New Vanderbilt Rehabilitation And Care Center, Inc

F-F685 re: communication/maintaining hearing.

9. Refer to

F-F842 re: resident records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 335372 Department of Health & Human Services Printed: 09/17/2025 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 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

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 0865 14. Refer to

F-F865 re: QAPI.

Level of Harm - Minimal harm or 15. Refer to Resident R0610, Resident R0830, and Resident R1022 re: criminal history record check. potential for actual harm 16. Refer to I210 re: signage for COVID vaccine availability. Residents Affected - Some 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 335372 Department of Health & Human Services Printed: 09/17/2025 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 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

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44842 potential for actual harm Based on observation, and interviews conducted during the Recertification survey from 07/09/2024 to Residents Affected - Some 07/16/2024, the facility did not ensure infection control practices and procedures were maintained to provide

a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) Registered Nurse Supervisor #8 failed to practice hand hygiene and glove changes during wound care, 2), Licensed Practical Nurse #4 failed to practice appropriate infection control during wound care treatment, and 3). Licensed Practical Nurse #5 did not perform hand hygiene

during Medication Administration for a resident with a gastrostomy tube This was evident for 2 (Resident #189 and Resident #167) of 7 residents reviewed for Pressure Ulcer/Injury and 1 resident (Resident #193) observed during Medication Administration out of 39 sampled residents.

The findings are:

The facility policy titled Pressure Sore Prevention Program & Wound Care Management reviewed June 2024 documented that for residents with existing pressure sores, treatment, evaluation and monitoring are needed to prevent the progression of existing wounds, the development of new breakdown and complications such as infections.

The facility's policy titled Infection Prevention and Control Program with revised date of 06/09/2024 documented the facility will require staff to perform hand hygiene as indicated by Centers for Disease Control guidelines.

1. Resident #189 had diagnoses of Stage 4 pressure ulcer of sacral region, Paraplegia, and Peripheral vascular disease.

The Quarterly Minimum Data Set assessment dated [DATE REDACTED] documented Resident #189 had intact cognition and Stage 4 pressure ulcers.

The Physician's Orders renewed on 06/02/2024 documented cleanse sacral ulcer with normal saline solution, pat dry, Skin Prep to outer wound edges, apply Silvasorb, and Calcium Silver Alginate Sheet to wound bed, cover with Silicone Border dressing every day and as needed.

On 07/15/2024 at 10:51 AM, wound care observation was conducted for Resident #189 with Registered Nurse Supervisor #8 performing wound care. Registered Nurse Supervisor #8 entered the room, placed the supplies, and washed their hands. Registered Nurse Supervisor #8 then donned gloves and removed Resident #189's soiled dressing from the wound on their sacrum. Registered Nurse Supervisor #8 then changed their gloves without washing their hands and cleansed the wound, applied the treatment, and placed the clean dressing on the wound. Registered Nurse Supervisor #8 then removed their gloves and performed hand hygiene.

Registered Nurse Supervisor #8 did not change their gloves or wash their hands after removing the soiled dressing, cleaning the wound, and before applying the treatment and clean dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 335372 Department of Health & Human Services Printed: 09/17/2025 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 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

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 07/15/23 at 11:40 AM, Registered Nurse Supervisor #8 was interviewed and stated they were instructed to wash their hands during dressing change or use hand sanitizer if soap is not available. Registered Nurse Level of Harm - Minimal harm or Supervisor #8 further stated they used sanitizing wipes instead of washing their hands. However, surveyor potential for actual harm did not observe the Registered Nurse Supervisor #8 using hand sanitizer wipes when performing wound care.

Residents Affected - Some On 07/16/2024 at 1:55 PM, the Director of Nursing who is also serving as the Infection Preventionist was interviewed and stated that hand hygiene is supposed to be performed in between changing gloves when performing wound care. The Director of Nursing further stated the Registered Nurse Supervisor #8 was supposed to change gloves and wash their hands after removing the soiled dressing, then again after cleaning the wound, and also before applying the treatment and clean dressing.

50894

2. Resident #167 was admitted to the facility with diagnoses that included an Unstageable pressure ulcer, Diabetes Mellitus, Alzheimer's disease, and Malnutrition.

The Admission Minimum Data Set assessment dated [DATE REDACTED] documented Resident #167's cognition as moderately impaired, and that the resident was at risk of developing pressure ulcers and had one Stage 3 pressure ulcer that was present upon admission/reentry to facility.

The Nursing Progress Note dated 07/8/24 documented that Resident #167 had a sacral ulcer which measured 2.5 cm x 4cm x 0.1 cm, 100% granulation, scant serous exudate. Treatment was documented as: cleanse area with NSS, pat dry, apply calcium alginate, cover with foam dressing daily & PRN.

The Physician's Order renewed 7/09/2024 documented cleanse with normal saline solution, pat dry, apply calcium alginate, and cover with foam dressing daily.

On 07/15/2024 at 10:42 AM, a wound care observation was conducted with Licensed Practical Nurse #4. Licensed Practical Nurse #4 entered the room of Resident #167 wearing a gown and gloves, with a tray containing wound care supplies that they placed on Resident #167's overbed table. Licensed Practical Nurse #4 performed hand hygiene and donned gloves. Licensed Practical Nurse #4 removed the dressing from Resident #167's sacral region and disposed of it in the trashcan positioned next to the bed. Licensed Practical Nurse #4 removed and disposed of their gloves in the trashcan and walked to the sink in Resident #167's room to perform hand hygiene. Licensed Practical Nurse #4 asked Certified Nursing Assistant #6 to kick the trashcan at the bedside over to the sink, which Certified Nursing Assistant #6 did. Licensed Practical Nurse #4 completed hand hygiene and kicked the trashcan back to the resident's bedside. Licensed Practical Nurse #4 donned gloves and picked up a piece of dry gauze from a multipackage of gauze and poured saline onto it. Licensed Practical Nurse #4 then rubbed the wet gauze horizontally across the wound to clean it. Licensed Practical Nurse #4 then disposed of the gauze in the bedside trash can, picked up a piece of calcium alginate, and placed it on gauze, then applied it to the wound before applying a foam dressing. Licensed Practical Nurse #4 returned to the sink and completed hand hygiene. Licensed Practical Nurse #4 took the multipack of gauze from the resident's bedside table and returned it to the medication cart positioned outside of Resident #167's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 335372 Department of Health & Human Services Printed: 09/17/2025 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 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

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 Licensed Practical Nurse #4 did not sanitize the bedside table or place a drape on the table before placing supplies down, did not clean the wound from inner to outer aspects, did not perform hand hygiene after Level of Harm - Minimal harm or cleaning the wound, and did not maintain infection control standards when returning the opened multipack of potential for actual harm gauze to the medication cart.

Residents Affected - Some On 07/15/2024 at 02:34 PM, an interview was conducted with Licensed Practical Nurse #4 who stated that

they forgot to use the drape because they were nervous. Licensed Practical Nurse #4 also stated that they typically use single-use gauze for wound care but used the multipackage of gauze during Resident #167's

observation because they were nervous. Licensed Practical Nurse #4 further stated that they have been observed doing wound care in an in-service earlier this year, and also completed an infection control in-service earlier this year.

On 07/15/2024 at 02:49 PM, an interview was conducted with Registered Nurse Supervisor #3 who stated that they have done wound care twice since beginning employment at the facility around seven months ago. Registered Nurse Supervisor #3 also stated that the Wound Care Nurse is responsible for monitoring the wounds and reporting concerns during their weekly wound care rounds. Registered Nurse #3 failed to identify the steps for performing wound care appropriately, including the need to perform hand hygiene after cleaning a wound and before performing the ordered treatment.

On 07/16/2024 at 09:52 AM, an interview was conducted with the Staff Educator who stated wound care

observations are conducted upon hire and then yearly for all staff providing wound care in the facility. The Staff Educator stated that it was their responsibility to conduct the observation upon hire, and that the Wound Care Nurse conducts the yearly in-service wound care observations. If a staff member is identified as needing an additional in-service, the Staff Educator stated that they would do that with the assistance of the Wound Care Nurse. When asked about hand hygiene during wound care, the Staff Educator stated that after cleaning the wound and before applying treatment, they would remove the soiled gloves and put on new ones but failed to identify the need to perform hand hygiene after removing the soiled gloves.

On 07/16/2024 at 10:08 AM, an interview was conducted with the Wound Care Nurse who stated that they do an initial skin check on admitted patients, and weekly wound rounds with the doctors. They will also assist

the Licensed Practical Nurses on the floor with complex wound care, such as wounds requiring wound vac treatment. When asked for the steps on providing wound care, the Wound Care Nurse failed to identify the need to perform hand hygiene after cleaning a wound and before performing the ordered treatment. The Wound Care Nurse stated that most wound care competencies are completed by the Staff Educator and that

they try to do some but have not been able to complete many due to their current workload.

On 07/16/24 at 11:49 AM, an interview was conducted with the Director of Nursing who was able to accurately outline how wound care should be completed while maintaining infection control standards. The Director of Nursing stated that the Staff Educator was responsible for completing the upon-hire and annual wound care competencies for staff members providing wound care.

44864

3. Resident #193 was admitted to the facility with diagnoses that include Chronic Respiratory Failure and Dry eye Syndrome.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 335372 Department of Health & Human Services Printed: 09/17/2025 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 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

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 Quarterly Minimum Data Set, dated dated dated [DATE REDACTED] documented that Resident #193 had a feeding tube. Level of Harm - Minimal harm or potential for actual harm The Physician's Orders last renewed 6/24/24, documented Artificial tears 1.4% eye drops, apply 1.4 drops by eye route in each eye 2 times per day. Residents Affected - Some

On 07/12/24 at 08:14 AM, an observation of medication administration was completed with Licensed Practical Nurse #5.

Licensed Practical Nurse #5 entered Resident #193's room, washed their hands, and put on a pair of gloves. Licensed Practical Nurse #5 then administered the medications via the gastrostomy tube. Licensed Practical Nurse #5 then removed their gloves, donned a clean pair of gloves and proceeded to instill eye drops to both of Resident #193's eyes. Licensed Practical Nurse #5 did not perform hand hygiene between glove changes.

On 07/12/24 at 08:34 AM, immediately after the medication administration observation for Resident #193, Licensed Practical Nurse #5 was interviewed and stated that they were taught to wash their hands between glove changes, but that they did not clean their hands after they changed their gloves to administer the eye drops. Licensed Practical Nurse #5 also stated that they were nervous and forgot to wash their hands after taking off the gloves when they administered medications via the gastrostomy tube.

On 07/16/24 at 01:04 PM, the Director of Nursing was interviewed and stated that the staff is taught to wash their hands after every glove changes. The Licensed Staff are in-serviced during orientation, competencies are also done yearly, and Licensed Practical Nurse #5 was evaluated and knew the correct way to do glove changes. The Director of Nursing said that the nurses are monitored by the Registered Nursing Supervisors and reeducation is done by the Educator. The Registered Nursing Supervisors do random medication pass

observations to ensure that the nurses are using the correct measures. If there is an issue, they would be re-in-serviced.

10 NYCRR 415.19(b)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 335372