The Pines at Poughkeepsie Ctr for Nursing & Rehab

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 8/13/24-8/20/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, the walk-in refrigerator contained unlabeled, undated, and expired food products. The dry storage pantry contained expired and undated food products. Two employees were observed not wearing hair restraints, and one employee was leaning over dessert items with their apron touching items while they were wrapping the dessert items with cling wrap. The Refrigerator and Freezer Temperature Logs were not being documented twice a day, and the walk in freezer had areas of ice accumulation on floor.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Abbreviated Surveys (NY 00335861) from 8/13/24-8/20/24, the facility did not ensure that they developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by the facility and personnel acting on behalf of the facility for 2 of 2 residents (Resident #241 and #392) reviewed for admission. Specifically, 1) Resident #241 was admitted on [DATE] and their Baseline Care Plan was not developed or implemented until 3/11/24; [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey from 8/13/24-8/20/24, the facility did not ensure 1 of 4 residents (Resident #123) reviewed for pressure ulcers, received care and services to prevent new pressure ulcers from developing. Specifically, Resident #123's heels were not off-loaded according to the physicians' orders.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 8/13/24-8/20/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 1 of 2 residents (Residents #170) reviewed for accidents. Specifically, for Resident #170 had a history of falls and was observed in their room alone in their room in their wheelchair, rolling wobbly over a floor mat that was beside their bed.

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 8/13/2024 to 8/20/2024, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 (Resident #392) of 2 residents reviewed for respiratory care. Specifically, Resident #392 received oxygen for 4 days without a physician order.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/20/2024, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #127) reviewed for Dialysis. Specifically, Resident #127 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments. Additionally, there was not consistent ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 8/13/24 to 8/20/24, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months. Specifically, performance reviews were not documented every 12 months for 4 of 5 certified nurse aides reviewed (Certified Nurse Aide #9, #10, #11, and #12).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 8/13/24 to 8/20/24, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for two of five residents (Residents #170, and #90) reviewed for unnecessary psychotropic medications. Specifically, (1) Resident #170 who was admitting to the facility on 5/10/24 with a diagnosis of Dementia who had been receiving the antipsychotic Quetiapine(Seroquel) since admission, had no clinical rationale for use of the antipsychotic, had no psychiatric evaluations or follow ups, no documented evidence of behavioral monitoring, and no attempts at a gradual dose reduction in the absence of clinical symptoms. [...]

Inspectors wroteBased on record review and interview, during an abbreviated survey (NY00295899) on 3/11/2024 and 3/13/2024. The facility did not ensure that residents were free of significant medication errors, this was evident for 1 of 3 resident (Resident #1) reviewed for medication administration. Specifically, Resident #1 was not administered an intravenous antibiotic medication as prescribed on 3 occasions.

Inspectors wroteBased on observations, interviews and record review conducted on a recent Recertification Survey, it was determined that on two occasions the facility did not provide safe and secure storage of medications. Specifically, 1) a bottle of aspirin and a bottle of stool softener were left unattended on the top of a medication cart and 2) 33 blister packs of medications were left out at the nurses station unattended.

Inspectors wroteF880 Based on observation, interviews, and record reviews conducted during a recertification survey, the facility did not ensure that infection control protocols were followed for 1 resident (Resident#98). Specifically, Resident #98 was observed crawling on the dining room floor on his hand and knees and reaching down to touch the floor from his wheelchair during observations made on 10/5/21 between 11:54 am and 1:30 pm. Resident #98 was not provided hand hygiene after staff assisted him/her back to the wheelchair. Furthermore, Resident#98 was not provided hand hygiene before beginning his/her lunch meal which took place during the same observation period and was observed eating a sandwich with his/her hands.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that all drugs and biologicals in 3 of 5 medication carts, and 1 of 3 medication rooms currently in use in the facility were labeled and stored in accordance with professional standards. Specifically, three bottles of medication, a bottle of hydrogen peroxide had past due expiration dates, and individually packaged medications did not include expiration dates.

Inspectors wroteBased on observations and interviews conducted during a recertification survey, the facility did not ensure that food was prepared, stored and served in accordance with professional standards for food service safety. Specifically, (1.) cooling logs were not completed for TCS (time and temperature control for safety) foods and (2.) 4 out of 5 nourishment unit refrigerators ( 2nd, 3rd, 4th and 5th floors) contained foods and commercial supplements that were either unlabeled, undated, or expired or were not stored according to manufacturers' recommendation.

Inspectors wroteBased on record review and interview, the facility did not develop a person-centered care plan to address: (1.) a care plan for a resident who was receiving hospice care (Resident #74) and 2.) implementation of the care plan for fluid intake monitoring for a resident who had an indwelling catheter and a resident at risk for dehydration (Resident #s 169,182).

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, the facility did not ensure that residents received care and services in accordance with comprehensive assessment and person-centered care plan for 2 of 3 residents (#42 and #108) reviewed for positioning and mobility. Specifically, (1.) Resident # 42 did not receive timely intervention to address proper positioning and body alignment while in a wheelchair and (2.) the foot rest on Resident #108's wheelchair used as an assistive device was in disrepair and did not effectively support the resident's lower extremities while sitting in wheelchair.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that 1 of 5 residents (Resident #47) reviewed for falls was provided the necessary supervision and assistive device to prevent recurrent falls. Specifically, investigations and assessments of recurrent falls did not address: (1.) the use an assistive device required to prevent sliding from the resident's wheelchair and (2.) the effectiveness of planned interventions to ensure adequate supervision to prevent recurrent falls.

Inspectors wroteBased on record review and interview the facility did not ensure for 1 of 4 residents (Resident #169) reviewed for urinary catheter or Urinary Tract Infection (UTI) that a urinary indwelling (Foley) catheter was discontinued as soon as it was clinically possible . Specifically, a Foley catheter that was inserted to assist in healing the resident's pressure ulcers was not discontinued after the pressure ulcers have healed in order for the resident to restore or improve as much bladder function to the extent possible.

Inspectors wroteBased on observation, record review and staff interviews conducted during a recertification survey the facility did not ensure that a resident's medication regimen was free of unnecessary medications. Specifically, there was no documented justification for the use of Zyprexa, an anti-psychotic medication for 1 of 5 residents (#146) reviewed for unnecessary medications. The finding is: Resident #146 was admitted with diagnoses including dementia with behavioral disturbance and anxiety disorder. Physician orders dated 11/9/18 document Zyprexa 5 mg (Olanzapine) 0.5 tablet by mouth 2 times/day for psychotic disorder. The Minimum Data Set (MDS; a resident assessment tool) dated 4/27/18 (Annual) and 7/28/18 (Quarterly) documented the resident had been taking antipsychotic medication daily for the 7 day look back period. Each assessments further revealed the resident exhibited no behaviors. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 5 residents (Residents # 6 and #149) observed during a medication pass, for a total of 2 out of 31 opportunities for error resulting in an error rate of 6.4%.

Inspectors wroteBased on observations, interviews and record review conducted during a recertification survey, the facility did not ensure that its staff followed proper hand hygiene to prevent cross contamination and the spread of infection during a lunch meal observation on 1 of 5 facility units (Unit 6) for residents (R) #11, #71, and #188. Additionally, proper gloving and hand hygiene were not observed during a wound care treatment for 1 of 4 residents (#169) reviewed for pressure ulcers.