Concourse Rehabilitation and Nursing Center, Inc

Based on observation, record review, and interviews conducted during the recertification survey from 4/6/2024 to 4/12/2024, the facility did not ensure the results of the most recent facility survey were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for 12 of 12 residents (Resident #s 5, 11, 41, 64, 77, 129, 146, 188, 203, 209, 215, and 295) during the Resident Council Meeting. Specifically, there were no observations of posted survey results in the facility. The findings are: During the Resident Council Meeting on 4/8/2024 at 10:30 AM, Resident #s 5, 11, 41, 64, 77, 129, 146, 188, 203, 209, 215, and 295 stated they were not aware of the location of the facility's posted survey results. On 4/8/2024 at 11:50 AM, the 6th Floor was observed with a posting documenting the New York State Department of Health survey results were located on the 1st Floor bulletin board outside the Admissions Office. There were no other observations of a posting providing the location of the facility's survey results. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a Recertification and Abbreviated (NY00331425) survey from 4/7/2024 to 4/12/2024, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health immediately or within 2 hours after the allegation was made. This was evident for 2 (Resident #80 and #119) of 38 total sampled residents. Specifically, 1) Resident #80 had a fall resulting in a fracture that was not reported to the New York State Department of Health, and 2) Resident #119 had an unwitnessed fall resulting in a fracture that was not reported to the New York State Department of Health. The findings are: The facility policy titled Prevention of Mistreatment, Neglect and Abuse and Misappropriation of Resident Property dated 10/4/2022 documented the Director of Nursing will report any accident or incident where there is reasonable cause to believe that resident abuse occurred to the New York State Department of Health. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that the baseline care plan was developed within 48 hours of a resident's admission and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 10) of 38 total sampled residents. Specifically, the baseline care plan was not completed within 48 hours of Resident #10's admission to the facility and a copy was not provided to Resident #10. The findings are: The facility policy titled Baseline Care Plan dated 9/2023 documented a baseline care plan will be developed within 48 hours of resident's admission and the resident and their representative will be provided with a summary of the baseline care plan prior to the completion of the comprehensive care plan. Resident #10 was admitted to the facility on [DATE] with diagnoses of unspecified convulsions and acute osteomyelitis of the left ankle and foot.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, a comprehensive care plan was not developed and implemented for Resident #24's use of antipsychotic medication. The findings are: The facility policy titled Comprehensive & Interim Care Plan dated 8/10/2023 documented that a care plan is developed for each resident's problem, with a measurable goal and interventions necessary to achieve the goal. Resident #24 had diagnoses of delusional disorder and bipolar disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident # 24 was moderately impaired in cognition and received antipsychotic medication. The Physician Order dated 3/10/2024 documented Resident #24 received Quetiapine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #27) of 6 residents reviewed for pressure ulcers out of 38 total sampled residents. Specifically, Resident #27 was observed without on multiple occasions resident #27 was observed without heel float boots, a pressure-relieving device, in accordance with the Physician's Order. The findings are: The facility policy titled Pressure Ulcers dated 10/2023 documented assistive devices were used to treat and prevent pressure ulcers. Bony prominences were protected as needed. Resident #27 had diagnoses of dementia and respiratory failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #27 was severely cognitively impaired and was dependent on staff to perform activities of daily living. On 4/08/2024 at 11:00 AM and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 4/7/2024 to 4/12/2024, the facility did not ensure dental services were provided from an outside resource to meet the needs of the resident. This was evident for 1 (Resident #203) of 38 total sampled residents. Specifically, the facility did not obtain outside dental services for Resident #203 when a tooth extraction was recommended. The findings are: The facility policy titled Dental Consultation dated 8/2023 documented residents were provided access to dental consultations as part of their comprehensive primary care. Resident #203 had diagnoses of diabetes mellitus and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #203 was moderately cognitively impaired. On 4/10/2024 at 12:42 PM, Resident #203 was interviewed and stated a Dentist saw them in the facility a few months ago and recommended a tooth extraction. The facility did not assist with scheduling an appointment to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews conducted during the Recertification survey from 4/7/2024 through 4/12/2024, the facility did not ensure the Binding Arbitration Agreement granted the resident or representative the right to rescind the agreement within 30 calendar days of signing it. This was evident for 1 (Resident #156) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Resident #156 did not grant the resident 30 calendar days to rescind the agreement. The findings are: The facility's sample admission Agreement contained a Binding Arbitration Agreement that documented the agreement can be rescinded within 10 days of the resident's admission to the facility. Resident #156 signed a Binding Arbitration Agreement on 12/22/2021. There was no documented evidence Resident #156 was provided 30 calendar days to rescind the agreement. On 4/12/2024 at 12:51 PM, the Director of Social Service was interviewed and stated they were unaware that the resident or their representative should have the right to rescind the agreement within 30 days of signing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview conducted during the recertification survey, the facility did not ensure a resident is free from physical restraint. Specifically, a resident was observed in the day room, sitting on a wheel chair with a lap tray attached to the resident's body, and the resident was unable to remove it. This was evident for 1 of the 1 resident reviewed for Physical Restraints out of a sample of 39 residents. (Resident # 302). The finding is: The facility policy on Physical Restraint dated 2016 documented the following: Residents being considered for restraints/Device will be evaluated by a team composed of a Licensed Nurse and a rehabilitation therapist and or a social worker. The policy also documented that, prior to instituting a device, a verbal or written order must be obtained from the resident or a designated representative, if at all possible. The policy further documented that the monitoring for continued need will be documented on the tracking sheet for each resident. In addition, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview conducted during the recertification survey, the facility did not ensure a care plan was developed for a resident. Specifically, there was no care plan developed for a resident using a laptray. This was evident for 1 resident out of a sample of 39 residents. (Resident # 302) The finding is: The facility policy for Assessment and Care Process/Development dated 11/2018 documented the following that it is the responsibility of the facility to provide care necessary for each resident to reach his/ her highest practicable physical, mental and psychosocial well-being. The policy also documented that a care plan is developed for each resident in order to have a systematic blueprint of the resident's problems and interventions determined to be necessary to achieve the measurable specified and individualized. The policy further documented that the the Comprehensive Care Plan must reflect the residents specific problems, and also the basis guidelines for the Certified Nursing Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident's total plan of care was reviewed by the Physician following readmission. Specifically, The family member of Resident #58 complained to SA that the resident was not walking post fall and was not receiving Physical Therapy/Occupational Therapy. Record reviews revealed that prior to having a fall in the facility and being hospitalized the resident was receiving PT/OT. The Nurse Practitioner (NP#9) assessed the resident upon the resident's readmission, however, the NP did not refer the resident to PT/OT for evaluation. The NP documented that they would confer with the resident's Medical Doctor (MD). There was no documented evidence that the NP conferred with the MD or that the MD evaluated the resident post fall and hospitalization. The resident was never referred to PT or OT for revaluation. This was evident for one of five residents reviewed for Unnecessary Medications and Dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a resident who continuously used oxygen was observed on multiple occasions to have oxygen tubing on the floor. (Resident #120) The findings are: The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #120 had moderately impaired cognition and a diagnosis of Respiratory Failure and Chronic Obstructive Pulmonary Disease. The resident was also documented as receiving suctioning, Tracheostomy care and oxygen therapy. The most recent Physician Orders reviewed on 7/23/19 documented that the resident is to have continuous oxygen 3 liters per minute via trach collar. On 07/31/19 at 10:28 AM, Resident #120 was observed in his room, out of bed, and in a wheelchair next to his bed. The oxygen tubing connecting the oxygen concentrator to the Tracheostomy collar was observed to be lying on the floor between the wheelchair and bed. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.