Queens Center for Rehabilitation & Residential Health Care

Based on record review and staff interview, the facility did not ensure that the Department of Health (DOH) was notified within 30 days of an employee termination following receipt of a hold in abeyance notice. This was evident for 1 of 2 prospective employees receiving negative determination letters as a result of a Criminal History Record Ccheck (CHRC).

This resulted in no actual harm with potential for more than minimal harm.

The finding is:

During the criminal history record check review, records of 2 prospective employees receiving negative determination letters were reviewed.

Employee # 1 was offered a position as a Certified Nursing Assistant in October of 2010. On 10/18/2010, the facility received a hold in abeyance notice. The prospective employee never returned to the facility to begin employment. There is no documented evidence that the CHRC 105 form was submitted to the DOH.

The Authorized Person was interviewed on 7/27/11 at approximately 10:30AM. He stated that he thought that the 105-E letters only had to be submitted for employees who were terminated, and that he was waiting for a final disposition from DOH before having the employee removed from the facility's roster.

Based on record review, resident and staff interviews, the facility did not ensure that a resident was notified prior to arrival of two new roommates in his room. This was evident for 1 out of 39 residents reviewed. ( Resident #24)

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident # 24 is 70 year old male admitted to the facility on 6/17/2011 with diagnoses which include Hip Replacement, Cervical Myelopathy, and Hypertension.

The MDS (Minimum Data Set) 3.0 assessment dated 6/24/2011 documents the resident with intact memory and cognition.

On 7/25/2011 at 12:13 PM and on 7/27/2011 at 12:55 PM, the resident was interviewed and stated he has been in the same room since admission and two of his current roommates came to the room after him, and he was not notified prior to their arrival or introduced to them. He stated, "No one spoke to me about anyone coming to the empty bed in my room. I just saw new person in that bed. It would be nice if they tell us in advance."

Review of the resident's medical record did not reveal documentation regarding notification about placement of two new roommates in the same four bedded room on 7/13/2011 and 7/15/2011 respectively.

On 7/27/2011 at 1:17PM the unit Social Worker was interviewed and stated that she just started working 3 weeks ago and she spoke with the resident about new roommates, but did not document as there is no requirement to document notification to the resident already in the room.

On 7/27/2011 at 11: 55AM the Director of Social Work was interviewed and stated that the residents already in the room should be notified in advance that they will receive a new roommate and this should be documented in the social work progress notes, also a care plan for adjustment should be developed if there are any issues identified in new roommates' interactions.

415.5(e)(2)

Based on record review and interview, the facility did not ensure that each resident's plan of care was implemented. Specifically, the facility did not ensure that a Physician order was followed for blood sugar monitoring. This was evident for 1 of 24 resident reviewed. (Resident # 24)

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #24 is a 70 year old male with diagnoses which include Diabetes and Hypertension.

The MDS (minimum data set) 3.0 dated 7/13/11 documents the residents BIMS (Brief Interview for Mental status) score as 13/15. The resident is cognitively intact.

The Physicians orders dated 7/14/11 documents " Fingerstick every Monday and Thursday " However there is no documented evidence that fingersticks were obtained from 7/14/11-7/26/11 (4 x).

On 7/27/11 at 9:45am, the Licensed Practical Nurse (LPN) who transcribed the Physician's order to the MAR (Medication Administration Record ) was interviewed and stated that she can not remember what happened and she can not explain why there is no documentation.

On 7/27/11 at 9:50am, the resident was interviewed and stated that he has not had a fingerstick in a while and can not recall when it was done last.

415.11(c)(3)(ii)

Based on observation it was determined that the facility did not ensure that doors to hazardous areas were self closing and positively latching in their frames. This was evidenced by the door to the biohazard room not positively latching and the laundry room door that was manually held open.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy..

The Findings are:

On July 22,2011 during the Annual Life Safety evaluation of the facility between the hours of 10:30 AM and 2:45 PM, it was observed that the door to the biohazard room on the second floor did not positively latch in its frame when tested. Also, the laundry room door on the lower level was observed to be held opened using a plastic bag.

In an interview with the maintenance director at approximately 2:30 PM, he stated that these concerns will be immediately corrected.

NFPA 101 2000 19.3.2.1
10NYCRR 711.2(a)(1)

Based on facility record review and interview it was determined that the facility did not ensure that fire detection system was maintained and tested in accordance with NFPA 72. There was no documented evidence that the smoke and heat detectors in the elevator and boiler rooms had been tested.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The Findings include:

On July 22, 2011 during an Annual Life Safety inspection of the Facility it was observed that fire detection systems (smoke detectors and heat detectors) were installed in the elevator room located on the roof and boiler room located at the lower level area. However, during the maintenance log review of the smoke detectors, the records did not identify whether the smoke detector in the elevator room and heat detector in the boiler room were included in the cleaning and testing that had been done in the facility on 2/22/11.

In an interview with the Administrator at approximately 3:30 PM on the same day, he stated that the company comes and cleans them and that they might have failed to document them. However, he stated that all future testing will be done and it would be documented.

2000 NFPA 101 9.6.1.4, 1999 NFPA 72 7-3.2