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NYS Health Profiles
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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 917) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 2 out of 6 residents (Resident #5, #2) reviewed for Quality of Care. Specifically, (1) Resident #2 was admitted to the facility with orders for nothing to be administered by mouth and a feeding tube the facility did not address Resident #2 ability to receive oral medication or include an order for [REDACTED].#5 was admitted with orders for nothing by mouth with a feeding tube, Resident #5 was evaluated on 1/19/2025 by Physician Assistant #1 with orders including [MEDICATION NAME] tablet, [MEDICATION NAME] tablet and [MEDICATION NAME] capsules to be administered by mouth. (3) The pharmacy review for resident #5 recommended to discontinue [MEDICATION NAME] (medication used in the treatment of [REDACTED]. Nurse practitioner #1 initiated the new medication but did not discontinue the [MEDICATION NAME]. For 30 days resident received both medications. The findings are: The facility Physician's Visit policy dated 2/1/2016 and last revised 1/2020 documented the attending physician must make visits in accordance with applicable state and federal regulations. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. 1) Resident #2 was an [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum (MDS) data set [DATE] documented resident had a Brief Interview for Mental Status score of 6/15 which indicated a significant cognitive impairment. Resident #2 had an advanced directive dated 12/30/2024 which included Send to hospital, when medically necessary. A review of the Patient Review Instrument dated 12/26/2025 documented (19) Eating = 5 Tube of [MEDICATION NAME] feeding for primary intake of food. (Not just for supplemental nourishments.) The speech therapy evaluation dated 12/30/2024 documented resident should have nothing by mouth (NPO). The physician orders [REDACTED]. Any drug which cannot be crushed, may be given whole in applesauce. Physician orders [REDACTED]. [MEDICATION NAME] Oral Capsule 30 MG (Oseltamivir [MEDICATION NAME]) Give 1 capsule by mouth one time a day for flu for 5 days. Tylenol Oral Tablet 325 MG ([MEDICATION NAME]) Give 2 tablet by mouth every 6 hours as needed for pain. Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. During an interview conducted with the Medical Director on 2/12/2025 at 3PM they stated the physician/practitioner should review the recommendations from the speech pathologist for the resident's intake status. They further stated if a resident is deemed nothing by mouth (NPO) there should be physician order [REDACTED]. 2) Resident#5 was admitted to the facility with a medical [DIAGNOSES REDACTED]. The review of the Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 15 indicating intact cognition for decision making, eating not attempted due to medical condition or safety concerns, feeding tube on admission, while a resident, the resident received through [MEDICATION NAME] or tube feeding-51% or more, for the Resident. The review of the Order Recap Report dated 1/11/2025 documented Tube Feed diet, nothing by mouth. The review of the physician orders [REDACTED]. The review of the Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/21/2025 were unsuccessful. 3) The medication Regimen review dated 1/10/2025 documented consultant pharmacy recommendations including currently receiving [MEDICATION NAME] ([MEDICATION NAME]) by PEG (feeding tube) for benign prostate hypertrophy which should not be crushed. Please consider discontinue and start Silodosin ([MEDICATION NAME]) 8 Mg daily opened spinked in applesauce and given via GT. The physician/ prescriber response indicated Agree; Will do signed and dated by the prescriber on 1/13/ 2025. The physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. During an interview conducted with Nurse Practitioner #1 on 2/13/2025 at 2pm they stated they reviewed the recommendations from the pharmacy. They further stated they agreed to switch to Silodosin ([MEDICATION NAME]) which could be given via the feeding tube. Nurse Practitioner #1 stated [MEDICATION NAME] should have been discontinued and it was an oversight. They stated they would do it immediately. 10NYCRR 415. 15(b)(2)(iii) | Plan of Correction: ApprovedApril 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Action: Resident # 2 and Resident #3 no longer reside at the facility. The MEDICATION ORDERS FOR [REDACTED]. Nursing and Activity staff directly involved in the care of Resident #2 and Resident #3 were immediately re-educated on proper dietary restrictions and swallowing precautions, ensuring that residents with GT who are NPO are maintained NPO and are not administered anything by mouth. The Medical Director in-serviced the medical staff involved on providing a person-centered care including but not limited to reviewing recommendations from other disciplines such as the speech pathologist recommendations as well as the consultant pharmacy recommendations. In addition, providers were educated on ordering medication routes according to residents' plan of care such ordering medication via [DEVICE] when residents are NPO. II. Identification: All residents with NPO order or that are aspiration precautions or altered diets have the potential to be affected by this finding. The Director of Nursing audited all residents with a Gastrostomy tube to review their NPO status to ensure medications orders are to be administered via GT. Any finding was addressed immediately. The residents with altered diet orders were audited to ensure they only receive food or meal services according to their diet orders. The Activity Department was provided with an up-to-date list of residents on altered diets, food allergies [REDACTED]. III. Systematic Changes: The policies titled Accidents and Incidents Investigating and Reporting, and Aspiration Precautions were reviewed by the Director of Nursing, Administrator and Medical Director and no revisions were necessary. The clinical staff, Nursing, PT/OT, and medical providers were re-educated on ensuring residents are provided person-centered care and services necessary to meet and maintain the highest practicable physical, mental and psychological wellbeing, as well as, ensuring the following: 1. Providing supervision for residents who are at risk for aspiration and choking and are on altered diets 2. Ensuring that residents with GT who are NPO are maintained NPO and are not administered anything by mouth 3. Ensuring residents with GT receive the right evaluation by the physician including following recommendations from the speech pathologist. 4. Examples of hazards and supervision, ensuring that the resident environment is free from hazards. Unit Managers/Designee will monitor residents with NPO order to ensure the facility provides person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being New admissions with a feeding tube will be monitored during morning meetings to ensure the medication route is according to residents' plan of care. Activity Department will receive an up-to-date list of residents on altered diets, food allergies [REDACTED]. A log sheet will be maintained by the activities department to verify the daily receipt of this report. The menu and diet report will be disbursed to both nursing units and to all areas activities will take place for easy reference by all staff. IV. Monitoring: The Director of Nursing/ Designee will audit residents who have a Gastrostomy Tube and NPO to ensure medications are ordered via the right route (GT) weekly X 4 weeks, monthly X 3 months. Director of Nursing /Designee will audit 10 residents with altered diet orders randomly during activity programs to ensure they only receive food according to their plan of care at activity programs weekly X 4 weeks, monthly X 3 months. The result of all audits will be presented to QAPI committee for review and feedback monthly for the duration of audit. V. Responsible Party: The Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and closed record reviews , during an abbreviated survey (NY 917), the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) out of three (3) residents. Specifically, on [DATE] at 8:01 PM, Resident #2 was evaluated for symptoms including fever and [MEDICAL CONDITION] Nurse Practitioner #1 was notified on [DATE] at 6:30 PM of critical lab values and ordered to send Resident #2 to the hospital for an emergent blood transfusion. Registered Nurse Supervisor #1 documented Resident #2 would be sent to the hospital in the morning. Subsequently, on [DATE] at 1:20 AM, Resident #2 was found to be unresponsive, pulseless, and without respirations. Resident #2 expired at 2:01 AM. This resulted in Immediate Jeopardy with the likelihood for serious injury, serious harm, or death for all residents. Findings include: The facility policy titled Health Care Providers Services dated [DATE] documented (3) The health care providers will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs. Resident #2 was an [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (an assessment tool) dated [DATE] documented resident had a Brief Interview for Mental Status score of 6 which indicated a significant cognitive deficit. Resident #2 had an advanced directive dated [DATE] which included Send to hospital, when medically necessary. A Physician Encounter note dated [DATE] at 12:00 AM documented the Chief Complaint / Nature of Presenting Problem as Patient evaluated for fever, [MEDICAL CONDITIONS] (low blood pressure). Reviewed documents from [DATE] regarding chest x-rays with bilateral interstitial lung markings (abnormal findings on an x-ray that indicates inflammation and scarring of lung tissue) which was presumed likely [MEDICAL CONDITION] etiology. Patient currently on an [MEDICAL CONDITION] medication (used to treat the flu) renal dosing since ,[DATE]/ 2025. However, spiking fever with blood pressure ,[DATE] requires immediate fluid bolus and Tylenol 1 gram versus 650 milligrams. A Nursing Progress Note on [DATE] at 4:09 PM documented Resident #2 was noted with a temporal (forehead) temperature of 101. 1 Fahrenheit, hypotensive, and [MEDICAL CONDITION](increased heart rate). The note documented the Nurse Practitioner was made aware with new orders for intravenous bolus, initiated intravenous antibiotics, labs and chest x-ray to be obtained. A Nursing Progress Note dated [DATE] at 3:11 AM, documented resident was assessed (with) abnormal lung sounds; upon assessment lungs auscultated to have crackles bilaterally and the resident was only responsive to painful stimuli. Resident was suctioned (the process of removing something by way of vacuum or pump), vital signs stable (no documented measurements) outside of temp of 99. 9, ongoing care in progress. A Medication Administration Note, dated [DATE] at 6:50 AM, documented Resident #2 had an elevated temperature of 101. 2. A review of the lab results dated [DATE] documented a critical low level of hemoglobin at 4. 9g/dL, a critical low level of hematocrit at 17%, and a critical high level of Sodium at 161 mmol/L (normal range ,[DATE] mmol/L). A review of Resident #2's vital signs documented the following blood pressures: [DATE] 8:10 AM - blood pressure reading 80/ 30. No documented evidence the physician was notified. [DATE] at 9:10 AM - blood pressure reading 87/ 54. No documented evidence the physician was notified [DATE] at 6:19 PM - blood pressure reading of 100/ 50. No documented evidence the physician was notified. A Nursing Progress Note dated [DATE] at 6:32 PM, documented Registered Nurse Supervisor #1 received a call from the lab that Resident #1 had a critical result including a hemoglobin of 4. 9 and hematocrit of 17. 0. Resident with stable vitals (no measurements documented). The note further documented Nurse Practitioner #1 was notified and ordered Resident #1 be transferred to emergency room in the morning for blood transfusion. An On Call Telemedicine note written by Nurse Practitioner #2 on [DATE] at 10:21 PM documented the nurse (there is no documented evidence who Nurse Practitioner #2 spoke to) called in stating that the patient's sodium is elevated. No signs or symptoms. The note further document the nurse added that the patient is going to be sent to the hospital tomorrow morning for transfusion due to critical hemoglobin level. A Nursing Progress Note, dated [DATE] at 2:20 AM, documented that at approximately 1:20 AM Resident #2 was found unresponsive with no pulse. Cardiopulmonary Resuscitation initiated immediately. Emergency services were called and arrived on scene at 1:31 AM. Paramedics assumed care and Resident #2 was pronounced deceased at 2:01 AM. During an interview with Registered Nurse Supervisor #1 on [DATE] at 3:30 PM, they stated they received a call from the lab on [DATE] at approximately 6 PM regarding critical values for Resident # 2. They took vital signs and notified Nurse Practitioner # 1. Registered Nurse Supervisor #1 stated they were given orders to send Resident #2 for a blood transfusion in the morning. During an interview with Nurse Practitioner #1 on [DATE] at 1:15 PM, they stated they recalled receiving a phone call from the Registered Nurse Supervisor #1 on [DATE] at approximately 6 PM informing them of Resident #2's critical lab result. Nurse Practitioner #1 stated to their recollection they were only given the critical hemoglobin level and speculated that the other results may not have been completed at the time of the call. Nurse Practitioner #1 stated they believed something got lost in translation on the call with the nurse. Nurse Practitioner #1 stated they did not give the nurse an order to wait until the morning to send Resident #2 to the hospital for a blood transfusion. Nurse Practitioner #1 stated if Resident #2's hemoglobin level had been a little higher, they might have been able to schedule Resident #2's transfer to the hospital for a transfusion but not in this case. During an interview with Physician #1 on [DATE] at 3:00 PM, they stated Resident #2 would need the blood transfusion given the critical labs but could wait until the morning if the resident's vitals were stable. The physician stated the blood pressure were not indicative of stable vital signs. The Physician further stated Resident #2 should have been sent to the hospital immediately. During an interview with the Medical Director on [DATE] at 2:30 PM and [DATE] at 2:00 PM, they stated the treatment of [REDACTED]. The facility has a process for acute changes to call 911. The Medical Director further stated he is not involved with direct patient care, however if a resident presented in the Emergency Department with a hemoglobin of less than 8, they would need a blood transfusion right away. During an interview with the Director of Nursing on [DATE] at 2:05 PM they stated if blood pressure, pulse, respiration, or temperature documented by the staff are out of range, the system provides notification to the nurse with an out-of-range alert. If the resident is to be transferred, the Nurse Practitioner or physician should say it's immediate, otherwise the transportation line is used. They further stated Resident #2 was set to have a planned transfer. A planned transfer means if the patient is stable, they would contact transport and let the hospital know the patient is coming for continuation of care. The Director of Nursing confirmed that based on the residents' blood pressure and abnormal lab results, Resident #2 was not stable. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 17, 2025 I. Corrective Action: Resident # 2 is no longer in the facility. The Director of Nursing (DON) conducted a comprehensive review of their medical records to identify lapses in communication. The findings were discussed in a staff meeting to emphasize the importance of timely notification to residents' representatives. II. Identification: All residents had the potential to be affected by the same deficient practice. The facility conducted a comprehensive audit of all current residents' medical records over the past 30 days to identify any instances where there are changes in condition that occurred without proper notification to the residents' representative. Any findings identified will be addressed immediately. III. Systematic Changes: The facility's policy titled Change of Condition??ÿ was reviewed by the Director of Nursing and Medical Director and no revision was required. RN's, LPN's and Medical Providers will be educated on the policy of Change of Condition and emphasize the importance of timely and documented communication with residents and their representatives. Newly hired license nurses and medical providers will undergo this training during orientation process. IV. Monitoring: The DON will review the 24-hour reports with any resident with a change of condition and verify if resident and the representative were notified of the changes. Audit will be completed daily X 1 week; once weekly X 4 months; once monthly X 3 months; once every 6 months X one year. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings monthly until compliance is sustained. V. Responsible Party: Director of Nursing/Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and facility record review during an abbreviated survey (Case #NY 162), the facility did not 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 for 1 (Resident #2) of 3 residents reviewed for injuries of unknown origin. Specifically, for Resident #2, the facility staff did not ensure to report a serious bodily injury of unknown origin within 2 hours of an allegation when on 5/14/2023 at 2:17 PM, facility staff observed bruising to the resident's contracted right arm with vocalized pain in the arm. On 5/14/2021 at 10:30 PM, x-ray results confirmed the resident had an acute midshaft humeral (upper arm bone) fracture of their right arm. This is evidenced by: The facility policy titled Abuse Prevention stated All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, must be reported immediately, but no later than 2 hours after the allegation is made, if the events that caused 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 Department of Health. Resident #2 Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 4/4/2021, documented the resident could be understood and could usually understand others and had severe cognitive deficiency for decisions of daily living. The Comprehensive Care Plan (CCP) titled ADL (activities of daily living) Functional status/ Rehab potential documented Resident #2 had impaired physical mobility related to limited range of motion secondary to contracture of right upper extremity. The interventions included hand posies to bilateral hands, off with care, administer medications as ordered by the physician, monitor for changes and report to physician, OT/PT evaluation on admission and PRN, and provide emotional support with all care. The Nursing Progress Note dated 5/14/2021 at 2:17 PM, documented during weekly rounds, Resident #2 was observed lying in bed. The resident had a bruise to their right arm and discomfort was vocalized during the assessment. The Unit Manager was made aware, and the appropriate individual was notified. The Nursing Progress Note dated 5/14/2021 at 2:54 PM, documented Resident #2 had bruising to the right arm that was contracted. The arm was assessed and had bruising to the upper and inner arm but was not measurable due to the contracture. The resident was seen by Occupational Therapy (OT) recently for evaluation for a splinting device. The physician was called and made aware. There were new orders for x-ray. The Nursing Progress Note dated 5/14/2021 at 10:30 PM, documented the results from the x-ray to the right arm confirmed an acute midshaft humeral fracture. The Administrator was made aware. The facility investigation dated 5/14/2021, documented the resident has spastic [MEDICAL CONDITION] and [MEDICAL CONDITION] and documented at the time the bruises were discovered, the wound nurse went to assess the resident's right arm contracture status and found the resident with bruising and pain. RN (Registered Nurse) #1 assessed the resident, and they were unable to measure the bruising due to the residents severely contracted baseline. The resident had signs of pain where the arm was touched so a complete skin check was not completed. The investigation concluded the statements obtained during the investigation provided a timeline showing the injury happened the afternoon of 5/12/ 2021. During that time Resident #2 was assessed for range of motion (ROM) by an Occupational Therapist (OT). The OT did not see bruising or signs of injury prior to treatment. The report documented that the OT did not feel the injury occurred during ROM, the injury was consistent with an accidental fracture. It was possible the injury occurred during routine care with staff manipulating the resident's arm during dressing, but all staff interviewed denied manipulating the resident's arm. As it occurred accidentally, during a therapeutic treatment, it was not reportable per the NYS DOH reporting manual. There is no evidence of abuse or neglect. During an interview on 7/27/2023 at 2:30 PM, the Nursing Home Administrator (NHA) stated they were responsible for reporting to the Department of Health. At the time of the injury of unknown origin, they were following New York State Department of Health reporting guide. The NHA stated they now follow Centers for Medicare and Medicaid Services (CMS) guidelines. 10 NYCRR 415. 4(4) | Plan of Correction: ApprovedMarch 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Action: Resident #2 no longer resides in the facility. Resident #5 orders for both [MEDICATION NAME] and [MEDICATION NAME] were corrected and updated accordingly. Resident #2 and Resident #5 medical providers involved in the care were re-educated by the Medical Director regarding ordering medication route administration according to residents' plan of care, aspiration precautions, NPO status, and medical conditions. In addition, they were re-educated on Drug Regimen Reviews and interventions are implemented completely. II. Identification: All residents with a GT (Gastrostomy tube) have the potential to be affected by this finding. The facility conducted a review of all residents who are on GT to ensure NPO orders are in place as indicated and to ensure residents who are NPO have orders to have their medications administered via Gastrostomy Tube (GT). No negative findings were identified. All Residents with drug regimen review have the potential to be affected by this finding. All drug regimen reviews for the last 30 days were audited to ensure the recommendation and interventions were followed and implemented completely. No negative findings were identified III. Systematic Changes: The Director of Nursing and Administrator reviewed the facility's policy titled Physician's Visit and Enteral Feedings Safety Precautions and no revisions were necessary. Licensed nursing staff, dieticians and medical providers were re-educated on the policies. RN's and LPN's will perform daily checks to ensure that medication orders are being followed as per the updated care plan, including verifying that no oral medications are given to residents who are NPO and have a GT. Unit Managers/Designee will monitor residents with NPO orders to ensure they are maintained as NPO and are not administered anything by mouth. All medical providers were educated by the Medical Director on the comprehensive review of the pharmacy consultant drug regimen review to ensure all recommendations are followed thoroughly including transcribing/discontinuing orders. In addition, they were re-educated regarding ordering medication route administration according to residents' plan of care, aspiration precautions, NPO status, and medical conditions. IV. Monitoring: The Director of Nursing/ Designee will audit residents who have a Gastrostomy Tube and NPO to ensure medications are ordered via the right route (GT) weekly X 4 weeks, monthly X 3 months. The Director of Nursing/Designee will audit the pharmacy consultant Drug Regiment Review to ensure all recommendations are followed thoroughly, including transcribing/discontinuing orders, monthly X 3 months. The result of all audits will be presented to QAPI committee for review and feedback for the duration of audit. V. Responsible Party: The Director of Nursing |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: February 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an abbreviated survey (NY 917), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three of six residents (Resident #2 #3 #5) reviewed for Accidents. Specifically, (1) Resident #2 was identified as high risk for aspiration (choking) and was to be fed via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that allows nutrition directly through your stomach.) Resident #2 physician orders [REDACTED]. (2) Resident #3 was evaluated by speech and deemed to be at risk for aspiration, a physician's orders [REDACTED]. Resident #3 was given a dog biscuit which Resident #3 ate and subsequently began coughing and noted with abnormal lung sounds (stridor). (3) Resident #5 was identified at risk for aspiration, Resident # 5 was evaluated by speech with recommendations for nothing by mouth (NPO). Medication administration records dated (MONTH) 2025 indicated multiple medication administration by oral route. The findings are: The policy titled Accidents and Incidents Investigating and Reporting dated 5/2024 documented all accidents or incidents involving residents shall be investigated using the Report of Incident/Accident Form including the circumstances surrounding the accident or incident, the names of witnesses and their accounts, and other pertinent data as necessary or required. The facility policy titled Aspiration Precautions dated 5/2024 documented aspiration precautions were defined as measures taken to reduce the risk of aspiration during eating, drinking, and other activities. Nursing staff were responsible for monitoring residents for signs of aspiration risk, implementing precautions and communicating changes in condition. The Speech Language Pathologists assess swallowing function and recommend appropriate dietary modifications and interventions. Provide direct supervision for residents with high aspiration risk and observe for signs of difficulty such as coughing and choking. Documents observations in the resident's medical record. Resident #2 was a [AGE] year-old readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (an assessment tool) dated 1/03/2025 documented resident had a Brief Interview for Mental Status score of 6/15 which indicated a significant cognitive deficit. Resident #2 had an advanced directive dated 12/30/2024 which included Send to hospital, when medically necessary. A review of the Patient Review Instrument dated 12/26/2025 documented (19) Eating = 5 Tube of [MEDICATION NAME] feeding for primary intake of food. (Not just for supplemental nourishments.) The speech therapy evaluation dated 12/30/2024 documented resident should have nothing by mouth (NPO). The physician orders [REDACTED]. Any drug which cannot be crushed, may be given whole in applesauce. Physician orders [REDACTED]. Start Date: 1/17/2025, Discharge/Death 1/28/2025 [MEDICATION NAME] Oral Capsule 30 MG (Oseltamivir [MEDICATION NAME]) Give 1 capsule by mouth one time a day for flu for 5 days Start Date 1/26/2025, Discharge/Death 1/28/2025 Tylenol Oral Tablet 325 MG ([MEDICATION NAME]) Give 2 tablet by mouth every 6 hours as needed for pain. Start Date 1/13/2025, Discontinue 1/26/2025 The Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. (2) Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (an assessment tool) dated 11/8/2024 documented a Brief Interview for Mental Status score of 8/15 which signified a moderate cognitive deficit. Physician order [REDACTED]. A Speech Language Pathology Screen dated 9/14/2023 documented discharge status and recommendations documented puree consistencies. A nursing progress note dated 12/25/2025 documented Resident was given dog treat (solid consistency) to feed dog and resident subsequently ingested said dog treat. The note further documented resident presents with a persistent cough with stridor (Stridor is a high-pitched, [MEDICATION NAME] or noisy sound that occurs when breathing. It is caused by an obstruction or narrowing in the upper airway). The physician progress notes [REDACTED].#3 ate the treat with subsequent fit of coughing, stridor noted at the time but resolved. The facility accident and incident report dated 12/27/2025 documented during pet therapy the resident asked if he could give the dog a treat, Resident #3 was given a dog treat to feed dog, resident ingested dog treat which was a milk bone treat, Registered Nurse Supervisor was immediately notified. Registered Nurse Supervisor completed an assessment, resident noted with a persisting cough with slight stridor noted to lungs, resident refused vital signs at the time and the physician was made aware. During an interview conducted with the Speech Language Pathologist on 2/13/2025 at 1 PM they stated Resident #3 would present with immediate cough and throat clear with all intakes which indicates that he is at risk for aspiration with solid foods. They further stated resident could not tolerate a solid dog biscuit. (3) Resident #5 was admitted to the facility with a medical [DIAGNOSES REDACTED]. The review of the Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 15 indicating intact cognition for decision making, eating not attempted due to medical condition or safety concerns, feeding tube on admission, while a resident, the resident received through [MEDICATION NAME] or tube feeding-51% or more, for the Resident. The review of the Order Recap Report dated 1/11/2025 documented Tube Feed diet, nothing by mouth. The review of the physician orders [REDACTED]. The review of the Medication Administration Record [REDACTED]. Multiple attempts to reach Physician Assistant #1 on 2/14/2025, 2/20/2025 and 2/ 5 were unsuccessful. On 2/13/2025 at 2:20 PM, the Director of Nursing was interviewed and stated the nurses are aware of the residents with feeding tube. The Director of Nursing stated that Residents who are assessed to have nothing by mouth (NPO) should have orders to administer medication thru the feeding tube. They further stated staff are aware of Residents #5 feeding tube and should have notified the physician to change the order to reflect the medication be administered via the feeding tube. On 2/13/2025 at 1:18 PM, Medical Doctor #1 was interviewed and stated residents who are assessed to have nothing by mouth (NPO) should have orders to administer medication thru the feeding tube. They further stated Resident # 3 should not have consumed the dog biscuit. 10 NYCRR 415. 12(h)(1) | Plan of Correction: ApprovedApril 3, 2025 I. Corrective Action: On (MONTH) 9, 2025, the facility retained the services of a consultant to develop and implement a plan of correction and directed in-service program for the deficiencies cited under F0684 ?ö?ç?ú 483. 25 Quality of Care. Resident # 2 is no longer a resident in the facility. Post-Incident Review: Although Resident #2 is no longer at the facility, a comprehensive clinical review was conducted to identify any contributing factors to the incident and to develop strategies to prevent recurrence. An Ad Hoc QAPI Committee meeting consisting of the Medical Director, Administrator, Director of Nursing, and all department heads was immediately convened on (MONTH) 12, 2025, to review and address the areas identified in the deficiency. All licensed nursing staff involved in resident #2 care received a directed re-education to ensure that each resident receives treatment and care in accordance with professional standards of practice, such as, recognizing change in condition, abnormal labs, abnormal vital signs and critical lab values. II. Identification: All residents with a change in condition can be affected by deficient practice. An immediate audit of all current residents' clinical records was performed to identify any unreported abnormal vital signs and critical lab results. This audit aimed to ensure that all significant changes in residents' conditions were appropriately documented, communicated and addressed immediately with medical providers to ensure that each resident receives treatment and care in accordance with professional standards of practice. All findings were communicated to the resident representative. III. Systematic Changes: The facility policies titled Health Care Providers and Hospital Transfer Services were reviewed and revised by the Director of Nursing and Administrator. The Director of Nursing and Administrator reviewed the policy and procedures on Emergency Transfer or Discharge and Vital Signs, but no revisions were necessary. Licensed nursing staff received a directed re-education on the policies above. There was a directed education for licensed nursing staff for change in condition and the protocols for timely communication with medical providers, as well as, immediate actions to address urgent medical conditions to ensure that each resident receives treatment and care in accordance with professional standards of practice. RN's, LPN's, C.N.A.'s, dietician, PT and OT staff received a directed education for the recognition of change in condition, the recognition of abnormal vital signs, the protocols for timely communication with medical providers and the immediate actions to address urgent medical conditions. RN's and LPN's received a directed education on critical lab values, protocols for timely communication with medical providers and the immediate actions to address urgent medical conditions. A directed education was provided to all medical providers and nurses with the revised policies concerning hospital transfers and change in condition to ensure that each resident receives treatment and care in accordance with professional standards of practice. A directed education was provided to all activity staff, social workers and department heads with the revised policy for change in condition and protocols for timely communication with nursing staff to ensure that each resident receives treatment and care in accordance with professional standards of practice. All changes in conditions, critical labs and abnormal diagnostics will be reviewed during the morning meeting for immediate communication with medical providers and to initiate timely interventions to ensure that each resident receives treatment and care in accordance with professional standards of practice. Supervisors will monitor all changes in conditions, critical labs or abnormal diagnostics and they will be reviewed during the morning meeting for immediate communication with medical providers and to initiate timely interventions to ensure that each resident receives treatment and care in accordance with professional standards of practice IV. Monitoring: The DON/Designee is conducting an audit of residents with change in conditions including abnormal vital signs, and/or critical lab results to ensure that this is communicated to the medical provider and documented in the chart weekly x 4 then monthly x 3 to ensure that each resident receives treatment and care in accordance with professional standards of practice. Results of these audits will be reviewed by QAPI committee during the monthly Quality Assurance and Performance Improvement (QAPI) meetings until compliance is sustained. V. Responsible Party: The Director of Nursing. |