Verrazano Nursing and Post-Acute Center

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00352315), the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of three (3) residents (Resident #3). [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that each resident was offered the Pneumococcal and Influenza immunizations. This was observed in 5 of 5 residents (Residents #11, #23, #57, #84, #93) sampled for Immunizations out of a total of 26 sampled residents. Specifically, there was no documented evidence that Resident #23 was offered or educated on the Influenza immunization, and there was no documented evidence that residents #11, #23, #57, #84, and #93 were offered or educated on the Pneumococcal immunization. The facility policy titled Conducting the Influenza Vaccination Program for Residents, last reviewed 08/25/2023, documented that all residents/representatives will be provided with education on the influenza vaccine at the start of the influenza season. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey from 03/12/2025 to 03/19/2025, the facility did not ensure that each resident was offered the COVID-19 immunization. This was observed in 5 of 5 residents (Residents #11, #23, #57, #84, #93) sampled for Immunizations out of a total of 26 sampled residents. Specifically, there was no documentation related to the screening, administration or declination, and education on the COVID-19 immunizations for Residents #11, #23, #57, #84, and #93.

Inspectors wroteBased on record reviews and interviews conducted during the recertification survey from 03/12/2025 to 03/19/2025, the facility did not ensure that comprehensive care plans were developed. This was evident for 3 residents (Resident #28, #79, and #93) out of 26 sampled residents. Specifically, a diuretic care plan was not developed for Resident #28, a dialysis care plan was not developed for Resident #79, and a hospice care plan was not developed for Resident #93.

Inspectors wroteBased on observation, interviews and record review conducted during an Abbreviated Survey (NY 00342773), the facility did not ensure a resident's right to be free from physical abuse by nursing home staff. This was evident for one out of four residents sampled for abuse (Resident #1). Specifically, on 05/20/24 at 5:04 pm in the dining room, the facility's video footage showed Resident #1 threw a cup of water on Certified Nursing Assistant #1's back and Certified Nursing Assistant #1 turned around and slapped Resident #1 with an open right hand on the back of Resident #1's neck. The Registered Nurse Supervisor #2 assessed Resident #1 and there was no visible injury, no redness or discoloration to the skin. Resident #1 did not complain of pain. [...]

Inspectors wroteBased on interviews and record review during an Abbreviated Survey (Complaint # NY00314677), the facility failed to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This was evident in 1 (Resident #2) of 3 residents reviewed for pressure ulcers (ulcers which occur on the skin surface due to prolonged pressure). Specifically, Resident #2, who was at mild risk for developing a pressure ulcer, was identified with a pressure ulcer on the sacrum (a bone located on the lower back) on 03/28/2023. The resident's pressure ulcer was not promptly assessed, and treatment was not started until 04/07/2023. [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00322823), the facility did not ensure that the results of all investigations of alleged violations involving abuse were reported to the State Survey Agency within 5 working days of the incident. This was evident for 2 (Residents #4 and #5) of 4 residents reviewed for abuse. Specifically, on 08/26/2023, the facility received a report that Resident #5 inappropriately touched Resident #4. The facility submitted a Follow-up Investigation Report on 09/05/2023.

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00322823), the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident in 2 (Residents #4 and #5) of 4 residents sampled. Specifically, on 08/26/2023, the facility received a report that Resident #5 inappropriately touched Resident #4. The facility initiated an investigation but did not thoroughly investigate the allegation. The facility did not gather statements from staff members who may have potentially witnessed the allegation.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey (NY 00311407), the facility did not ensure Preadmission Screening for individuals with mental disorders and individuals with intellectual disability was done prior to admission. This was evident for 1 of 3 residents (Resident #1) sampled for Pre-admission Screening and Record Review (a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, Resident #1's Screen Form Department of Health-695 was dated 01/04/23. Level I was positive for serious mental illness but was not completed, and Resident #1 was not evaluated for Level II screening prior to admission to the facility. Resident #1 or the legal representative did not sign the Screen Form.

Inspectors wroteBased on record reviews and interviews conducted during an Abbreviated Survey (NY00322823), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was evident for 2 (Residents #4 and #5) of 4 residents reviewed for abuse. Specifically, a comprehensive care plan related to abuse was not developed for Resident #4 and Resident #5 following an allegation of sexual abuse.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY 00311407), the facility did not ensure that an effective discharge plan was developed that focused on the resident's discharge goals, preparation of the resident to be an active participant in their care and effectively transition the resident to post-discharge care. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was admitted to the facility on [DATE] and was discharged to the community on 11/01/2023. A discharge care plan was not developed for Resident #1.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 1/22/23 to 1/30/23, 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 Kitchen observation. Specifically, frozen food items were stored undated and with opened packaging.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated survey (NY00298195 and NY00305187) from 1/22/23 to 1/30/23, the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. This was evident for 3 of 3 resident units (Unit 2, 3, and 4). Specifically, 1) Resident #58 reported nursing staffing shortages led to deficits in medication administration, 2) actual nursing staffing was less than projected staffing on multiple occasions, and 3) Residents #82, #86, and #69 did not receive medications in accordance with physician orders.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and complaint survey (NY00305187) from 1/22/23 to 1/30/23, the facility did not ensure residents were free of significant medication errors. This was evident for 3 (Resident #s 82, 86, and 69) of 29 total sampled residents. Specifically, Residents #82, #86, and #69 were not administered medication in accordance with Physician Order (MDO).

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification survey from 01/22/2023 through 01/30/2023, the facility did not ensure Comprehensive Care Plans (CCP) were reviewed and revised after each assessment for 3 (Resdients #28, #45, and #50) of 29 sampled residents. Specifically, (1) The care plan for Behavior was not revised for Resident #28, 2) The care plan for Device/Splint was not revised for Resident #45, and 3) The care plan for Activities of Daily Living was not revised quarterly for Resident #50.

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification survey from 01/22/2023 through 01/30/2023, the facility did not ensure that a resident with a limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #45) of 2 resident(s) reviewed for Limited Range of Motion out of 29 sampled residents. Specifically, Resident #45 had left arm Hemiplegia and was observed without a hand splint as per rehab recommendation.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification Survey, 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 for 1 (Resident #44) of 2 residents reviewed for Pain Management. Specifically, Resident #44, a resident with Metastatic Ovarian Cancer on Palliative Care, reported frequent breakthrough pain despite as needed pain medication. The nursing staff did not reassess the resident or report the pain to the physician, and the resident remained on as needeed pain medication without any standing dose pain medication. The finding is: [...]