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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES"A" FORMAH
SUMMARY STATEMENT OF DEFICIENCIESSTATEMENT OF ISOLATED DEFICIENCIES WHICH CAUSE NO HARM WITH ONLY A POTENTIAL FOR MINIMAL HARMFOR SNFs AND NFs NAME OF PROVIDER OR SUPPLIER 
SPLIT ROCK REHAB AND HEALTH CARE CENTER 
PROVIDER #
335321
DATE SURVEYCOMPLETE:
2/2/2007
STREET ADDRESS, CITY, STATE, ZIP CODE
3525 BAYCHESTER AVEBRONX, NY
IDPREFIXTAG
MULTIPLE CONSTRUCTION
A. BUILDING
 ______________________ 
B. WING _____________________________ 
483.15(h)(2) HOUSEKEEPING/MAINTENANCEThe facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly,and comfortable interior.This REQUIREMENT is not met as evidenced by:
F 253
Based on observations and staff interviews the facility did not ensure that housekeeping services maintainedthe resident's environment in a sanitary, and orderly manner as evidenced by a soiled feeding pump andmicrowave oven. This was evident for 1 of 6 nursing units. Unit #3 North.This resulted in no actual harm with potential for minimal harm.The finding is:During the initial environmental tour on 1/3/07 at 9:45AM on 3 North, it was observed that the feeding pumpin room 306B had dust on it's base and dried yellow substance on the front of the machine.The Certified Nursing Assistant was interviewed on 1/31/07 at 10:30AM and stated "Housekeeping isresponsible for cleaning the feeding pumps. I will let the nurse know."The Registered Nurse in charge was interviewed on 1/31/07 at 10:40AM and stated "The resident wastransferred yesterday, and the pump should have been taken down to be cleaned by housekeeping and thenstored in the 1st. floor stock room. Housekeeping cleans the pumps".The Housekeeping Supervisor was interviewed on 2/1/07 at 12:45PM and stated "The feeding pumps arecleaned twice a week by housekeeping and as needed".At 10:58AM, the inside of the microwave oven was noted to have a large amount of encrusted dark brownstains.The RN in charge of the floor was interviewed at 10:59AM and she stated "The microwave could do with acleaning. I'll call housekeeping".The Housekeeping Supervisor was interviewed on 2/2/07 at 3:30PM and she stated "The microwave iscleaned by a maid on Monday and Friday. During the other days, the porter is responsible for it".415.5 (h) (2)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of 
The above isolated deficiencies pose no actual harm to the residents
031099
If continuation sheet 1 of 1
XL9B11Event ID:
 
A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 05/16/2007FORM APPROVED
(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________ 
 ______________________ 
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
335321
02/02/2007
BRONX, NY 10466
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SPLIT ROCK REHAB AND HEALTH CARE CENTER
3525 BAYCHESTER AVE
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)
F 246
SS=D
483.15(e)(1) ACCOMODATION OF NEEDSA resident has the right to reside and receiveservices in the facility with reasonableaccommodations of individual needs andpreferences, except when the health or safety of the individual or other residents would beendangered.This REQUIREMENT is not met as evidencedby:F 2462/5/07Based on record review and resident and staff interview, the facility did not ensure that aresident's preferences were accommodated asevidenced by not addressing the resident's needfor a room change and alternate placement. Thiswas evident for 1 of 3 out of sampled residents(resident #33)This resulted in no actual harm with potential for more than minimal harm.The finding is:Resident #33 is a twenty one year old residentadmitted to the facility on 6/6/06 with diagnoses of Asthma, and Depression.On 1/31/07 at 2:40PM, during a residentinterview, the resident stated "I am the youngestperson in this facility and I was placed in a 4bedded room since I came in the facility, I havebeen asking to be moved to a private room and Iwas told by the Administrators, that the privaterooms are for residents with medical necessities.In the 4 bedded room I cannot play my radio or watch the programs I want on television. I have toturn off the light when the other residents wantthe light off. I wake up in the mornings sweating
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURETITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatother safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 daysfollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation.
FORM CMS-2567(02-99) Previous Versions ObsoleteXL9B11
Event ID:
Facility ID:1243
If continuation sheet Page 1 of 13
 
A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 05/16/2007FORM APPROVED
(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________ 
 ______________________ 
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
335321
02/02/2007
BRONX, NY 10466
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
SPLIT ROCK REHAB AND HEALTH CARE CENTER
3525 BAYCHESTER AVE
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)
F 246Continued From page 1F 246and I feel like I am suffocating. I use to put the air conditioner on, but the other residents complainabout being cold. The air conditioner was recentlyremoved, and a heating system was placed. Thewindows were also nailed shut. I feel like I amgoing to die in that room."The Social Service Admission Assessment dated6/6/06 documented that the resident was"Oriented to person, place, and time;memory/recall short and long term intact; dailydecision making intact; customary routine: staysup late at night; unsettled relationships: unhappywith roommate and does not adjust easily tochange in routines".The Social Service Progress Note dated 6/07/06documented "This writer met with resident whowas upset that he was placed in a 4 beddedroom."The Comprehensive Care Plan (Social Service)dated 6/12/06 documented "Resident expressesdesire to return home; alteration in mood patterndemonstrated by persistently annoyed atplacement in nursing home, insomnia and sadaffect."The Social Service Progress Notes dated 6/13/06documented "It was reported by nursing dept.(department) that resident has been sleeping inday room; since admission resident has beenrequesting room change, no availability." Thesocial service progress note dated 6/26/06documented "He (resident) reported that he isvery annoyed with the new roommate because of the roommates "incontinence of bowel andbecause he makes noise."
FORM CMS-2567(02-99) Previous Versions ObsoleteXL9B11
Event ID:
Facility ID:1243
If continuation sheet Page 2 of 13
of 00

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