Staten Island Care Center

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 03/14/2024-03/21/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, visitors, or other individuals, where individuals wishing to examine survey results do not have to ask to see them. Specifically, the survey results were in a binder at sitting height at the front desk facing towards the inside area of the security desk and were not readily accessible for review. The finding is: The facility policy and procedure titled Survey Results reviewed on 01/08/2024 documented that it is the policy of the facility to post all survey results at the front desk for all residents and visitors to view. Signs are posted throughout the facility indicating where the results can be found. [...]

Inspectors wroteBased on record review and interviews during the Recertification survey from 3/14/24 to 3/21/24, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. This was evident for 1 of 2 residents (Resident #244) reviewed for Preadmission Screening and Resident Review (PASARR) out of 38 sampled residents. The finding is: Resident #244 was admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia, Anxiety Disorder, Depression, Bipolar Disorder. The Annual Minimum Data Set, dated [DATE] documented resident was cognitively intact and that Antipsychotics were received on a routine basis only. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 3/14/2024 to 3/21/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 of 1 resident (Resident #53) reviewed for Activities out of 38 total sampled residents. Specifically, Resident #53, a resident with severely impaired cognition, was observed for extended periods of time without meaningful activities, and there was no activity plan to provide activities to the resident while in their room.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification/complaints survey from 3/14/24 to 3/21/24, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident was not provided with handrolls and a splint device as ordered by the physician. This was evident for 1 of 1 resident (Resident #218) reviewed for Position/Mobility out of 38 sampled residents.

Inspectors wroteBased on observation, records review and staff interview during the recertification survey, the facility did not ensure that each resident's right to privacy and confidentiality of his or her personal and medical records was maintained. Specifically, the licensed nurse left an open laptop logged into a resident's electronic medical record (EMR) (Resident #141) and medication blister pack (Resident #83 and Resident #140) unattended, on top of the medication cart, in the hallway, exposing personal health information. This was evident for 3 of 4 residents reviewed for privacy (Resident #141, #140 and #83) on 1 of 5 units (Unit 2).

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, The facility staff did not follow infection control guidelines while handling clean and soiled linen to prevent the spread of infection; This was evident for 1 of 5 units observed for infection control (unit 5 and unit 1).

Inspectors wroteBased on interview and record review conducted during a recertification survey (U53P11) and facility reported incident (FRI) complaint investigation (NY00251863) completed on 2/04/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. Specifically, the facility did not report an incident where a resident was noted with a bleeding nose after they were found in another resident's room and this incident occurred on 01/30/2020 at 3:16 PM and was reported to NYSDOH on 01/31/2020 at 04:46 PM. Additionally, a resident was injured by the actions of another resident that occurred on 3/30/2021 at 04:00AM and reported to NYSDOH until 3/30/3021 at 06:37PM. This was evident for 3 of 6 residents reviewed for Abuse (Resident #19, Resident # 415 and Resident # 416). [...]

Inspectors wroteBased upon observation, interview and record review during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, a garbage container were observed being transported without a cover.

Inspectors wroteBased on record review and interviews the facility did not ensure that the Minimum Data Set (MDS) accurately reflected the status of the resident. Specifically, Resident #212 had three (3) consecutive MDS document a diagnosis of Schizophrenia. However, there was no corroborating documentation in the resident's medical record supporting this diagnosis. This was evident for 1 out of 35 sampled residents. The finding is: Resident #212 was admitted to the facility on [DATE] with diagnoses which included Post Traumatic Stress Disorder, generalized Anxiety, Depression and Peripheral Vascular Disease. The medical record was reviewed and the following was documented: The Preadmission Screening and Resident Review (PASSR) dated 4/12/18. was reviewed and documented: No dementia diagnosis, no serious mental illness and no Level II referrals were indicated. [...]

Inspectors wroteBased on observation, record review, and interviews during the re-certification survey, the facility did not ensure infection control practices were maintained to help prevent the development and transmission of communicable diseases and infections. Specifically, a housekeeper was observed exiting the room of Resident #115 who is on contact precautions for Acinetobacter Baumani without wearing personal protective equipment (PPE). He was mopping the floor. The same housekeeper was also observed using the same mop to clean the room of Resident #149. This deficient practice was observed for one housekeeping employee. The finding is. The facility policy and procedure titled, Isolation Procedure (Dated 05/29/18) was reviewed and documented the following. [...]