Central Queens Rehabilitation & Nursing Center
February 12, 2025 Complaint Survey

Standard Health Citations

FF15 483.12(b)(5)(i)(A)(B)(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: § 483. 12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: § 483. 12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. § 483. 12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: March 14, 2025

Citation Details

None

Plan of Correction: ApprovedMarch 4, 2025

I. IMMEDIATE CORRECTIVE ACTIONS 1. Residents #1, #2, and #3 no longer reside at the facility. 2. The Director of Nursing, Assistant Director of Nursing, and the Administrator were re-educated on: a. Gaps in practice cited by the NYSDOH at F 609. b. The key points in F609 c. The facility's Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. d. The requirements for reporting resident incident/accidents timely (F609), e. Identification criteria for reportable accident/incidents as per F 609. f. Appropriate timelines/timeframes for reporting (F609), g. Reporting whether the resident is confused, does not have capacity, or unable/unwilling to verbalize the occurrence h. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. i. The facility's accountability and responsibility for reporting alleged abuse, neglect, and mistreatment. j. Review of F609 definition of alleged violation' and 'serious bodily injury'. 3. Attendance sheets and lesson plans are filed for reference and validation. II. IDENTIFICATION OF OTHER RESIDENTS: 1. All Accidents and Incidents occurring during the last 30 days were reviewed to confirm timely initial reporting and submission as required under F 609. 2. No other deficient practices were found. III. MEASURES/SYSTEMATIC CHANGES TAKEN 1. The QAPI Committee will convene to examine the deficiency cited under Fed-F-609 483. 12(c)(1)(4) Reporting of Alleged Violations: 10 NYCRR 415. 4(b) a. Perform an assessment of the possible causative factors that may have contributed to the issues identified in the above deficiency. b. Identify the specific steps/interventions that must be initiated to eliminate and correct the causative factors identified during the assessment phase. c. Identify any routine triggers or parameters the facility will implement for F609 that will signal or alert all staff of an evolving problem or deficient practice situation. d. Indicate how this system will be implemented and sustained by the facility. e. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. 2. The QAPI committee reviewed the facility's Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. a. No deviation from regulations under F609 or current standards of practice was identified. 3. Nurse Managers/Supervisors and Department Heads will receive re-education on a. The Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure with an emphasis placed on the facility's responsibility to report the initial accident/incidents that fit the criteria and reporting requirements with F609 in a timely manner. 4. Attendance records and lesson plans will be filed for reference and validation IV. HOW CORRECTIVE ACTION WILL BE MONITORED 1. The QAPI Committee developed an audit tool with measurable goals designed to review Accident and Incidents to determine reportability to the State Survey Agency. 2. The Director of Nursing/designee will utilize the audit tool to monitor and review the timeliness of all reportable resident accident and incidents to the State Survey Agency. 3. Audits will be performed weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure and F 609. 4. Audits with negative findings will have immediate corrective actions including reporting per F609 and re-education for employees involved. 5. The Director or Nursing/designee will prepare a quarterly audit, summarizing the facility's accident/incident report findings and corrective plans implemented (if applicable) to the QAPI Committee for needed revisions to the action plan, improvement of our delivery of care services, resident outcomes, and compliance with F 609. 6. The Director of Nursing/designee will review Accident/Incidents daily to ensure the timely submission of all reportable accident/incidents to the State Survey Agency. V.TITLE OF PERSON RESPONSIBLE FOR CORRECTION OF DEFICIENCY: 1. Director of Nursing. 2. (MONTH) 14, 2025.