Inspection Reports for New Vanderbilt Skilled Nursing Facility

Failure to promote and facilitate resident self-determination through support of resident choice regarding shower frequency and preferences for multiple residents.

Failure to maintain a safe, clean, comfortable, and homelike environment including broken furniture, mismatched paint, leaks, and unsanitary conditions across multiple units.

Failure to protect a resident from physical abuse by a staff member who sprayed hand sanitizer on the resident, resulting in staff termination.

Failure to timely report a resident-to-resident altercation involving abuse to the New York State Department of Health within 2 hours.

Failure to thoroughly investigate allegations of staff-to-resident abuse including lack of staff and resident interviews.

Failure to revise comprehensive care plans quarterly after assessments, specifically related to activities of daily living for Resident #143.

Failure to provide appropriate care to maintain or improve resident mobility; Resident #143 was not provided with a prescribed floor ambulation program.

Failure to ensure psychotropic medications were only given when necessary and to assess for underlying medical causes before increasing doses; Resident #102's medication was increased without medical workup.

Failure to develop and follow menus that meet resident nutritional, religious, cultural, and ethnic needs; residents were denied requested foods due to strict kosher dietary adherence.

Failure to maintain complete and accurate medical records; documentation indicated Resident #143 received floor ambulation program which was not actually provided.

Failure to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address repeated deficiencies.

Facility did not ensure privacy and dignity during blood glucose monitoring for Resident #344.

Facility did not promote and facilitate resident self-determination through support of resident choice regarding shower frequency for Residents #143, #39, and #63.

Facility failed to discuss and document advance directives for Residents #502 and #233.

Facility failed to immediately notify physician of Resident #344's low blood sugar as ordered.

Facility did not maintain a safe, clean, comfortable, and homelike environment; maintenance issues and environmental deficiencies noted on multiple units.

Minimum Data Set assessments were not submitted and transmitted within required timeframes for 53 of 53 residents reviewed.

Licensed Practical Nurse #5 administered medications via gastrostomy tube by forcing medications with a syringe instead of gravity flow.

Facility menus did not consistently meet resident nutritional, religious, cultural, and ethnic needs; kosher dietary restrictions limited food choices and alternative menu options were not always followed.

Food was not stored, prepared, distributed, and served in accordance with professional standards; undated and unlabeled food items in refrigerator, expired items and improper temperature in dry storage, and cold food items served at improper temperatures.

Garbage compactor door was left ajar with multiple flies observed on garbage inside.

Facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program that identified and prioritized problems and opportunities; seven repeated deficiencies from prior survey.

Registered Nurse Supervisor #8 and Licensed Practical Nurse #4 failed to follow proper infection control practices during wound care; Licensed Practical Nurse #5 failed to perform hand hygiene during medication administration.

Licensed Practical Nurse #4 did not maintain infection control standards during wound care for Resident #167, including failure to perform hand hygiene and clean wound properly.

Facility failed to ensure appropriate catheter care; Foley catheter bags improperly positioned above bladder level compromising drainage for Residents #20 and #160.

Consultant pharmacist's recommendations for Resident #222 were not acted upon timely by attending physician; no documented Depakote serum level ordered or obtained.

Resident #143 was not provided with prescribed floor ambulation program as ordered by physician and physical therapy.

Bowel/bladder incontinence, catheter, uti; Care plan timing and revision; Department criminal history review; Dispose garbage and refuse properly; Drug regimen review; Encoding/transmitting resident assessments; Food procurement/store/prepare/serve-sanitary; Free from abuse and neglect; Free from unnec psychotropic meds/prn use; Increase/prevent decrease in rom/mobility; Infection control; Infection prevention & control; Menus meet resident needs/prep in advance/followed; Notify of changes (injury/decline/room, etc.); Qapi program/plan, disclosure/good faith attempt; Quality of care; Reporting of alleged violations; Request/refuse/discontinue treatment; Requirements before submitting a request; Resident records - identifiable information; Resident rights/exercise of rights; Responsibilities of providers; Safe/clean/comfortable/homelike environment; Self-determination

Building construction type and height; Corridor - doors; Electrical systems - other; Illumination of means of egress

Reporting - national health safety network

Failed to protect a resident's right to be free from physical abuse by nursing home staff, evidenced by CNA #1 physically restraining and slapping Resident #1.

Failed to protect a resident's right to be free from physical restraints unless medically necessary, evidenced by CNA #1 restraining Resident #1 on the floor and against the wall.

Failed to ensure each resident received necessary behavioral health care and services, including evaluation of interventions for aggressive behavior.

Behavioral health services; Free from abuse and neglect; Right to be free from physical restraints

Failure to protect residents from abuse; CNA slapped Resident #143 during care.

Failure to timely report suspected abuse and resident-to-resident altercation to NYSDOH.

Failure to provide appropriate treatment and care; Pulmonary consult ordered for Resident #35 with RSV was not completed.

Failure to implement infection prevention and control program; Resident #35 with RSV was not placed on Contact Precautions as per facility policy.

Facility did not ensure a surety bond was purchased to secure all personal funds of residents deposited with the facility, with resident funds exceeding the bond amount.

Facility did not ensure each resident was free from abuse; CNA #3 slapped Resident #143 on the buttocks during care.

Resident #126 was observed with bilateral full side rails without physician's order, assessment, or medical justification.

Facility failed to timely report allegations of abuse and resident-to-resident altercation to the New York State Department of Health.

Minimum Data Set assessments were submitted late for residents #68, #99, and #147.

Baseline Care Plan for Resident #546 was initiated but not completed within 48 hours of admission and was not provided to the resident.

Comprehensive care plans were not developed for dialysis for Resident #60 and anticoagulant use for Resident #547.

Resident #60's comprehensive care plan was not revised to reflect discontinuation of fluid restriction; Resident #546 was not invited to care plan meeting; Resident #97's smoking noncompliance was not addressed with revised care plan interventions.

Resident #35 with RSV was not placed on contact precautions as required by facility policy.

Resident #446 was prescribed Allopurinol once daily but was administered twice daily due to transcription error.

Resident #18 received opioid pain medications without ongoing monitoring of pain management efficacy.

Resident #126 had full side rails in use without assessment for entrapment risk, informed consent, or evaluation of bed dimensions.

Resident #107 was found smoking in their room against facility policy; facility failed to provide adequate supervision and did not update care plan interventions after noncompliance.

Elevators 1 and 3 had detached ceiling panels, missing screws, dust buildup, and water damage, creating an unsafe environment.

Accuracy of assessments; Baseline care plan; Bedrails; Care plan timing and revision; Develop/implement comprehensive care plan; Encoding/transmitting resident assessments; Free from abuse and neglect; Free from unnec psychotropic meds/prn use; Free of accident hazards/supervision/devices; Infection prevention & control; Pain management; Quality of care; Reporting of alleged violations; Right to be free from physical restraints; Safe/functional/sanitary/comfortable environment; Surety bond-security of personal funds

Discharge from exits; Egress doors; Electrical systems - essential electric system; Electrical systems - other; Exit signage; Hvac; Illumination of means of egress; Multiple occupancies - contiguous non-health; Physical environment; Smoking regulations; Sprinkler system - installation; Sprinkler system - maintenance and testing; Stairways and smokeproof enclosures

Reporting - national health safety network

Reporting - national health safety network

Infection prevention & control