infection control policy and procedures were not reviewed annually. This was evident for 1 of 28 residents reviewed in the investigation sample (Resident # 79). The finding is: 1) Resident # 79 was admitted on [DATE] with diagnoses which includes heart failure, dementia, seizure disorder, schizophrenia, PTSD and acute respiratory distress. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident cognition is severely impaired and required extensive assistance with all Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during the recertification survey, the facility did not ensure that advance directives were periodically reviewed with a resident. Specifically, advance directives were not discussed or reviewed periodically with a resident at least annually. This was evident for 1 of 1 resident reviewed for Advance Directives (Resident #123). The finding is: The facility policy titled Advance Directive dated 01/18 documented advance directives consist of HCP, Do Not Resuscitate, and Living Will. A HCP is a document delegating authority to another adult, known as a Health Care Agent, to make health care decisions on behalf of the resident when the resident has become incapacitated. HCP can update, modify MOLST at any time. The facility will ensure update of this record and the physician will sign off. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey, the facility did not ensure that residents' privacy and confidentiality were maintained. Specifically, a resident's privacy curtain when fully extended did not provide complete closure and privacy. This was evident for 1 of 1 resident reviewed for Privacy out of a total sample of 28 residents (Resident # 2). The findings is: Resident #2 was admitted with diagnoses which includes Type 2 Diabetes Mellitus with Diabetic Neuropathy and Unspecified Dementia with behavioral disturbance. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 11/18/19 at 11:00 AM, an interview was conducted with Resident #2 at the bedside. The resident stated that the privacy curtain does not provide privacy. Maintenance removed an additional curtain in Spring 2019. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the recertification Survey, the facility did not ensure a resident was free form Physical Restraints. Specifically, there was no documented evidence that a resident with an abnormal binder was assessed for the need of the restraint (abdominal binder), and that a least restrictive alternative was used prior to the implementation of the restraint. This was evident for 1 of 1 resident reviewed for Physical restraints out of a total sample of 28 residents( Resident #119).

Inspectors wroteBased on observations, interviews and record reviews during a recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, 1) the Minimum Data Set (MDS) assessment for Resident #123 did not identify the resident had a Health Care Proxy. 2) The MDS assessment for Resident #119 did not identify the use of a physical restraint (abdominal binder). This was evident for 1 of 2 residents reviewed for Advance Directives (Resident #123) and 1 of 1 resident reviewed for Physical Restraint (Resident #119).

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for residents, consistent with the resident rights that includes measurable objectives and time frames to meet residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, (1) a comprehensive care plan was not developed for a resident with dentures. This was evident for 1 of 2 residents reviewed for Dental (Resident #69). The findings is: [...]

Inspectors wroteBased on record reviews and staff interviews during the recertification survey, the facility did not ensure to the extent practicable, that residents participated in the development, review and revision of the comprehensive care plan (CCP). Specifically, residents were not invited to the comprehensive care plan meeting. This was evident for 2 of 4 residents reviewed for Participation in Care Planning (Residents # 69 and 76).