Peninsula Nursing And Rehabilitation Center

F-F880 Infection Prevention and Control.

The facility policy and procedure titled Enhanced Barrier Precautions, with a revision date of 05/2024, stated that the facility will utilize Enhanced Barrier Precautions which entails the use of gown and gloves during high-contact resident care activities for residents with wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with Multidrug Resistant Organisms (germs that are resistant to many antibiotics and can cause infections). The policy also stated that high-contact resident care activities include care and use of devices including central lines and wound care. Enhanced Barrier Precautions protocols are to be followed to inhibit opportunities for transfer of Multidrug Resistant Organisms to staff hands and clothing during high-contact resident care activities.

1(a). On 06/26/2024 at 09:32 AM, during the Medication Administration task, Registered Nurse #3 was observed performing dressing change for a Peripherally Inserted Central Catheter (An indwelling catheter that is inserted through a peripheral vein into a central vein for intravenous treatment) and administering intravenous antibiotic for Resident #377. Registered Nurse #3 was observed wearing gloves and a mask however was not wearing a gown. There was no signage that Resident # 377 was on Enhanced Barrier Precautions.

Order Details dated 6/28/2024 documented that Resident #377 required Enhanced Barrier Precautions

during high-contact care activities for the PICC (Peripherally Inserted Central Catheter) Line every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 335387 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335387 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center 50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 1(b). On 6/27/2024 at 10:36 AM, during during the Medication Administration task, Registered Nurse #4 was observed performing a dressing change for a Midline (an indwelling catheter that is inserted into a large Level of Harm - Minimal harm or peripheral vein in the upper arm for intravenous treatment) for Resident #50 and administering intravenous potential for actual harm antibiotic. Registered Nurse #4 was observed wearing gloves and a mask however was not wearing a gown. There was no signage that Resident #50 was on Enhanced Barrier Precautions. Residents Affected - Some

A facility document titled Enhanced Barrier Precautions List, dated 6/28/2024, documented a list of residents who were maintained on Enhanced Barrier Precautions. Resident #377 was included on the list, and Resident #50 was not.

On 06/27/24 at 03:08 PM, Registered Nurse #3 was interviewed and stated that at the time of the dressing change they did not know that Enhanced Barrier Precautions were needed. Registered Nurse #3 also stated that subsequently they learned that the resident had a Peripherally Inserted Central Catheter line and not a midline catheter, and that they were supposed to maintain Enhanced Barrier Precautions.

On 06/28/24 at 11:48 AM, Registered Nurse #4 was interviewed and stated that there was no Enhanced Barrier Precaution notice posted on Resident #50's door although Resident #50 has a midline. Registered Nurse #4 also stated that they did not wear a gown when administering the intravenous antibiotic because

they did not know a gown was needed.

On 07/01/2024 at 10:02 AM, the Infection Control Preventionist/Assistant Director of Nursing, was interviewed and stated when care is provided for a resident with a Peripherally Inserted Central Catheter, Enhanced Barrier Precautions should be maintained. The Infection Control Preventionist/Assistant Director of Nursing also stated that Registered Nurse #3 should have worn a gown.

On 07/02/24 at 12:09 PM, the Director of Nursing was interviewed and stated Enhanced Barrier Precautions are to be maintained for dressing changes and any care needs for a Resident with a Peripherally Inserted Central Catheter. The Director of Nursing further stated that Registered Nurse #3 did not use the gown as an Enhanced Barrier Precaution.

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1(c). Resident #23 was admitted with diagnoses of Non-Alzheimer's Disease and Cerebrovascular Accident.

The Admission Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #23 was moderately cognitively impaired and had one Stage 3 pressure ulcer and one unstageable pressure ulcer.

The Order Details dated 5/1/2024 documented Enhanced Barrier Precautions during high contact resident care activities (Wounds).

The Order Details dated 5/28/2024 discontinue use of Enhanced Barrier Precautions.

The Order Details dated 6/4/2024 document to cleanse left heel wound, pat dry, apply sting free skin prep to peri-wound, allow to dry, pain with betadine, cover with abdominal pad and loosely wrap with rolled gauze. Every night shift for wound care and as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 335387 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335387 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center 50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The Order Details dated 6/25/2024 documented to clean sacral area wound, pat dry, apply sting free skin prep to peri-wound. Allow to dry, apply treatment every day shift every Monday, Wednesday, Friday for Level of Harm - Minimal harm or wound care. potential for actual harm

The Wound Care Consult done on 6/4/2024 documented that resident has sacrum to bilateral buttocks Residents Affected - Some pressure ulcer Stage 3 measuring 7cm x 8cm x 0.3cm, 100% granulation tissue, moderate serous drainage, peri-wound intact.

The Interdisciplinary Team Weekly Wound Documentation done on 6/4/2024, 6/13/2024, 6/18/2024 and 6/25/2024 by wound care nurse documented that Resident #23 has Stage 3 pressure ulcer to the sacrum.

On 07/01/24 at 11:39 AM, Registered Nurse #5 was observed performing wound care for sacral pressure ulcer for Resident #23 with assistance of Certified Nursing Assistant. There was no signage indicating Enhanced Barrier Precautions on Resident #23's door. Registered Nurse #5 did not don a gown or face mask before entering the room. Wound care was performed with no concerns and Registered Nurse #5 performed hand hygiene and exited the room.

On 07/02/24 at 02:35 PM, the Registered Nurse #5 was interviewed and stated that Enhanced Barrier Precautions are for residents who have intravenous devices, feeding tubes and wounds. Registered Nurse #5 also stated that Resident #23 is not on Enhanced Barrier Precautions currently because Resident #23's wound has been healing and currently, they only have excoriation to the sacrum. Registered Nurse #5 stated that Enhanced Barrier Precautions has not been used because of current wound status and cannot recall if

they have ever used Enhanced Barrier Precautions for Resident #23 since they started working on the unit one month ago. Registered Nurse #5 stated there are two residents on Enhanced Barrier precautions due to feeding tubes. Registered Nurse #5 stated it is necessary to wear gown, gloves and mask before entering

the room of those residents.

On 07/03/24 at 10:13 PM, the Certified Nursing Assistant #3 was interviewed and stated that Resident #23 was on Enhanced Barrier Precautions before but is currently off it now. If resident was currently on Enhanced Barrier Precautions, it would show up in the Electronic Medical Record which it does not. Certified Nursing Assistant #3 stated that resident has a dressing on sacrum which the nurse changes.

On 07/03/24 at 10:19 AM, the Nursing Supervisor #1 was interviewed and stated that Resident #23 was on Enhanced Barrier Precautions from 5/1/2024-5/28/2024 and is currently not on precautions. Nursing Supervisor #1 also stated that residents are usually placed on Enhanced Barrier Precautions when they have chronic wounds, peripherally inserted central catheters or foley catheters. Nursing Supervisor #1 further stated Resident #23 may have been taken off precautions as the wound was either healing or healed. Nursing Supervisor #1 stated that the current ulcer staging in the Electronic Medical Record is a Stage 3 pressure ulcer to the sacrum. Nursing Supervisor #1 also stated that the wound care doctor evaluates resident with wounds 2-3 times a month and puts in the final order to discontinue use of Enhanced Barrier Precautions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 335387 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335387 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center 50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/03/24 at12:53 PM, the Assistant Director of Nursing and Infection Preventionist #1 was interviewed and stated that newly admitted residents are assessed for the need to be on Enhanced Barrier Precautions. Level of Harm - Minimal harm or If applicable, residents are placed on Enhanced Barrier Precautions particularly if have multi drug resistant potential for actual harm organisms, foley catheters, feeding tubes, peripherally inserted central catheter lines. If a wound is healing which is determined by assessing the size, drainage, slough and drainage, then the Enhanced Barrier Residents Affected - Some Precautions are lifted. The wound care nurse does daily assessments of wounds and will report it the doctor.

The doctor will also evaluate the wound. The Wound care doctor makes the final decision on lifting Enhanced Barrier Precautions after consultation with the Infection Preventionist. If there is normal progression of healing from a 3-month period, then the wound is considered as healing and the Enhanced Barrier Precautions are lifted. If not, the resident would continue to be on precautions. Wound care nurse will continually assess resident and if wound is not healing, resident would continue to be on Enhanced Barrier Precautions.

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2. The facility policy titled Hand Hygiene Protocol effective 11/2017 documented the facility follows hand hygiene protocol in preventing the spread of potential pathogens on the hands. All personnel must perform hand hygiene as per standard guidelines. Alcohol based soaps are the most effective product for effective hand hygiene. Soap and water should be used if hands are visibly soiled. Guidelines for hand hygiene before and after eating. Resident hand hygiene should be performed before meals.

The facility policy titled Meal Service-Assistance of Residents effective 4/2016 documented the facility will provide each resident a nourishing, palatable diet at proper temperature to meet the dietary needs of each resident. Certified Nursing Assistant wash resident's hands or offer handwipes. Offer and/or assist resident to cleanse their hands with a hand wipe.

During an observation on 06/27/2024 at 11:46 AM, Certified Nursing Assistant #4 was observed in the dining room handing out hand wipes for residents to clean their hands for lunch meal. Certified Nursing Assistant #4 assisted Resident #37 with hand hygiene, removed Resident #37 used oral supplement and giving hand wipe to Resident #133, Resident #158, Resident #168, Resident #54, and Resident #5. Certified Nursing Assistant #4 collected hand wipes from some residents and asked some of them to put it in a plastic cup for used hand wipes. Certified Nursing Assistant #4 discarded the plastic cup with dirty hand wipes in the trash and wiped their own hands with hand wipes after.

On 06/27/2024 at 11:50 AM, Certified Nursing Assistant #4 stated that they discarded the plastic cup with dirty wipes in the trash and cleaned their hands. They used the plastic cup to collect used wipes that needed to be disposed of. Certified Nursing Assistant #4 also stated that they thought they cleaned their hands with wipes in between residents, and it may have slipped their mind that they did not clean their hands. Certified Nursing Assistant #4 further stated that resident's hands may have bacteria and they do not want to spread any bacteria to other residents.

On 07/03/2024 at 10:40 AM, Registered Nurse #7 stated that they monitored the dining room this past week. Staff should wash their hands first for 20 seconds. Certified Nursing Assistants should use hand wipes to clean their hands or wash their hands when it is visibly soiled. The Certified Nursing Assistants should stop and clean hands, so we do not have cross contamination. Registered Nurse #7 also stated that they have not noticed any issues with hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 335387 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335387 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center 50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 10 NYCRR 415.19 (b)(4)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 335387