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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 821) initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's need was developed and implemented for each resident. This was identified for one (Resident #55) of five residents reviewed for Unnecessary Medications. Specifically, on 9/24/2024 Resident #55 was transferred to the hospital due to unresponsiveness. The resident was readmitted on [DATE] with a [DIAGNOSES REDACTED]. There was no documented evidence that a comprehensive care plan with appropriate interventions was developed to prevent further potential Opioid Overdose. The finding is: The facility's Opioid Overdose Management/Use of [MEDICATION NAME] policy and procedure dated 12/2024 documented the facility will have [MEDICATION NAME] (a medicine that reverses Opiod overdose) available on each nursing unit for use in the event of an apparent or suspected Opioid overdose is identified. The Medical Director shall approve standing orders for the facility to allow the administration of [MEDICATION NAME] by any licensed nurse to any resident upon reasonable suspicion of Opioid overdose, without having to first obtain a verbal or written order to prevent delay in treatment that may result in resident harm. Such reasonable suspicion shall be based on the presentation of symptoms of Opioid overdose. The facility's Comprehensive Interdisciplinary Care Plan Completion of Minimum Data Set 3. 0 policy and procedure reviewed 12/2024 documented that the interdisciplinary team will assess the resident holistically to develop a plan that will promote quality of care and quality of life to assist the resident in achieving goals. Resident #55 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated intact cognition. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms present and was receiving Anti-Anxiety, anti-depressants, Opioid, and hypnotic medications; indicators were present for the use of the medications. A Nurse Practitioner's note dated 9/24/2024 documented the resident was re-examined and found non-responsive to verbal as well as tactile (touch) stimuli. The resident was responsive to deep and painful stimuli. [MEDICATION NAME] ([MEDICATION NAME]) Spray 4 milligram Nasal time one dose was given and within seconds the resident had opened their eyes, became slowly responsive to their name, and was moaning. 911 was activated to transfer the resident to the hospital for further treatmentfor [DIAGNOSES REDACTED]. A Health Status Note dated 9/24/2024 at 4:39 PM documented the resident was transferred to the hospital for severe lethargy. A Patient Review Instrument dated 9/30/2024 documented primary [DIAGNOSES REDACTED]. During an interview on 2/7/2025 at 4:05 PM, the Minimum Data Set Coordinator stated they or the admission nurse could have initiated a care plan that addressed the drug overdose to prevent further occurrences. The Minimum Data Set Coordinator stated they usually initiated the original care plans, and the unit nurses were responsible for updating and initiating the interim care plans. The Minimum Data Set Coordinator further stated a care plan with interventions specifically addressing the Opioid overdose should have been developed. During an interview on 2/7/25 at 4:15 PM, the Director of Nursing Services stated that a care plan addressing the Opioid overdose should be developed and implemented. The Minimum Data Set Coordinator was responsible for initiating the care plans. The Director of Nursing Services stated that the Minimum Data Set Coordinator should have initiated a care plan with appropriate interventions that addressed the Opioid overdose to prevent further occurrences and if the Minimum Data Set Coordinator was not available, the Registered Nurse Supervisors could have initiated the care plan. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F 656. Resident #55 care plan was updated on 2/10/2025 by MDS Coordinator to include [DIAGNOSES REDACTED]. All residents on opioids and/or have a history of opioid overdose have the potential to be affected by this alleged deficient practice A full house audit was conducted on all residents by MDS Coordinator/DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that addresses their risk for opioid overdose and have appropriate goals and interventions to prevent potential opioid overdose. Any negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Comprehensive Care Plan was reviewed by MDS Coordinator/ DON/ Social Worker, Coordinator/DON/social worker The DON/MDS Coordinator educated the nursing staff and IDT on 2/25/2025 about ?ôComprehensive Care Plans?Ø with emphasis on developing a person-centered care plan for those residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression, with appropriate goals and interventions to prevent further potential opioid overdose. Care plans were immediately updated to reflect an accurate, person-centered plan of care for the residents based upon the residents assessed condition and needs, if required. . Staff were reminded of the potential consequences to both the residents and staff if the policy is not followed. Any staff found responsible for the deficient practice will be referred to the DON for counseling. An audit was conducted on all residents by MDS Coordinator /DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that accurately reflects their physical and mental health needs and assures their needs are addressed and met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator /DON/Designee will audit 5 resident care plans x 4 weeks, then 5 resident care plans monthly x 3 months to ensure that residents with moderate to high risk index for opioid overdose or serious opioid-induced respiratory depression have a person- centered care plan addressing potential for opioid overdose with appropriate goals and interventions to prevent further potential opioid overdose. Any adverse findings will be immediately corrected. Audit findings will be presented to the QA Committee monthly meetings x 6 months. The results of these audits will be reviewed in the monthly QA Committee monthly meetings for 6 months or until 100% compliance is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. The date for correction and the title of the person responsible for correction of each deficiency: DON is responsible for the compliance by 03/10/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details Based on observation, interviews, and record review conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task. Specifically, 1) several food items were stored in the walk-in refrigerator and walk-in freezer without proper labeling and dating; multiple frozen item bags were observed with ice and frost inside their packaging; Additionally, a plastic container and milk crates in the dry storage area were observed to be dirty. 2) Cold food items including yogurt, milk, chicken salad sandwich, and egg salad temperatures were observed above 41 degrees Fahrenheit. The findings are: A facility policy and procedure titled Food Storage effective 10/2024, documented food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. A date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Plastic containers with tight-fitting covers must be used for storing broken lots of bulk foods. All containers must be legible, accurately labeled, and dated. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Refrigerated food storage: all foods should be covered, labeled, and dated. A facility policy and procedure titled Cleaning and Sanitation of Dining and Food Service Areas, effective 10/2024, documented the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Tasks shall be designated to be the responsibility of specific positions in the department. All staff will be trained on the frequency of cleaning necessary. During an initial tour of the kitchen on 2/3/2025 at 9:26 AM, the walk-in refrigerator was observed with multiple food items (tapioca pudding, and beet salad) not properly labeled and dated. The walk-in freezer was observed with multiple food items (corn, French toast, chicken nuggets, French fries, turkey burger, beef burger, pork chops, and frankfurters) not properly labeled and dated. The bags of turkey burgers, beef burgers, pork chops, and frankfurters were observed to have ice/frost build up on the inside of the packaging. There were also two packages of Perogies and a corned beef outside of their original delivery pack without a delivery date. A plastic container of jelly was not dated in the reach-in refrigerator; the edges and the lid of the container had remnants of peanut butter on it. The Food Service Director was immediately interviewed and stated the cooks are responsible for labeling and dating food returned to the freezer. The Food Service Director stated the cooks should ensure that the food packages are sealed to prevent freezer burn. The container of jelly should have been dated and the edges should have been cleaned. During an interview on 2/3/2025 at 9:35 AM, Cook #1 stated the cooks are responsible for labeling and dating food packages when returning to the freezer. Cook #1 stated food with freezer burn cannot be served and should be discarded. During a tour of the dry storage area on 2/3/2025 at 9:40 AM, a plastic tub of beef soup base was observed with black dust on the lid. The plastic tub was stored on top of milk crates which were observed with a buildup of the soup base powder along the top and edges. The Food Service Director stated that the container and the milk crates should have been cleaned. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated that stored food should be labeled and dated. The Administrator stated they were not aware the kitchen was not following the food storage procedure. 2) A facility policy and procedure titled Food Temperatures effective 3/2022 last reviewed 1/2025, documented it is the policy to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Food temperatures will be checked on all items prepared in the dietary department. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. No food will be served that does not meet the food code standard temperatures. Place cold menu items such as ham salad or egg salad over an ice bath in a pan and not beside a heated steam table. The Cook's Temperature Log Sheet maintained by the facility did not include evidence of cold food temperature monitoring. During an interview on 2/6/2025 at 12:25 PM, Cook #2 stated they only measure the temperature of cold entr?â?®es but do not take the temperature of the other cold food items that are placed on the individual resident tray such as milk, yogurt, sandwiches, etc. During the Kitchen observation on 2/6/2025 at 12:32 PM, two trays of sandwiches were not kept in an ice bath. During an observation and interview on 2/6/2025 at 12:33 PM, Cook #3 stated they did not keep the sandwiches (such as American cheese, egg salad, tuna salad) on ice during preparation, nor did they take the temperatures of the sandwiches. Cook #3 measured the temperatures of the sandwiches. The American cheese sandwich temperature was measured at 60 degrees Fahrenheit, and the chicken salad sandwich temperature was measured at 50 degrees Fahrenheit. Cook #3 stated the temperature of the sandwiches should be below 40 degrees Fahrenheit. During an interview on 2/6/2025 at 12:40 PM, the Food Service Director stated the proper serving temperature for cold food should be 41 degrees Fahrenheit or below. The Food Service Director stated they do not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt. During an interview and observation on 2/6/2025 at 12:45 PM, Dietary Aide #1 stated that they do not measure the temperature of the cold food items before they place the food items on the individual resident trays. Dietary Aide #1 stated they usually kept cold items in a cooler, but the cooler was broken and was never replaced. Dietary Aide #1 measured the temperature of cold food items, finding yogurt at 50 degrees Fahrenheit, milk at 50 degrees Fahrenheit, and a cup of egg salad at 60 degrees Fahrenheit. Dietary Aide #1 stated the temperature of the cold food should be less than 41 degrees Fahrenheit. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated they were aware of the food temperature standards and cold food should be maintained at a temperature of 41 degrees Fahrenheit or below. The Administrator stated they did not know the Food Service Director was not monitoring the temperature of the cold food items served to the residents. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedMarch 3, 2025 Pine(NAME)Center For Rehabilitation and Healthcare provides the Following Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F 812. The Food Service Director ensured that all improper labeled and dated food items were discarded immediately. The Food service Director gave in-services to the cooks on 2/4/2025 on properly labeling and dating food items The Food service Director cleaned the edge of the lid immediately upon recognition. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this alleged deficient practice. Food Service Director did a kitchen-wide tour on 2/03/2025 to ensure that the facility is in compliance with food storage procedure. All negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Administrator and Food Service Director reviewed the policy on Food Storage. No changes were made. They also reviewed the policy on Cleaning and Sanitation of Dining and Food Service Areas and the policy on Food Temperatures and no changes were made. Kitchen staff were in serviced on 2/04/2024 on the policies with specific focus on proper labeling of food packages, disposing of freezer burned food, and on the cleanliness of the food storage areas. They were also in-service on Cold Food temperatures, with specific focus on keeping all cold food items on ice during preparation to adhere to the regulations. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Facility has implemented tray line temperature audits to ensure the facility is in cold food temperature compliance. Audits will be done weekly for the 1st 4 weeks and then monthly for the following 5 months. The facility has implemented audits on proper labeling/dating as well as cleanliness to ensure staff are adhering to state and federal regulations and will be done weekly for the 1st 4 weeks and then monthly for the following 5 months following. Audits will be discussed at the QA meeting to monitor for compliance 5. The date for correction and the title of the person responsible for correction of each deficiency The Administrator will be responsible for implementation and compliance by 03/10/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 821), the facility did not ensure that an investigation of alleged abuse was thoroughly and timely investigated to prevent further potential abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #55) of two residents reviewed for Abuse. Specifically, on 12/28/2024 Resident #55 verbalized that a Certified Nursing Assistant scratched them during the morning care. There was no documented evidence that an investigation to rule out abuse, neglect, or mistreatment was initiated until 12/30/ 2024. The finding is: The facility Accident/Incident Report reviewed 1/2025 documented all accidents/incidents involving residents must be reported to the Director of Nursing Services and or Assistant Director of Nursing. An Accident/Incident Report must be completed on the shift in which the accident/incident occurred. A copy of this report is to be provided to the Assistant Director of Nursing/designee within 24 hours of such incident. Resident #55 was readmitted to the facility with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score as 12, which indicated the resident had moderately impaired cognition. The resident required partial to moderate assistance for toileting, bathing, dressing, rolling left to right, and personal hygiene. There was no functional limitation in the range of motion to the upper and lower extremities. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms. A Late entry note dated 1/15/2025 for 12/30/2024, entered by the Director of Nursing Services, documented that on 12/30/2024, Resident #55's representative reported that the resident had a scratch on their buttocks. A complete body check was done, and the resident's skin was found to be intact, without scratches or redness. Resident #55 then informed the Director of Nursing Services that on 12/28/2024 at approximately 7:30 AM, during care, Certified Nursing Assistant #5 squeezed the resident's fingers. The assigned Certified Nursing Assistant #4 was also present in the room. The Accident and Incident Report dated 12/30/2024 documented the resident alleged they were scratched by a Certified Nursing Assistant during care on 12/28/2024 at approximately 7:30 AM. The resident's statement on the Accident/Incident Report documented the Certified Nursing Assistant scratched me on purpose. A Summary of Investigation dated 12/30/2024 documented Resident #55 had initially reported their buttock injury, which was caused by a Certified Nursing Assistant during morning care, to the nurse on Saturday 12/28/ 2024. The report documented that the nurse initially examined the area and had no findings; however, Resident #55 was upset and continued to insist that they were scratched on the right buttocks. During a skin assessment, the nurse noted visible lines of indented skin on the resident's right upper thigh caused by the brief. There was no documented evidence that an investigation was initiated on 12/28/2025 including statements from the involved Certified Nursing Assistant #4 and Certified Nursing Assistant #5 to rule out abuse, neglect, or mistreatment. There was no documented evidence of a nursing progress note related to the allegations made by the resident regarding staff intentionally scratching the resident's buttock area or squeezing their finger during care. A Typed statement signed by Resident #55 dated 12/30/2024 documented that on 12/28/2024 around 7:30 AM Certified Nursing Assistant #4 and Certified Nursing Assistant #5 came to their room to change them. Certified Nursing Assistant #4 proceeded to change them while Certified Nursing Assistant #5 was standing on the left side of the room. Certified Nursing Assistant #4 closed the left side of the brief and then asked Certified Nursing Assistant #5 to assist. Certified Nursing Assistant #5 came to the right of the bed. Resident #55 told Certified Nursing Assistant #5 not to touch them as they usually have only one Aide helping them and did not want Certified Nursing Assistant #5 to assist. Resident #55 grabbed the strap of the brief with both hands to stop Certified Nursing Assistant # 5. While Resident #55 was turning to their left side for Certified Nursing Assistant #4 to close the right side of the brief, Certified Nursing Assistant #5 grabbed the resident's right hand and squeezed the resident's hand hard, and with their (Certified Nursing Assistant #5) other hand they scratched the resident's right buttock. A Comprehensive Care Plan dated 1/14/2025 documented the resident has accusatory, attention-seeking, and fabrication behaviors towards staff and peers. Interventions included a two-person approach during care and to observe for changes in the resident's behavior. During an interview on 2/6/2025 at 12:26 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #55 on 12/28/ 2024. Certified Nursing Assistant #4 stated that on 12/28/2024 the resident asked to be changed, and they informed the resident that they would get a second Certified Nursing Assistant to assist with their care. Certified Nursing Assistant #4 stated that during the brief change Certified Nursing Assistant #5 assisted with applying the brief on one side. Certified Nursing Assistant #4 stated after they had fastened the tape on the left side of the brief, Certified Nursing Assistant #5 was about to fasten the tape on the other side when the resident screamed Don't touch me, at that time Certified Nursing Assistant #5 left the room to get Licensed Practical Nurse # 1. Certified Nursing Assistant #4 stated Licensed Practical Nurse #1 came and stayed in the resident's room until the care was completed. Certified Nursing Assistant #4 stated during care Resident #55 did not complain Certified Nursing Assistant #5 scratched them or squeezed their hand. During an interview on 2/6/2025 at 12:45 PM, Certified Nursing Assistant #5 stated on 12/28/2024 they had assisted Certified Nursing Assistant #4 with the care of Resident # 55. Certified Nursing Assistant #5 stated the resident was a two-person approach and was upset because the resident did not want them in the room. Certified Nursing Assistant #5 stated as they were about to fasten the brief, Resident #55 grabbed the brief and said, Don't touch me. Certified Nursing Assistant #5 stated they did not touch the resident and left the room right away to get Licensed Practical Nurse # 1. Certified Nursing Assistant #5 stated shortly after the incident, Registered Nurse #2 Supervisor interviewed them regarding the resident's complaint of being scratched. Certified Nursing Assistant #5 stated they had short nails and were wearing gloves during care. Certified Nursing Assistant #5 stated they did not touch the resident and did not squeeze the resident's hand. During an interview on 2/6/2025 at 1:42 PM, Registered Nurse #2, the 7:00 AM-3:00 PM shift supervisor, stated on 12/28/2024 between 9:00 AM -10:00 AM the resident called the receptionist to speak with the Supervisor. Registered Nurse #2 stated the resident reported that someone scratched them on their leg; however, the resident did not want to be touched. Registered Nurse #2 stated they observed two lines on the resident's right upper thigh that were red and looked like the lines of indented skin caused by the brief. Registered Nurse #2 stated when they assessed the resident on 12/28/24 that they did not document their assessment in the medical record. Registered Nurse #2 stated that they had forgotten to document their assessment in the chart and did not start an investigation. During an interview on 2/7/2024 at 12:00 PM, Resident #55 stated while the staff was applying their brief, they asked Certified Nursing Assistant #5 not to touch them. Resident #55 stated they held onto their brief and Certified Nursing Assistant #5 held on to their (the resident's) right hand to remov | Plan of Correction: ApprovedMarch 5, 2025 Pine(NAME)Center for Rehabilitation and Healthcare Provides this Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F 610. SW met with resident #55 on 2/28/2025 and offered psychological and psychiatric services. Resident declined the services, and resident denied any emotional distress. RN #2 was re-educated on 3/01/2025 on the policy and procedure on initiating abuse/mistreatment/neglect investigation and reporting guidelines and on proper documentation. Certified Nurses Assistant #4 and #5 was re-educated on 2/26/2025 on the policy and procedure of abuse/mistreatment/neglect and exploitation Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. Facility did an audit/review on 2/25/2025 on investigations of allegations, and no potential reportable allegations of abuse were found. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Abuse Reporting and Investigating was reviewed by DNS, Admin, and Social Worker and no updates were made. All RN Supervisors were re-educated on 3/01/2025 on the Policy and Procedure for Abuse Reporting and Investigation Policy by the DON/designee. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure allegations of abuse, neglect or mistreatment are investigated immediately as required. Any adverse findings will be immediately corrected accordingly. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure pharmaceutical services met the needs of each resident including appropriately administering all drugs and biologicals in accordance with the professional standards of practice. This was identified for one (Resident # 21) of five residents reviewed for unnecessary medications. Specifically, Resident #21 was prescribed [MEDICATION NAME] Sodium ([MEDICATION NAME]) Injection Solution 5000 units per milliliter and the nursing staff administered the injection without rotating the subcutaneous injection sites. Cross Reference: F658- Services Provided Meet Professional Standards The finding is: The Policy and Procedure for Injection Site Rotation dated (MONTH) 2023 documents that rotation of the injection site is required. The pdr.net/drug summary/ [MEDICATION NAME] Sodium injection website for [MEDICATION NAME] subcutaneous injection administration documented to rotate the injection site frequently. The National Library of Medicine; National Center for Biotechnology Information: Nursing Skills 2nd edition 2023 documented it is important to rotate [MEDICATION NAME] sites to avoid bruising in one location. Resident # 20 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current physician's orders [REDACTED]. The Medication Administration Record [REDACTED] 2025. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated [MEDICATION NAME] injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of [MEDICATION NAME] administration should be documented accurately and the injection site should be rotated. If the [MEDICATION NAME] injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of [MEDICATION NAME] is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415. 11(c)(3)(i) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F 755. Resident #20 was reassessed by the RN Supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated on 2/26/2025 to include rotating sites with each administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON/Designee and no updates were made. All Nurses were re-educated on 3/01/2025 by the DON on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The consultant pharmacist will monitor externally for appropriate site rotation based on administration records and will report negative findings to DON. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 20) of five residents reviewed for unnecessary medications. Specifically, Resident #20 had a physician's orders [REDACTED]. The nursing staff were not rotating the injection sites when administering [MEDICATION NAME]. Cross Reference: F755- Pharmacy Svcs/Procedures The finding is: The Policy and Procedure for Injection Site Rotation dated (MONTH) 2023 documented that rotation of the injection site is required. Resident # 20 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current physician's orders [REDACTED]. The Medication Administration Record [REDACTED] 2025. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated [MEDICATION NAME] injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of [MEDICATION NAME] administration should be documented accurately and the injection site should be rotated. If the [MEDICATION NAME] injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of [MEDICATION NAME] is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415. 11(c)(3)(i) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F 658. Resident #20 was reassessed by RN supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated ON 2/26/2025 to include rotating sites with each administration. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON and no updates were made. All Nurses were re-educated on 3/01/2025 by DON/Designee on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months on all residents on [MEDICATION NAME] to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency DON will be responsible for implementation and compliance by 03/10/ 2025. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 4, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |