New Vanderbilt Rehabilitation And Care Center, Inc
NEW VANDERBILT REHABILITATION AND CARE CENTER, INC in STATEN ISLAND, NY — inspection on July 16, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F685 re: communication/maintaining hearing.
9.
Refer to
F-F842 re: resident records.
335372
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335372 B.
Wing 07/16/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
New Vanderbilt Rehabilitation and Care Center, Inc 135 Vanderbilt Ave Staten Island, NY 10304
F-F865 re: QAPI.
potential for actual harm 16.
Refer to I210 re: signage for COVID vaccine availability.
16.
Refer to
F-F880 re: repeat deficiencies.
On 07/16/24 at 4:05 PM, the Administrator was interviewed and stated when any deviation from expected performance, or a negative trend occurs the findings are brought to the attention of the Quality Assurance committee.
Staff report quality concerns to the Quality Assurance committee through their chain of command, the compliance officer, or the hotline.
The facility works on issues that trigger and issues that the department feels need improvements.
Also, weekly rounds are done with the department heads and the findings are reported to the Quality Assurance and Performance Improvement Committee.
The nursing team and department heads will give a report on whether the corrective actions are effective, and if improvement is occurring.
Monthly Quality Assurance and Performance Improvement committee meetings have been implemented in order to fix the issues.
They compare month to month from the monthly progress reports from the departments.
They meet as a team and discuss the inputs and ideas on how to change and correct the deficiencies.
The Administrator stated at the time of the last survey, the facility submitted a plan of correction, and they continue to work on Quality Assurance and Performance Improvement and provide in-service training for the staff.
The Administrator stated the facility performs competencies on staff and measure improvements and are working on recruiting staff with enticements such as bonuses.
The Administrator stated the facility tracks performance by bringing it up to the team and move on if effective, if not effective then they continue to do Quality Assurance and Performance Improvement until compliance.
The Minimum Data Set assessments are being worked on and Abuse issues are being worked on also.
The Administrator further stated the Director of Nursing is new at the facility and started a month ago and they took over as Administrator late last year.
10 NYCRR 415.27
335372