Latta Road Nursing Home West
January 21, 2025 Certification/complaint Survey

Standard Health Citations

FF15 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A

Citation Details

Based on observations, interview, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, the facility did not maintain the kitchen in accordance with professional standards for food service safety. Specifically, an exhaust hood and filters were dirty, and a dishwashing machine was not functioning properly to sanitize dishware. The findings are: Record review of the undated daily cleaning lists revealed there was no documented cleaning of the kitchen exhaust hood and filters. During observations on 1/14/2025 at 8:55 AM and again on 1/15/2025 at 12:00 PM, the exhaust hood and filters above the cooking range in the main kitchen had visible accumulation of grease and dust. During an interview at this time, the Kitchen Supervisor stated their vendor comes in to clean the hood once a year in September, and staff should clean the hood as well when it needs it. During observations on 01/14/2025 at 8:47 AM, a low temperature dishwashing machine in the main kitchen was not functioning as designed. The label on the machine read wash at 120 degrees Fahrenheit and rinse at 120 degrees Fahrenheit with chlorine sanitization. Further observations included the chlorine sanitizer did not inject into the dish machine while in operation and the Kitchen Supervisor had to manually depress the dispenser button to introduce sanitizer into the machine. During an interview at this time, the Kitchen Supervisor stated they just noticed the sanitizer was not automatically dispensing during a cycle and needed to manually activate the dispensing unit to add sanitizer. During observations on 01/15/2025 at 12:06 PM, the low temperature dishwashing machine in the main kitchen was not functioning properly. The chlorine sanitizer did not automatically dispense during a cycle and the dispensing line was observed to be leaking sanitizer when activated manually. During an interview at this time, the Kitchen Supervisor stated the dish washer was still not functioning properly and the vendor had yet to get back to them. The Kitchen Supervisor also stated that when manually operating the sanitizing dispenser, they noticed the hose was leaking sanitizer so that would need to be addressed, and may be why sanitizer measurements were erratic. The Kitchen Supervisor also stated that instead of having to manually use the dispenser and measure sanitizer levels each time, it was decided to use disposable utensils and plates and wash with the three-bay sink until the dish machine could be addressed. 10NYCRR: 415.14(h), 14-1.95, 14-1.96(c), 14-110(d), 14-113(a), 14-1.175(b)

Plan of Correction: ApprovedFebruary 10, 2025

1. The dishwasher was fixed by the(NAME)representative on 01/15/2025 confirming that the dish machine was sanitizing pumping between 50-100ppm during the rinse cycle. 2. The exhaust hood and filters were cleaned on 1/15/2025 by the food service manager. 3. Food Service Manager has created a policy for cleaning of the exhaust hood and filters. Exhaust hood and filter will be cleaned on a weekly basis, this will be indicated on a weekly audit form. Audits will be presented to the quality assurance team monthly then quarterly thereafter. 4. The dishwasher will be checked daily for full functionality of the sanitation process. Audits will be reported to the quality assurance team monthly then quarterly thereafter. Responsible party: Dietary manager

FF15 483.45(f)(1):FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE

REGULATION: §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/14/2025 to 01/21/2025, for one (Resident #13) of two residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two medication errors for 26 opportunities resulting in a medication error rate of 7.7 percent. Specifically, during an observation of medication administration Resident #13's physician's orders were not followed for the administration of one medication and a second medication was administered without a prescribed dose included in the physician's order. This is evidenced by the following: The Medication Error Protocol, dated (MONTH) 2020, documented in part that the nursing staff and medical provider shall try to prevent medication errors and adverse consequences and shall strive to identify and manage them appropriately when they occur. An example of a medication error includes orders received from a medical provider not transcribed promptly or accurately. 1. Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/16/2024, documented the resident was cognitively intact. Review of current physician's orders as of 01/16/2025 revealed [MEDICATION NAME] five milligrams one time daily for orthostatic blood pressure (blood pressure that changes from sitting to standing) with parameters to hold the medication for a systolic blood pressure greater than 90 and a Vitamin B12 tablet in the morning. There was no dose listed for the Vitamin B12. During an observation of medication administration on 01/16/2025 at 9:37 AM, Licensed Practical Nurse #2 obtained and documented Resident #13's blood pressure of 124/82. Licensed Practical Nurse #2 then administered the [MEDICATION NAME] five milligrams and the Vitamin B12 at a dose of 1000 micrograms. During an interview on 01/16/2025 at 11:37 AM, Licensed Practical Nurse #2 stated the [MEDICATION NAME] five milligrams should be held if Resident #13's systolic blood pressure was greater than 90. When Resident #13's blood pressure was reviewed at this time, Licensed Practical Nurse #2 stated they should not have given the medication. Additionally, Licensed Practical Nurse #2 stated if a physician's order did not include a dose, a note should be entered in the medical provider's log making them aware that the order was incomplete, and the medication should not be given until the medical provider verified the order. Licensed Practical Nurse #2 generated the list of medications that had been administered revealing the Vitamin B12 medication had been given without a dose ordered by the medical provider. During an interview on 01/16/2025 at 11:49 AM, Nurse Practitioner #1 stated the nurse should check the parameters and if the parameters indicated to hold the medication for a systolic blood pressure greater than 90, and the resident's blood pressure was 124/82, the medication should not have been given. The Nurse Practitioner stated if documentation showed that the medication had been held enough times, they would reach out to the family and discuss the possibility of discontinuing it. Nurse Practitioner #1 stated all physician's orders should have a dose included and nursing staff should not proceed without a dose. Nurse Practitioner #1 stated it was an error on their end, and the nurse administering the medication should have brought it to their attention. During an interview on 01/16/2025 at 3:25 PM, the Director of Nursing stated the nurse should check the resident's blood pressure, read the physician's order, and follow the ordered parameters. The Director of Nursing stated they were not aware there were physician's orders that did not have a dose included because upon entering an order, the system should not allow you to save the documentation if the order was incomplete. The Director of Nursing stated the nurse should have called the medical provider to verify the order prior to giving the medication. 10 NYCRR 415.12(m)(1)

Plan of Correction: ApprovedFebruary 7, 2025

1. Resident #13. The resident was evaluated by the Medical Provider on 1/16/2025. The Nurse involved was provided counseling and re-education on 1/16/2025. 2. The facility will conduct a review of all current residents?ÇÖ medication orders to ensure that all components of the order is present and review all current resident medication orders to ensure that all of the residents with parameters in the orders are being followed as written. The Medical Provider will be notified of any residents that were identified with significant findings for. Any recommendations and changes in resident orders will be completed as written from the medical providers. Completion date: 2/28/2025 3. The facility will provide all licensed nurses with education on medication orders and reduction risks of medication errors. The facility?ÇÖs medication administration policy has been reviewed with the Director of Nursing, Administrator and Medical Director. Completion date: 2/28/2025 4. The facility Director of Nursing will conduct audits on all residents?ÇÖ new orders, to ensure all components including the dose are present in the order and all resident orders that have parameters to monitor for parameter compliance. Weekly for three months and then monthly for three months.