Central Park Rehabilitation And Nursing Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report alleged violations involving abuse, neglect, exploitation, and mistreatment within the required timeframe. Specifically, three residents were involved in incidents that were not reported to the New York State Department of Health within the mandated two-hour window. Resident #1 complained of pain in their private area and suspected inappropriate touching, but the facility delayed reporting the incident for five days, citing the need for a complete investigation and the resident's recantation of their statement. Despite the facility's policy requiring immediate reporting, the Assistant Director of Nursing and the Administrator acknowledged the delay, attributing it to the desire for concrete details before reporting. In another incident, Resident #2 was struck on the head with a soda can by Resident #3 in the dining room. Although staff were present, they could not prevent the altercation. The facility reported this incident the following day, reasoning that there was no serious bodily injury and Resident #2 refused assessment. The Director of Nursing and the Administrator both indicated that the incident was not initially considered to fall under the category requiring immediate reporting due to Resident #3's cognitive impairment and the lack of serious injury. The facility's policy on reporting abuse allegations was not adhered to in these cases, as both incidents were reported later than the required two-hour timeframe. The facility's investigation into the incidents concluded that there was no credible evidence of abuse in the first case and that the altercation in the second case was unavoidable. However, the delay in reporting these incidents to the appropriate authorities constitutes a deficiency in compliance with federal and state regulations.

Plan Of Correction

Plan of Correction: Approved March 4, 2025 I. IMMEDIATE CORRECTIVE ACTIONS 1. Residents #1, #2, and #3 no longer reside at the facility. 2. The Director of Nursing, Assistant Director of Nursing, and the Administrator were re-educated on: a. Gaps in practice cited by the NYSDOH at F609. b. The key points in F609. c. The facility’s Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. d. The requirements for reporting resident incident/accidents timely (F609). e. Identification criteria for reportable accident/incidents as per F609. f. Appropriate timelines/timeframes for reporting (F609). g. Reporting whether the resident is confused, does not have capacity, or unable/unwilling to verbalize the occurrence. h. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. i. The facility’s accountability and responsibility for reporting alleged abuse, neglect, and mistreatment. j. Review of F609 definition of “alleged violation” and “serious bodily injury.” 3. Attendance sheets and lesson plans are filed for reference and validation. II. IDENTIFICATION OF OTHER RESIDENTS 1. All Accidents and Incidents occurring during the last 30 days were reviewed to confirm timely initial reporting and submission as required under F609. 2. No other deficient practices were found. III. MEASURES/SYSTEMATIC CHANGES TAKEN 1. The QAPI Committee will convene to examine the deficiency cited under Fed-F-609 483.12(c)(1)(4) Reporting of Alleged Violations: 10 NYCRR 415.4(b) a. Perform an assessment of the possible causative factors that may have contributed to the issues identified in the above deficiency. b. Identify the specific steps/interventions that must be initiated to eliminate and correct the causative factors identified during the assessment phase. c. Identify any routine triggers or parameters the facility will implement for F609 that will signal or alert all staff of an evolving problem or deficient practice situation. d. Indicate how this system will be implemented and sustained by the facility. e. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. 2. The QAPI committee reviewed the facility’s Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. a. No deviation from regulations under F609 or current standards of practice was identified. 3. Nurse Managers/Supervisors and Department Heads will receive re-education on: a. The Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure with an emphasis placed on the facility’s responsibility to report the initial accident/incidents that fit the criteria and reporting requirements with F609 in a timely manner. 4. Attendance records and lesson plans will be filed for reference and validation. IV. HOW CORRECTIVE ACTION WILL BE MONITORED 1. The QAPI Committee developed an audit tool with measurable goals designed to review Accident and Incidents to determine reportability to the State Survey Agency. 2. The Director of Nursing/designee will utilize the audit tool to monitor and review the timeliness of all reportable resident accident and incidents to the State Survey Agency. 3. Audits will be performed weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure and F609. 4. Audits with negative findings will have immediate corrective actions including reporting per F609 and re-education for employees involved. 5. The Director of Nursing/designee will prepare a quarterly audit, summarizing the facility’s accident/incident report findings and corrective plans implemented (if applicable) to the QAPI Committee for needed revisions to the action plan, improvement of our delivery of care services, resident outcomes, and compliance with F609. 6. The Director of Nursing/designee will review Accident/Incidents daily to ensure the timely submission of all reportable accident/incidents to the State Survey Agency. V. TITLE OF PERSON RESPONSIBLE FOR CORRECTION OF DEFICIENCY: 1. Director of Nursing. 2. March 14, 2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with severe cognitive impairment and diagnoses including dementia and Parkinson's disease. Observations revealed that the resident's room was in disarray, with food debris on the floor, a tipped-over bedside tray table, and a stained privacy curtain. The resident's bed lacked linens, and the mattress had large tears. These conditions persisted over multiple days, indicating a lack of timely housekeeping and maintenance intervention. Interviews with staff highlighted several issues contributing to the deficiency. Certified Nurse Aide #2 reported that linens were often in short supply, and they were waiting for delivery to make the resident's bed. Housekeeping was responsible for cleaning the room, but the housekeeper assigned to the unit was delayed in reaching the resident's hallway. The Housekeeping Supervisor noted that there was no set expectation for when rooms should be cleaned, and staff were not informed about the stained privacy curtain or the lack of linens. The Registered Nurse Manager and Housekeeping Supervisor both indicated that there were communication breakdowns among staff. The nurse manager was not informed about the mattress issue, and the housekeeping staff were not notified about the need for immediate cleaning or linen shortages. The facility's procedures for maintaining a clean and safe environment were not effectively implemented, leading to the observed deficiencies.