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PRINTED: 06/10/2019

DEPARTMENT OF HEALTH AND HUMAN SERVICES


FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 483.10(g)(14)(i)-(iv)(15) Notify of Changes F 580 I. The following actions were accomplished 06/11/2019
SS=J (Injury/Decline/Room, etc.) for the residents identified in the sample:
Resident #402
§483.10(g)(14) Notification of Changes. • Resident is no longer at the facility
(i) A facility must immediately inform the • A medical record review has been
resident; consult with the resident's physician; completed to ensure all improvement
and notify, consistent with his or her authority, opportunities related to the change of
the resident representative(s) when there is- condition that was identified without
(A) An accident involving the resident which physician notification have been identified
results in injury and has the potential for and addressed in this plan of correction.
requiring physician intervention; • LPN #5 is no longer employed by the
(B) A significant change in the resident's facility
physical, mental, or psychosocial status (that is, • LPN #4 is no longer employed by the
a deterioration in health, mental, or psychosocial facility
status in either life-threatening conditions or • LPN #4 investigation into incident with
clinical complications); resident #402 has been completed
(C) A need to alter treatment significantly (that II. The following corrective actions will be
is, a need to discontinue an existing form of implemented to identify other residents
treatment due to adverse consequences, or to who may be affected by the same practice:
commence a new form of treatment); or All residents have the potential to be
(D) A decision to transfer or discharge the affected by this practice:
resident from the facility as specified in • Progress notes for all residents over the
§483.15(c)(1)(ii). past thirty (30) days have been reviewed to
(ii) When making notification under paragraph ensure any resident with an identified
(g)(14)(i) of this section, the facility must ensure change in condition, that the Physician/PA
that all pertinent information specified in has been notified.
§483.15(c)(2) is available and provided upon • Progress notes for all residents over the
request to the physician. past thirty (30) days have been reviewed to
(iii) The facility must also promptly notify the ensure Licensed Practical Nurses are
resident and the resident representative, if any, practicing within their scope of practice,
when there is- specifically as it relates to assessing
(A) A change in room or roommate assignment residents
as specified in §483.10(e)(6); or III. The following system changes will be
(B) A change in resident rights under Federal or implemented to assure continuing
State law or regulations as specified in compliance with regulations:
paragraph (e)(10) of this section. As per the Directed Plan of Correction, the
(iv) The facility must record and periodically Consultant has developed and
update the address (mailing and email) and implemented an In-service Program to
phone number of the resident address:
representative(s). • The Abuse Reporting and Prevention
policy has been newly adopted
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 05/10/2019
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 1 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 1 F 580


§483.10(g)(15) o Administrator and Department
Admission to a composite distinct part. A facility Management have been re-educated on
that is a composite distinct part (as defined in this policy as it relates to the investigation
§483.5) must disclose in its admission of all alleged or suspected incidents of
agreement its physical configuration, including abuse, neglect, mistreatment, or
the various locations that comprise the misappropriation of resident property
composite distinct part, and must specify the o All staff have been re-educated on
policies that apply to room changes between its this policy as it relates to the reporting of all
different locations under §483.15(c)(9). alleged or suspected incidents of abuse,
neglect, mistreatment, or misappropriation
This REQUIREMENT is not met as evidenced of resident property
by: • The Notification of Significant Changes
policy has been newly adopted
Based on record review and interview during the o All licensed nurses have been re-
abbreviated survey (NY00231469) the facility did educated on this policy with emphasis on
not ensure the physician and family the prompt notification of medical provider
representative were notified of a change in with change in condition
resident condition for 1 of 6 residents (Resident • The Licensed Practical Nurse Job
#402) reviewed for quality of care. Specifically, Description has been reviewed without
Resident #402 had a decline in condition, revision.
remained compromised for several hours and o All licensed practical nurses have
the physician was not notified. Emergency been re-educated on the contents of their
Medical Services was called, and the resident job description as it relates to providing
expired in the hospital. This resulted in care within their scope of practice
Immediate Jeopardy and Substandard Quality of • The On-Call Nursing Administration
Care for Resident #402. policy and procedure has been newly
adopted
The facility policy Notification of Changes for o All licensed nurses have been
Residents updated 12/1/17 documented the educated on the policy with emphasis on
facility shall promptly notify the resident and/or contacting an RN, on-call RN with any
the resident representative and his or her change of condition as soon as it is
physician or delegate of changes in the observed
resident's condition or status in order to obtain • The Stop and Watch Early Warning Tool
orders for appropriate treatment and monitoring. policy has been reviewed without revision
The nurse will immediately notify the resident's o All licensed nurses and certified nurse
physician of a significant change in the aides have been re-educated on the Stop
resident's physical status that is a deterioration and Watch with emphasis on reporting
in health. identified changes of condition
• All new staff will be educated on the
Resident #402 was admitted to the facility on above policy details during general
8/3/16 and had diagnoses including chronic orientation

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 2 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 2 F 580


obstructive pulmonary disease (COPD), IV. The facility’s compliance will be
diabetes and hypertension. The 8/17/18 monitored utilizing the following quality
Minimum Data Set (MDS) assessment assurance system:
documented the resident's cognition was As per the Directed Plan of Correction, a
moderately impaired and he required QA&A Committee meeting was held on
supervision for bed mobility, transfers, limited May 2, 2019 to examine this deficiency.
assistance for personal hygiene and extensive • Progress notes will be audited weekly
assistance for dressing. for three (3) months to ensure:
o any identified changes in condition
A nursing progress note dated 12/16/18 by have been communicated to the
registered nurse (RN) #3 documented on Physician/PA
12/15/18 she was asked by a certified nurse o investigations have been conducted
aide (CNA #8) at 11:30 PM to check on the and appropriate actions taken when
resident. The resident was in his room, warranted
unresponsive. At 12:40 AM on 12/16/18 the o Licensed Practical Nurses have
resident's oxygen saturation was 79% and RN notified the RN once a change in condition
#3 placed 3 liters of oxygen on the resident and has been identified, and
his oxygen saturation increased to 83%. He o LPNs are not completing
remained unresponsive, 911 was called and the assessments
resident was sent to the emergency room. • All Stop and Watch forms will be audited
weekly for three (3) months to ensure all
Hospital records documented the resident identified changes in condition have been
arrived at the emergency room at 1:22 AM on addressed
12/16/18. The resident arrived with secretions in • Audit results will be reported to the
his airway, obvious aspiration (inhalation of a QA&A Committee monthly for three
foreign substance in the lungs) and was months. Frequency of on-going audits will
responsive only to pain. He was hypoxemic (lack be determined by the Committee based on
of oxygen to the brain) with an oxygen saturation audit results.
of 50% and was arousable to tactile (touch) • Consultant will participate in QA&A
stimuli only. The laboratory results from the Committee Meeting monthly for 3 months.
emergency room included a white blood cell Completion Date: June 11, 2019
count (WBC, indicates infection) of 22.87 Responsibility: Director of Nursing
(normal 4-11), blood glucose of 43 (normal 70-
100) and encephalopathy (brain disease) in the
setting of pneumonia and a urinary tract
infection (UTI). The resident expired in the
hospital on 12/23/18.

During an interview with certified nurse aide


(CNA) #8 on 2/1/19 at 10:10 AM she stated she
had worked the evening and night shifts starting

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 3 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 3 F 580


on 12/15/18. When she arrived at 2:00 PM she
saw the resident and he was complaining of leg
pain. She told LPN #11 who stated he had
already had Tylenol. A little while later she
checked on him and he was still complaining of
leg pain. She told LPN #5 who started work at
3:00 PM and she said she would get him
something for the pain. CNA #8 stated she
checked on the resident again and he was still
complaining of pain and wanted to go to bed.
Once in bed he started yelling out, so they put
him back in his wheelchair. Sometime after 5:00
PM she entered the resident's room and he was
not responding and was drooling. She notified
LPN #5 who obtained the resident's vital signs.
His oxygen level was 82%. and the resident was
put back to bed. LPN #5 obtained his blood
sugar and it was in the 70's. CNA #8 stated she
had tried to give him orange juice to raise his
sugar level and he was not able to swallow it
and just came back out of the sides of his
mouth. She did not know if the supervisor (LPN
#4) was called but sometime after 6:00 PM she
saw LPN #4 talking with LPN #5 at the
medication cart. She did not see LPN #4 go in
the resident's room and check on him. CNA #8
stated she had checked on the resident
periodically throughout the remainder of the shift
and obtained his vital signs. At one point his
oxygen level was reading in the 50's and she
had notified LPN #4. When RN #3 came in
around 11:00 PM she met her at the front door
and asked her to check on the resident.

During an interview with CNA #18 on 4/16/2019


at 4:20 PM she stated she had worked the
evening of 12/15/2018 and when she started her
shift at 2:00 PM there was something not right
about the resident as he was normally more
"uppity". Sometime before 5:30 PM she noticed
the resident was falling asleep and sluggish at

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 4 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 4 F 580


which time LPN #5 instructed the CNAs to get
vital signs. His oxygen saturation was lower than
70% at that time. Throughout the shift his
oxygen saturations were in the 50's, he was not
talking, was not able to keep his eyes open very
long and he continued to struggle to breath. She
had notified both LPN #5 and LPN #4 the
resident was struggling to breathe, several times
during the shift, and they did not do anything for
him.

During an interview with LPN #5 on 1/31/19 at


1:10 PM she stated she had worked the evening
shift on 12/15/18 and when she went into
Resident #402's room he was not responding,
and he appeared to be struggling to breathe.
She could not remember what time she went
into to see him after the start of her shift at 3:00
PM. She took his blood glucose which was 79
and they put the resident to bed. She checked
his oxygen saturation and it was fluctuating in
the 80's and 90's, his baseline was usually in the
high 90's. She notified LPN #4 who was the
nursing supervisor. LPN #4 came to the unit and
looked at the resident's diagnoses and told LPN
#5 it was part of his illness and there was
nothing the hospital could do for him. She did
not see LPN #4 go in to the resident's room.
LPN #5 stated the resident remained in the
same condition the rest of the shift. After 11:00
PM registered nurse (RN) #3 saw the resident
and called the ambulance. LPN #5 also stated
she had not called the physician to report the
resident's change in condition as it was the
responsibility of the supervisor to call the
physician.

During an interview with LPN #4 on 2/1/19 at


12:15 PM she stated she had worked the day
and evening shift on 12/15/18 as a medication
nurse and the nursing supervisor. On the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 5 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 5 F 580


she had been called and told the resident was
complaining of pain in his knees. She did
attempt to see the resident, but he was in his
room sleeping. After dinner, she was called
again and was told the resident was not eating
and was hard to arouse. She was in the middle
of a medication pass so when she finished she
went to look at the resident and he was in bed
sleeping and snoring. She stated she could not
recall the time. She attempted to wake the
resident up, he was hard to arouse and when he
did awaken he said he was sleepy and went
right back to sleep. She went out and asked the
staff if that was normal for him and the CNA told
her he was normally up, eating and watching
television at that time. LPN #4 stated she
reviewed the resident's diagnoses with LPN #5
and she may have said to LPN #5 the snoring
was part of his illness. She did not remember
being told his oxygen saturation was low. She
did not call the physician as the resident was
just sleeping and snoring.

During an interview with RN #3 on 2/14/19 at


8:20 AM she stated on 12/15/18 when she
arrived for the night shift around 11:00 PM she
was immediately notified by CNA #8 that
Resident # 402 was sick. She went into the
resident's room around 11:30 PM and he was
unresponsive. She tried to wake him, performed
a sternal rub and there was no response. RN #3
stated his oxygen saturation was low, she
applied oxygen and called 911. She had advised
CNA #8 to call the ambulance herself next time
as there were two nurses that worked that
evening and they had not addressed the
resident's condition. RN #3 stated this was an
ongoing issue when LPN #4 was the supervisor
as LPN #4 did not do anything when residents
got sick. RN #3 stated she had previously
communicated her concerns to administration

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 6 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 6 F 580

During an interview with the resident's attending


physician on 2/14/19 at 10:45 AM, he stated if a
resident had a change in condition and had a
low oxygen saturation he would expect the
resident to be assessed by an RN and the on-
call provider notified. He was not aware the
resident had a change in condition and the
provider had not been notified. During a second
interview on 4/16/19 at 10:05 AM, the physician
stated he had discussed his concerns with the
previous DON, RN #7 regarding the nursing staff
working out of their scope of practice.

During an interview with the RN #7 (Director of


Nursing, DON at the time of the incident) on
1/30/2019 at 2:00 PM she stated RN #3 had
raised some concerns regarding LPN #4 and her
care of the residents. LPN #4 had been working
at the facility for years, did a lot and really was
the "top dog". LPN #4 was the wound nurse, the
infection control nurse, the unit manager of one
of the units and frequently worked as the nursing
supervisor.

On 4/16/2019 at 8:00 AM when the surveyors


entered the facility and asked for the supervisor,
LPN #4 was called.

During an interview with RN #7, (DON at the


time of the incident)) on 4/16/2019 at 10:25 AM
she stated after she was notified of concerns on
2/14/2019 she had a conversation with the
owner and the Administrator regarding LPN #4's
care and supervision of the residents. She
requested LPN #4 be terminated and they told
her LPN #4 was a great employee and had been
working for the facility for a long time. The LPN
was not terminated and continued to work in the
same capacity. There had been no investigation
into the incident with Resident #402 and there

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 7 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 7 F 580


was no training or re-education provided to LPN
#4.

During a telephone interview with the current


DON on 4/16/2019 at 10:54 AM she stated she
did not know much about Resident #402 as the
previous DON had been looking in to that. She
was aware there were concerns regarding LPN
#4 and there had been no training or
reeducation provided to her. When a resident
exhibited a change in condition she would
expect vital signs to be done, the physician
notified, and a nursing progress note written.

During an interview with the Administrator on


4/16/2019 at 11:12 AM she stated she was the
administrator on record as of 2/5/2019. After she
was notified there were supervisory concerns
regarding LPN #4 there was no investigation or
re-education done. When a resident had a
change in condition she would expect the
physician to be notified.

The Administrator was notified on 4/17/2019 at


4:07 AM of an Immediate Jeopardy to the health
and safety of the 52 residents currently residing
in the facility.

Immediate Jeopardy was removed on 4/18/2019


prior to exit based on the following corrective
actions taken. The facility
-terminated LPN #4;
-would provide RN Supervision or RN on-call
coverage at all times;
-would immediately initiate LPN education
regarding the requirement to notify the RN and
the physician of a change in condition as soon
as it is observed; and
-would review the job description including the
scope of practice of each LPN working in the
facility.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 8 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 580 Continued From page 8 F 580

10NYCRR 415.3(e)(2)(ii)(d)
F 684 483.25 Quality of Care F 684 I. The following actions were accomplished 06/11/2019
SS=J for the residents identified in the sample:
§ 483.25 Quality of care Resident #401
Quality of care is a fundamental principle that • Resident is no longer at the facility
applies to all treatment and care provided to • A medical record review has been
facility residents. Based on the comprehensive completed to ensure all improvement
assessment of a resident, the facility must opportunities related to the change in
ensure that residents receive treatment and care condition that was identified without
in accordance with professional standards of physician notification or timely treatment or
practice, the comprehensive person-centered intervention have been identified and
care plan, and the residents' choices. addressed in this plan of correction.
Resident #402
This REQUIREMENT is not met as evidenced • Resident is no longer at the facility
by: • A medical record review has been
completed to ensure all improvement
Based on record review and interview during the opportunities related to the change of
abbreviated survey (NY00231469), the facility condition that was identified without
did not ensure residents received treatment and physician notification, not addressed timely
care in accordance with professional standards have been identified and addressed in this
of quality for 2 of 6 residents (Residents #401 plan of correction.
and 402) reviewed for quality of care. • LPN #5 is no longer employed by the
Specifically, Resident #402 had a change in facility.
condition that was not addressed timely. • LPN #4 investigation into incident with
Resident #401 had an emergent decline in resident #402 has been completed
condition and there was no documented • LPN #4 is no longer employed by the
evidence of appropriate and timely facility
treatment/interventions. Both residents required
Emergency Medical Service response and II. The following corrective actions will be
expired in the hospital. This resulted in implemented to identify other residents
Immediate Jeopardy and Substandard Quality of who may be affected by the same practice:
Care for Resident #402 and actual harm to All residents have the potential to be
Resident #401 that was not Immediate affected by this practice:
Jeopardy. • Progress notes for all residents over the
Findings include: past thirty (30) days have been reviewed to
ensure any resident with an identified
The facility policy Notification of Changes for change in condition, that the Physician/PA
Residents updated 12/1/17 documented the has been notified.
facility shall promptly notify the resident and/or • All Licensed Practical Nurses have had
the resident representative and his or her their employee file reviewed to determine if

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 9 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 9 F 684


physician or delegate of changes in the Job Description has been reviewed and
resident's condition or status in order to obtain signed
orders for appropriate treatment and monitoring. • Progress notes for all residents over the
The nurse will immediately notify the resident's past thirty (30) days have been reviewed to
physician of a significant change in the ensure that Licensed Practical Nurses
resident's physical status that is a deterioration have notified the RN with any change of
in health. condition
• All residents have had their advanced
1) Resident #402 was admitted to the facility on directive/MOLST reviewed to determine
8/3/16 and had diagnoses including chronic advance directive is in place
obstructive pulmonary disease (COPD), • All Physician orders written in the past
diabetes and hypertension. The 8/17/18 fourteen (14) days have been reviewed to
Minimum Data Set (MDS) assessment ensure they have been signed by the
documented the resident's cognition was medical provider
moderately impaired and he required • All progress notes written in the past
supervision for bed mobility, transfers, limited fourteen (14) days have been reviewed
assistance for personal hygiene and extensive against the 24-hour report to determine if
assistance for dressing. any identified change of condition has
been documented
The Medical Orders for Life-Sustaining • All progress notes written over the past
Treatment (MOLST) dated 8/3/16 and signed by fourteen (14) days and medication
the resident documented he was a do not administration records have be reviewed
resuscitate (DNR, do not perform for documentation of PRN medication
cardiopulmonary resuscitation) and he wanted administration.
limited medical interventions which included
receiving medications by mouth or through a III. The following system changes will be
vein, heart monitoring and all other necessary implemented to assure continuing
treatment. compliance with regulations:
As per the Directed Plan of Correction, the
A nursing progress note dated 12/16/18 by Consultant has developed and
registered nurse (RN) #3 documented on implemented an In-service Program to
12/15/18 she was asked by a certified nurse address:
aide (CNA #8) at 11:30 PM to check on the • The Abuse Reporting and Prevention
resident. The resident was in his room, policy has been newly adopted
unresponsive. At 12:40 AM on 12/16/18 the o Administrator and Department
resident's oxygen saturation was 79% and RN Management have been re-educated on
#3 placed 3 liters of oxygen on the resident and this policy as it relates to the investigation
his oxygen saturation increased to 83%. He of all alleged or suspected incidents of
remained unresponsive, 911 was called and the abuse, neglect, mistreatment, or
resident was sent to the emergency room. misappropriation of resident property
o All nursing staff have been re-

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 10 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 10 F 684


Hospital records documented the resident educated on this policy as it relates to the
arrived at the emergency room at 1:22 AM on reporting of all alleged or suspected
12/16/18. The resident arrived with secretions in incidents of abuse, neglect, mistreatment,
his airway, obvious aspiration (inhalation of a or misappropriation of resident property
foreign substance in the lungs) and was • The Notification of Significant Changes
responsive only to pain. He was hypoxemic (lack policy has been newly adopted
of oxygen to the brain) with an oxygen saturation o All licensed nurses have been re-
of 50% and was arousable to tactile (touch) educated on this policy with emphasis on
stimuli only. The laboratory results in the the prompt notification of medical provider
emergency room included a white blood cell with change in condition
count (WBC, indicates infection) of 22.87 • The Licensed Practical Nurse Job
(normal 4-11), blood glucose of 43 (normal 70- Description has been reviewed without
100) and encephalopathy (brain disease) in the revision.
setting of pneumonia and a urinary tract o All licensed practical nurses have
infection (UTI). The resident expired in the been re-educated on the contents of their
hospital on 12/23/18. job description as it relates to providing
care within their scope of practice
During an interview with certified nurse aide • The On-Call Nursing Administration
(CNA) #8 on 2/1/19 at 10:10 AM she stated she policy and procedure has been newly
had worked the evening and night shifts starting adopted
on 12/15/18. When she arrived at 2:00 PM she o All licensed nurses have been
saw the resident and he was complaining of leg educated on the policy with emphasis on
pain. She told LPN #11 who stated he had contacting an RN, on-call RN with any
already had Tylenol. A little while later she change of condition as soon as it is
checked on him and he was still complaining of observed
leg pain. She told LPN #5 who started work at • The MOLST (Medical Orders for Life
3:00 PM and she said she would get him Sustaining Treatment)/Healthcare Proxy
something for the pain. CNA #8 stated she Forms policy has been newly adopted
checked on the resident again and he was still o All licensed nurses will be educated
complaining of pain and wanted to go to bed. on the policy and procedure related to
Once in bed he started yelling out, so they put advanced directives, specifically as it
him back in his wheelchair. Sometime after 5:00 relates to following the resident’s MOLST
PM she entered the resident's room and he was with an identified change in condition
not responding and was drooling. She notified • The Physicians Orders policy has been
LPN #5 who obtained the resident's vital signs. newly adopted
His oxygen level was 82%. and the resident was o All licensed nurses will be educated
put back to bed. LPN #5 obtained his blood on the policy and procedure related to
sugar and it was in the 70's. CNA #8 stated she physician orders, specifically as it relates to
had tried to give him orange juice to raise his signing of orders
sugar level and he was not able to swallow it • The Nursing Documentation policy has
and just came back out of the sides of his been newly adopted

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 11 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 11 F 684


mouth. She did not know if the supervisor (LPN o All licensed nurses will be educated
#4) was called but sometime after 6:00 PM she on documentation, specifically as it relates
saw LPN #4 talking with LPN #5 at the to documentation of change in condition
medication cart. She did not see LPN #4 go in and obtaining vital signs
the resident's room and check on him. CNA #8 • The Administration of Medication policy
stated she had checked on the resident has been reviewed without revision
periodically throughout the remainder of the shift o All licensed nurses will be re-
and obtained his vital signs. At one point his educated on the administration of
oxygen level was reading in the 50's and she medications, specifically as it relates to
had notified LPN #4. When RN #3 came in providing Tylenol ordered PRN for elevated
around 11:00 PM she met her at the front door temperature and documentation of
and asked her to check on the resident. medication administered
• The Stop and Watch Early Warning Tool
During an interview with LPN #5 on 1/31/19 at policy has been reviewed without revision
1:10 PM she stated she had worked the evening o All licensed nurses and certified nurse
shift on 12/15/18 and when she went into aides have been re-educated on the Stop
Resident #402's room he was not responding, and Watch with emphasis on reporting
and he appeared to be struggling to breathe. identified changes of condition
She could not remember what time she went • Nursing Supervisor/Nursing Shift to Shift
into to see him after the start of her shift at 3:00 Report policy has been newly adopted
PM. She took his blood glucose which was 79 o All licensed nurses will be educated
and they put the resident to bed. She checked on nursing 24-hour report with emphasis
his oxygen saturation and it was fluctuating in that it does not replace documentation in
the 80's and 90's, his baseline was usually in the the medical record
high 90's. She notified LPN #4 who was the • All new staff will be educated on the
nursing supervisor. LPN #4 came to the unit and above policy details during general
looked at the resident's diagnoses and told LPN orientation
#5 it was part of his illness and there was
nothing the hospital could do for him. She did IV. The facility’s compliance will be
not see LPN #4 go in to the resident's room. The monitored utilizing the following quality
resident remained in the same condition the rest assurance system:
of the shift. After 11:00 PM registered nurse • As per the Directed Plan of Correction, a
(RN) #3 saw the resident and called the QA&A Committee meeting was held on
ambulance. LPN #5 had not called the physician May 2, 2019 to examine this deficiency.
to report the resident's change in condition as it • Progress notes will be audited weekly
was the responsibility of the supervisor to call for three (3) months to ensure any
the physician. identified changes in condition have been
communicated to the Physician/NP and
During an interview with LPN #4 on 2/1/19 at investigations were conducted with
12:15 PM she stated she had worked the day appropriate actions taken if warranted
and evening shift on 12/15/18 as a medication • New employee, LPN files will be audited

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 12 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 12 F 684


and the nursing supervisor. If a resident had a weekly for three (3) months to ensure all
change in condition she would look at the newly hired Licenses Practical Nurses
resident and notify the physician for further have a job description which has been
instructions. On the evening shift LPN #4 was reviewed, signed, and maintained in the
called and told the resident was complaining of employee file
pain in his knees. She did attempt to see the • Progress notes will be audited weekly
resident, but he was in his room sleeping. After for three (3) months to ensure that
dinner she was called again and was told the Licensed Practical Nurses have notified the
resident was not eating and was hard to arouse. RN with any change of condition and
She was in the middle of a medication pass so advanced directives/MOLST has been
when she finished she went to look at the reviewed to determine what advance
resident and he was in bed sleeping and directives are in place
snoring. She could not recall the time. She • All Physician orders will be audited
attempted to wake the resident up, he was hard weekly for three (3) months to ensure they
to arouse and when he did awaken he said he have been signed by the medical provider
was sleepy and went right back to sleep. She • All progress notes will be audited weekly
went out and asked the staff if that was normal for three (3) months against the 24-hour
for him and the CNA #8 told her he was normally report to determine if any identified change
up, eating and watching television at that time. of condition has been documented
LPN #4 stated she reviewed the resident's • All progress notes will be audited weekly
diagnoses with LPN #5 and she may have said for three (3) months to ensure medication
to LPN #5 that the snoring was part of his administration is consistent with the
illness. She did not remember being told his documentation of PRN medication
oxygen saturation was low. She did not call the administration in the medication
physician as the resident was just sleeping and administration record
snoring. • All Stop and Watch forms will be audited
weekly for three (3) months to ensure all
During an interview with RN #3 on 2/14/19 at identified changes in condition have been
8:20 AM she stated on 12/15/18 when she addressed
arrived for the night shift around 11:00 PM she • 24-hour report sheets will be audited
was immediately notified by CNA #8 that weekly for three (3) months to ensure all
Resident # 402 was sick. She went into the change of condition information has been
resident's room around 11:30 PM and he was documented in the medical record
unresponsive. She tried to wake him, performed • Audit results will be reported to the
a sternal rub and there was no response. RN #3 QA&A Committee monthly for three
stated his oxygen saturation was low, she months. Frequency of on-going audits will
applied oxygen and called 911. She had advised be determined by the Committee based on
CNA #8 to call the ambulance herself next time audit results.
as there were two nurses that worked that • Consultant will participate in QA&A
evening and they had not addressed the Committee Meeting monthly for 3 months
resident's condition. RN #3 stated this was an Completion Date: June 11, 2019

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 13 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 13 F 684


#4 was the supervisor as LPN #4 did not do Responsibility: Director of Nursing
anything when residents got sick. RN #3 had
communicated her concerns to administration in
the past.

During an interview with RN #7 (Director of


Nursing, DON at the time of the incident) on
1/30/2019 at 2:00 PM she stated RN #3 had
raised some concerns regarding LPN #4 and her
care and supervision of the residents. LPN #4
had been working at the facility for years, did a
lot and really was the "top dog". LPN #4 was the
wound nurse, the infection control nurse, the unit
manager of one of the units and frequently
worked as the nursing supervisor.

During an interview with the resident's attending


physician #16 on 2/14/19 at 10:45 AM, he stated
if a resident had a change in condition and had a
low oxygen saturation he would expect the
resident be assessed by an RN and the on-call
provider notified. He was not aware the resident
had a change in condition and the provider had
not been notified. During a second interview on
4/16/19 at 10:05 AM, the physician stated he
had discussed his concerns with the previous
DON, RN #7 of the nursing staff working out of
their scope of practice.

On 4/16/2019 at 8:00 AM when the surveyors


entered the facility and asked for the supervisor,
LPN #4 was called.

During an interview with RN #7 (DON at the time


of the incident) on 4/16/2019 at 10:25 AM she
stated after she was notified of concerns on
2/14/2019 she had a conversation with the
owner and the Administrator regarding LPN #4's
care and supervision of the residents. She
requested LPN #4 be terminated and they told
her LPN #4 was a great employee and had been

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 14 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 14 F 684


working for the facility for a long time. The LPN
was not terminated and continued to work in the
same capacity. There had been no investigation
into the incident with Resident #402 and there
was no training or reeducation provided to LPN
#4.

During a telephone interview with the current


DON on 4/16/2019 at 10:54 AM she stated she
did not know much about Resident #402 as the
previous DON had been looking in to that. She
was aware there were concerns regarding LPN
#4 and there had been no training or
reeducation provided to her. When a resident
exhibited a change in condition she would
expect vital signs to be done, the physician
notified, and a nursing progress note written.

During an interview with the Administrator on


4/16/2019 at 11:12 AM she stated she was the
administrator on record as of 2/5/2019. After she
was notified there were supervisory concerns
regarding LPN #4 there was no investigation or
re-education done. When a resident had a
change in condition she would expect the
physician to be notified.

The Administrator was notified on 4/17/2019 at


4:07 AM of an Immediate Jeopardy to the health
and safety of the 52 residents currently residing
in the facility.
Immediate Jeopardy was removed on 4/18/2019
prior to exit based on the following corrective
actions taken. The facility:
-terminated LPN #4;
-would provide RN Supervision or RN on-call
coverage at all times;
-would immediately initiate LPN education
regarding the requirement to notify the RN and
the physician of a change in condition as soon
as it was observed; and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 15 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 15 F 684


would review the job description including the
scope of practice of each LPN working in the
facility.

2)Resident #401 was admitted to the facility on


12/4/07 and readmitted on 12/14/18 and had
diagnoses including dementia, myocardial
infarction (MI, heart attack) and history of sepsis
(system wide infection). The 12/21/18 Minimum
Data Set (MDS) assessment documented the
resident's cognition was severely impaired and
he was totally dependent for all activities of daily
living (ADLs).

The resident's Medical Orders for Life-


Sustaining Treatment (MOLST) dated 7/10/07
documented the resident was a do not
resuscitate (DNR, do not perform
cardiopulmonary resuscitation) and a do not
intubate (DNI, do not place a breathing tube)
and he wanted limited medical interventions
which included oral and intravenous medications
and cardiac monitoring.

The 12/15/18 24-hour report (nursing


communication) documented on the 7:00 AM-
3:00 PM shift the Resident #401's heart rate was
240 beats per minute (normal 60-100). The
nurse practitioner (NP) #15 was aware and
increased the Metoprolol (used to treat heart
failure) to 50 milligrams (mg).

A physician order dated 12/15/18 at 1:00 PM


documented to increase the Metoprolol to 50 mg
daily. The order documented the prescriber was
nurse practitioner (NP) #15 and the order was
taken by licensed practical nurse (LPN) #4. The
physician order was not signed by a provider.

The 12/2018 medication administration record


(MAR) documented the Metoprolol 50 mg was

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 16 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 16 F 684


not administered until 12/17/18 at 9:00 AM.

The 12/16/18 24-hour report documented the


resident was pale, lethargic and staring off. His
temperature was 100.8 degrees Fahrenheit
(normal 98.6) and heart rate was 113.

NP #15 documented on 12/17/19 the resident


was being reviewed for a gradual dose reduction
(GDR) of his psychotropic medications. The
resident was resting comfortably in his chair and
had a tachycardic (fast heart rate) rhythm (rate
was not documented). The resident was recently
hospitalized for an MI and the plan was to do
blood work including a comprehensive metabolic
panel (CMP), complete blood count (CBC),
thyroid stimulating hormone and magnesium
level. There was no documentation regarding
the heart rate of 240 or increasing the
Metoprolol dosage on 12/15/18.

There was no physician order for labs


documented by the NP in the 12/17/18 progress
note.

The 24-hour report documented the following:


-On 12/17/18 on the night shift the resident was
tired and weak and his heart rate was 122. On
the day shift he was weak and tired. On the
evening shift he had emesis (vomiting) x 1,
difficulty swallowing his medications and
drinking.
-On 12/18/18 during the night the resident was
weak, tired and had difficulty swallowing. On the
day shift his blood pressure was 95/58 and heart
rate was 120. On the evening shift he had
emesis x 1.
-On 12/19/18 the resident had a large "jelly like"
stool and he was lethargic and had a heart rate
of 115.
-On 12/20/18 the resident had a heart rate of

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 17 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 17 F 684


122 and his temperature was 100.0.

There was no documentation in the medical


record reflecting what was documented on the
24-hour report.

A nursing progress noted completed by LPN #4


dated 12/21/18 documented the resident was
pale and sweating, cool compresses were
applied, the resident did not have a temperature
(there was no temperature documented) and NP
#15 was aware. There were no instructions or
new orders documented in the medical record.

A nursing progress note dated 12/22/18


documented the resident was tired and pale. He
was reaching out for staff when they entered the
room.

The 12/24/18 24-hour report documented on the


night shift the resident was awake most of the
shift and diaphoretic (sweating heavily). No vital
signs were documented.

There was no documentation in the medical


record reflecting what was documented on the
24-hour report.

A nursing progress note dated 12/24/18


completed by LPN #4 documented the resident
had a temperature of 104.4 (no other vital signs
were documented), Tylenol was given at 9:00
AM and cool compresses were applied.
Physician #16 "noted". The resident's
temperature was rechecked at 12:00 PM and
was 103.2. Physician #16 was notified, and he
ordered Tylenol. The temperature was
rechecked at 2:00 PM and was 103.3, heart rate
was 126, blood pressure was 56/32 and
respirations were 44. Physician #16 was
notified, and he ordered the resident to the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 18 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 18 F 684


hospital.

Review of the 12/18 MAR did not document any


Tylenol administration from 12/14/18 - 12/24/18.

A facility resident transfer form dated 12/24/18 at


2:15 PM documented the resident had a fever
lasting 2 shifts, Tylenol did not bring it down and
he was recently hospitalized 2 weeks ago for the
same issue.

The ambulance form dated 12/24/18


documented they responded to the nursing
home to find the resident not able to speak or
comprehend. The resident appeared pale and
warm and was hypotensive, tachycardic with
shallow respirations.

The hospital record dated 12/24/18 documented


per the nursing facility the resident had
symptoms of decreased mentation, hypotension
(low blood pressure), tachycardia and febrile
(high fever) illness x 3 days. The resident's
hospital blood work documented he had a white
blood cell count of 26,000 (normal 4,000-
11,000), sodium of 160 (normal 135-145) and
chloride of 124 (normal 97-107). The resident
arrived at the hospital on 12/24/18 at 2:53 PM
and expired at 4:35 PM.

During an interview with certified nurse aide


(CNA) #10 on 2/1/19 at 11:00 AM she stated
she was notified at the beginning of the day shift
on 12/24/18 the resident felt warm and she took
the resident's temperature rectally and it was
104.6. Later in the shift she took another rectal
temp and it was over 103. She notified LPN #4
who was the nursing supervisor and LPN #4
said she did not want to send him to the hospital
because it was a holiday. The Dietary Director
told LPN #4 that she should send him to the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 19 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 19 F 684


hospital. At 2:00 PM, LPN #4 called the
physician and received an order to send the
resident to the hospital. CNA #10 stated the
resident had not been doing well for some time
prior to that day. She stated one day his heart
rate was in the 200's.

During an interview with the Food Service


Director on 2/1/19 at 11:15 AM she stated she
was in the facility on 12/24/18 when Resident
#401 had a really high temperature. The Food
Service Director witnessed LPN #4 state she did
not want to send the resident to the hospital as it
was a holiday. The Food Service Director
recommended to LPN #4 the resident should be
sent out for treatment or he would not be around
for another holiday.

During an interview with LPN #4 on 2/14/19 at


12:15 PM she stated she was the Unit Manager
for the resident's unit and she frequently worked
as the nursing supervisor. On 12/24/18 Resident
#401 had a really high temperature and she
could not recall what it was. He had a lot of
medical issues and had a decline over the past
several weeks. The elevated temperature was
very scary, but she had called the physician and
he told me to just monitor him. She gave the
resident Tylenol but that did not help the
temperature. At 2:00 PM, the physician gave her
the order to send the resident to the hospital.
She did not recall saying she did not want to
send the resident to the hospital because it was
a holiday. She stated she recalled saying the
resident would probably wait until the end of her
shift to be sent out.

During an interview with LPN #13 on 2/14/19 at


7:35 AM she stated she had worked the night
shift on 12/23/18 going into 12/24/18. Resident
#401 had not been doing well for a few days

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 20 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 20 F 684


prior to that night. On the morning of 12/24/18
CNA #10 told LPN #13 the resident felt warm.
The resident's skin was hot to the touch and he
was breathing heavily. LPN #13 took an axillary
(arm pit) temperature and it was normal, but she
put cool compresses on him as he felt hot. She
did not notify the physician and there was no RN
in the building at the time. When CNA #10 took
the resident's rectal temperature and it was high.
LPN #13 stated she notified LPN #4 prior to
leaving and LPN #4 said she was not sending
the resident to the hospital as it was a holiday.

During an interview with physician #16 on


2/14/19 at 10:45 AM he stated if a resident was
running a high temperature, he would expect to
be notified. If the temperature was greater than
104 the resident was probably septic and would
require hospitalization for intravenous
antibiotics. He did not recall being notified of
Resident #401's history of high temperatures or
his decline in condition, and he would not have
given the directive to just monitor and give
Tylenol. He was notified of the resident's
condition just prior to the resident being sent to
the hospital on 12/24/18.

LPN #4 was interviewed a second time on


2/14/19 at 11:40 AM she stated she had been
very concerned when the resident had a high
temperature and she had reported the
temperature to the physician. She stated the
physician just wanted the resident to have
Tylenol. She did not know why Tylenol was not
documented on the MAR. She had directed the
medication nurse, LPN #5, to give the resident
Tylenol. She did not know what the resident's
other vital signs were. She had been very
concerned about the resident, but she needed a
physician order to send the resident to the
hospital.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 21 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 21 F 684

During an interview with LPN #5 on 2/19/18 at


2:25 PM she stated she had worked the day
shift on 12/24/18 and Resident #401's
temperature was really high. She had given him
Tylenol once that shift, could not remember the
time she gave it and may have forgotten to
document it. She had applied cold compresses
throughout the shift. Later in the shift when the
CNA rechecked the resident's temperature it
was still high. LPN #5 kept asking LPN #4 about
sending the resident to the hospital and LPN #4
did not want to. LPN #5 stated she had not
called the physician herself as that was the
responsibility of the supervisor, LPN #4.

During a follow up interview with LPN #4 on


2/28/19 at 10:30 AM she reviewed the 12/15/18
24-hour report and stated one of the CNAs had
reported to her the resident had a heart rate that
was 240, she went and rechecked it herself
radially (in the wrist) and it was high. She
notified NP #15 who wanted to increase his
Metoprolol which would have started the next
day. The NP did not direct her to do anything
else for the resident. She did not know why the
physician order was unsigned or why the
Metoprolol was not started until 12/17/18.

During an interview with NP #15 on 2/26/19 at


11:30 AM he stated he did not recall being
notified Resident #401 had a heart rate of 240. If
the heart rate was reported to him as 240, he
would have nursing verify the heart rate and
obtain vital signs. A heart rate of 240 was life
threatening and he would have sent the resident
to the emergency room. He would not have
ordered to increase the Metoprolol. If he did
order a change in medication, he would expect it
be given at that time and not two days later. He
did see the resident on 12/17/18 for a Gradual

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 22 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 684 Continued From page 22 F 684


Dose Reduction (GDR) and wanted blood work
done because the resident was recently treated
for sepsis and an MI. If he had been notified the
resident had elevated temperatures and heart
rates he would have included that in his note on
12/17/18. The labs should have been done on
the next lab day and he was not aware the labs
had not been done. He could not recall being
notified on 12/21/18 the resident was pale,
sweating and had a poor appetite and had been
having an elevated heart rate and temperature.

10 NYCRR 415.12
F 689 483.25(d)(1)(2) Free of Accident F 689 I. The following actions were accomplished 06/11/2019
SS=D Hazards/Supervision/Devices for the residents identified in the sample:
Resident #402
§483.25(d) Accidents. • Resident is no longer at the facility
The facility must ensure that - • A medical record review has been
§483.25(d)(1) The resident environment remains completed to ensure all improvement
as free of accident hazards as is possible; and opportunities related to the fall on
12/15/2018 have been identified and
§483.25(d)(2)Each resident receives adequate addressed in this plan of correction
supervision and assistance devices to prevent • LP #4 is no longer employed by the
accidents. facility
• LPN #11 is no longer employed by the
This REQUIREMENT is not met as evidenced facility
by: Resident #404
• Resident is no longer at the facility
Based on record review and interview during the • A medical record review has been
recertification and abbreviated surveys completed to ensure all improvement
(NY00231469 and NY00233843), the facility did opportunities related to the fall on
not ensure adequate supervision was provided 1/29/2018 have been identified and
for 2 of 6 residents (Resident #402 and #404) addressed in this plan of correction
reviewed for falls. Specifically, for Residents • LPN #4 is no longer employed by the
#402 and 404, licensed practical nurses (LPNs) facility
were independently evaluating the resident's • LPN #11 is no longer employed by the
after falls without adequate supervision and facility
direction.
Findings include: II. The following corrective actions will be
implemented to identify other residents
The facility Post Fall Follow-Up policy revised who may be affected by the same practice:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 23 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 23 F 689


11/17 documented when a resident sustains a All residents have the potential to be
fall, do not move the resident and notify the affected by this practice:
charge nurse or supervisor immediately. The • All Accident and Incident reports for the
registered nurse (RN) must perform an in-depth past thirty (30) days will be reviewed to
assessment of the resident's condition prior to ensure physician/PA notification has been
moving them. In the absence of an RN, the completed for all falls
charge nurse must relate all pertinent • All Accident and Incident reports for the
observations to the physician and follow all past thirty (30) days will be reviewed to
orders for follow up care and evaluation. ensure an RN assessment has been
Appropriate interventions will be initiated completed
immediately for all emergent needs including
blood pressure, temperature, respirations, III. The following system changes will be
oxygen saturations levels and blood sugars. implemented to assure continuing
compliance with regulations:
1) Resident #402 was admitted to the facility on As per the Directed Plan of Correction, the
8/3/16 and had diagnoses including chronic Consultant has developed and
obstructive pulmonary disease (COPD), implemented an In-service Program to
diabetes and hypertension. The 8/17/18 address:
Minimum Data Set (MDS) assessment • The Abuse Prevention and Reporting
documented the resident's cognition was policy has been newly adopted
moderately impaired, he required supervision for o Administrator and Department
bed mobility, transfers, limited assistance for Managers have been educated on this
personal hygiene, extensive assistance for policy with emphasis on identification and
dressing and had 2 falls without injury and 1 fall investigation related to suspected abuse
with injury since the prior assessment. • The Notification of Significant Changes
policy has been newly adopted
The comprehensive care plan (CCP) updated on o All licensed nurses have been re-
11/20/18 documented the resident had potential educated on this policy with emphasis on
for injury related to fall risk and anticoagulant the prompt notification of medical provider
(blood thinner) therapy. Interventions included with change in condition
maintain a record of falls and evaluate for • The Licensed Practical Nurse Job
patterns. Description has been reviewed without
revision.
A nursing progress note dated 12/15/18 o All licensed practical nurses have
completed by LPN #4 documented at 11:20 AM been re-educated on the contents of their
the resident was found sitting on the floor job description as it relates to providing
between the wheelchair and sink. The resident's care within their scope of
plan of care was discussed with the medication practice specifically related to RN
nurse. The resident had stated he had assessment prior to moving resident from
shakiness in his legs. He had denied pain, the location of the fall
discomfort and was able to move all his • The On-Call Nursing Administration

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 24 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 24 F 689


extremities. The nurse practitioner (NP) #15 was policy and procedure has been newly
notified and a new order for Gabapentin (used to adopted
treat nerve pain) 200 milligrams (mg) was o All licensed nurses have been
obtained. The progress note did not contain any educated on the policy with emphasis on
vital signs or neurological checks. contacting an RN, on-call RN with any
change of condition as soon as it is
On 1/30/2019 a copy of the residents 12/15/18 observed, specifically related to falls
accident/incident report, vital signs and • The Accident and Incident Reporting
neurological checks was requested. and Follow Up policy has been newly
adopted
During an interview with LPN #11 on 2/1/19 at o All licensed nurses have been
1:10 PM, she stated on 12/15/19 she was educated on the policy with emphasis on
walking past the resident's room and she noticed ensuring Incident Reports are initiated at
he was on the floor next to the sink. She called the time of the incident, the physician/NP
for the supervisor. LPN #4 came in the room and has been notified, vital signs and
checked the resident over and LPN #4 assisted neurological checks following falls are
LPN #11 with moving the resident back into his completed and documented, and the RN
wheelchair. She would not have moved the was notified prior to moving a resident from
resident off the floor by herself. She could not the location of the fall
remember doing vital signs or neuro checks on • All new staff will be educated on the
the resident after he had fallen above policy details during general
orientation
During an interview with LPN #4 on 2/1/19 at
12:15 PM, she stated she had worked the day IV. The facility’s compliance will be
and evening shift on 12/15/18 as a medication monitored utilizing the following quality
nurse and the nursing supervisor. Resident #402 assurance system:
had fallen that day and he was moving all his • As per the Directed Plan of Correction, a
extremities and did not appear to have any QA&A Committee meeting was held on
injuries. She called the nurse practitioner (NP) to May 2, 2019 to examine this deficiency.
report the resident was complaining of • All Accident and Incident reports will be
shakiness in his legs and the NP ordered audited weekly for three (3) months to
Gabapentin. She was not sure if she notified the ensure:
NP of the fall and did not receive any directions o physician/NP notification has been
prior to getting the resident off the floor. When completed
she entered the resident's room after the fall, o the RN was notified prior to moving
LPN #11 was helping the resident back into his residents from location of fall
wheelchair. The resident's roommate told LPN o an RN assessment has been
#4 Resident #402 did not hit his head. When she completed
checked the resident, he did not have any red o vital signs and neurological checks
marks. She started an incident report, obtained have been completed, as appropriate
vital signs and started neurological checks. The • Audit results will be reported to the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 25 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 25 F 689


vital signs and neurological checks would be QA&A Committee monthly for three
documented on the incident report. months. Frequency of on-going audits will
be determined by the Committee based on
During an interview with NP #15 on 2/26/19 at audit results.
11:30 AM, he stated when a resident fell he • Consultant will participate in QA&A
would expect a RN assessment, vital signs, Committee Meeting monthly for 3 months
neuro checks, and an incident report be Completion Date: June 11, 2019
completed. LPN #4 had called him to report falls. Responsibility: Director of Nursing
He did not give her any instructions or directions
over the phone to assess residents before she
moved them. He assumed when she called and
reported a fall the resident had already been
assessed by an RN. She was an LPN and could
not perform assessments. He did not give LPN
#4 any direction to move Resident #402 off the
floor on 12/15/18 and could not remember
ordering the Gabapentin.

During an interview with the Director of Nursing


(DON) RN #7 on 2/1/19 at 12:55 PM, she stated
she was not able to find an incident report for
Resident #402 for 12/15/18 and she was not
able to find any documented vital signs or
neurological checks that were done after the fall.
She stated when an incident report was started,
it was placed in a box in the office for a
registered nurse (RN) to complete after she
assessed the resident. The DON would then
review the incident report and put it in her log
book. She had checked her log book and there
was no incident report for the resident. When an
LPN was working in the capacity of a supervisor,
there was no registered nurse (RN) on duty. If a
resident fell, the LPN would make observations
of the resident and call the physician or the DON
to report the observations. The physician or
DON would give directions to evaluate and to
move the resident based on the observations.
The DON stated she did not remember receiving
a call about Resident #402 on 12/15/18 or giving
instructions on moving the resident after a fall.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 26 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 26 F 689

On 2/13/2019 at 1:00 PM, the DON provided the


surveyor with an incident/accident form for
Resident #402 and it was dated 12/15/2018.
She stated it was given to her on 2/13/2019 by
LPN #4. She stated the incident report was not
complete as it was missing information and
there were no vital signs or neuro checks
documented on the report.

The incident/accident report dated 12/15/18 at


11:20 AM documented the resident, per the
resident's roommate, was leaning forward in his
wheelchair and fell out and he did not hit his
head. The resident was noted with confusion
and he denied pain and stated he had increased
shakiness in his legs. NP #15 was notified and
discussed diabetes, blood sugars and tingling
sensation and a new order for Gabapentin was
obtained. There were no vital signs, blood sugar
or neurological checks documented on the
incident report.

2) Resident #404 was admitted to the facility on


1/28/19 and had diagnoses including severe
cardiomyopathy (disease of the heart muscle),
chronic kidney disease and congestive heart
failure (CHF, inefficient pumping of blood). The
resident was discharged to the hospital on
2/3/2019. The 2/3/19 Minimum Data Set (MDS)
assessment documented the resident's cognition
was severely impaired, required extensive
assistant with most activities of daily living
(ADLs) and had no falls since admission.

An incident/accident report dated 1/29/19 at 1:00


AM completed by LPN #13 documented the
resident was found on the floor next his bed at
1:00 AM. She asked him how he got there, and
he had no response. She assisted him back to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 27 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 27 F 689


and gave him his call bell. The report
documented he did not have any injuries and
"previous bruising" was noted to his arms and
legs. His lower extremities were weak. The
incident report documented the nurse
practitioner (NP) and the family were notified of
the fall at 7:00 AM. An attached
incident/accident statement form documented
the RN assessment was completed at 6:15 AM
and the resident had no injuries and no
complaints. His neurological checks were within
normal limits. The RN documented floor mats
were implemented to both sides of his bed. The
incident report was signed indicating it was
reviewed by the Director of Nursing (DON).

During an interview with LPN #12 on 2/14/19 at


7:20 AM, she stated she worked the night shift
and there was not always a RN in the building at
that time. If a resident fell, she would check the
resident over by having them move their arms
and legs. If they seemed ok she would get them
off the floor. She would not call another RN,
Director of Nursing (DON) or provider during the
night unless the resident had an obvious injury.
If there was an injury she would call the on-call
provider at that time, otherwise the provider
would be called in the morning.

During an interview with LPN #13 on 2/14/19 at


7:35 AM, she stated she worked the night shift
and there was not always an RN in the facility.
When a resident fell during her shift and there
was no RN, she would look at the resident to
make sure they could move their arms and legs
and would check for any bumps or bruises. If the
resident did not have any bleeding or obvious
injuries, she would assist the resident back to
bed. She would not call anyone for directions
before putting them back to bed. A RN would
complete the assessment when they were

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 28 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 28 F 689


available. On 1/29/19, she had found Resident
#404 on the floor of his room. She asked him
what had happened, and he could not tell her.
She checked him, and he did not appear to have
any injuries so one of the CNAs helped her get
him back to bed. RN #3 had arrived in the
morning and completed an assessment.

During an interview with RN #3 on 2/14/19 at


8:20 AM, she stated LPNs were making the
judgement to get the resident's off the floor after
a fall without the direction of a provider or RN.
On 1/29/19, she was notified when she arrived
for work, around 6:00 AM, that Resident #404
had fallen during the night and needed an
assessment. She completed the assessment
and he did not have any injuries. She then called
the physician and family to notify them of the fall.
She had notified administration the LPNs were
working outside of their scope of practice and
the practice continued.

During an interview with the DON on 2/14/19 at


12:30 PM, she stated it was facility policy when
there was no RN in the facility and the LPN
responded to a fall, the LPN was to make
observations of the resident and get vital signs.
The LPN would call the on-call provider, give
them their observations and then get instructions
from them before getting the resident off the
floor. If the provider did not call back, they
should call the DON or call 911 before getting
the resident off the floor. LPNs were not allowed
to make the determination if it was safe to move
a resident after a fall. She reviewed Resident
#404's accident/incident report and stated her
signature on the report indicated she reviewed it.
She stated when she reviewed the report prior to
2/14/19 she had not noticed that the LPN had
not received instructions to get the resident off
the floor. The LPN should not have done that, it

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 29 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 689 Continued From page 29 F 689


was not their policy.

10NYCRR 415.12(h)(1)
F 760 483.45(f)(2) Residents are Free of Significant F 760 I. The following actions were accomplished 06/11/2019
SS=D Med Errors for the residents identified in the sample:
Resident #403
The facility must ensure that its- • Resident is no longer at the facility
§483.45(f)(2) Residents are free of any • A medical record review has been
significant medication errors. completed to ensure all improvement
opportunities related to the significant
This REQUIREMENT is not met as evidenced medication error in which resident did not
by: receive ordered anticoagulant therapy for
21 consecutive days have been identified
Based on record review and interview during the and addressed in this plan of correction.
abbreviated survey (NY00231469), the facility • LPN #4 is no longer employed by the
did not ensure residents were free of significant facility
medication errors for 1 of 6 residents (Resident
#403) reviewed for medication regimens. II. The following corrective actions will be
Specifically, Resident #403 was found to have a implemented to identify other residents
blood clot and his medication orders were not who may be affected by the same practice:
followed. In addition, the facility did not have a All residents have the potential to be
process in place to identify transcription errors in affected by this practice:
physician orders. • All medication orders written in the past
Findings include: thirty (30) days will be reviewed to ensure
that any suspected medication errors have
Resident #403 was admitted to the facility on been investigated and reported
2/21/18 and had diagnoses including dementia • All medication orders written in the past
and atrial fibrillation (irregular heart rhythm). The thirty (30) days will be reviewed to ensure
12/5/18 Minimum Data Set (MDS) assessment that orders were transcribed accurately
documented the resident's cognition was • All residents receiving anticoagulation
severely impaired and he required extensive therapy will have anticoagulant therapy
assistance for most activities of daily living orders reviewed with physician/PA to
(ADLs). The MDS documented the resident ensure orders are appropriate and
received an anticoagulant (blood thinner) accurate
medication daily.
III. The following system changes will be
The comprehensive care plan (CCP) dated implemented to assure continuing
12/19/18 documented the resident was on compliance with regulations:
anticoagulant therapy related to atrial fibrillation As per the Directed Plan of Correction, the
and was on Xarelto (anticoagulant medication). Consultant has developed and
Interventions included to observe for signs of implemented an In-service Program to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 30 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 760 Continued From page 30 F 760


bleeding and update the Unit Manager, address:
physician or nurse practitioner (NP) of any • The Abuse Prevention and Reporting
changes. policy has been reviewed without revision
o Administrator and Department
A nursing progress note dated 12/18/18 Managers have been re-educated on this
documented the resident continued with swelling policy with emphasis on identification and
to lower extremities and a new order was investigation of medication errors and
obtained for a Doppler study (an ultrasound that reporting as indicated to the NYSDOH
measures blood flow through veins and arteries) • The Medication or Treatment Variances
of the right leg. policy has been newly adopted
o All licensed nurses have been
A nurse practitioner (NP) progress note dated educated on the policy with emphasis on
12/19/18 documented the resident had recurrent significant medication errors
cellulitis (infection of the skin) of his right lower • The Physicians Orders policy has been
extremity and after treatment with multiple newly adopted
antibiotics a doppler ultrasound was obtained o All licensed nurses have been
which was positive for a deep vein thrombosis educated on this policy with emphasis on
(DVT/blood clot) in the right leg. The resident accuracy of transcription of orders and
was on Xarelto 20 milligrams (mg) daily and process for taking Verbal Orders
"yesterday via a verbal order" was changed to verification of transcription order by a
Xarelto 15 mg twice daily. The resident would second nurse check
remain on the 15 mg twice daily for three weeks orders flagged for physician review and
and then would transition back to 20 mg daily. signature
The NP would continue to monitor the resident's • All new staff will be educated on the
lower extremities. above policy details during general
orientation
The 12/2018 medication administration record
(MAR) documented the Xarelto 20 mg was IV. The facility’s compliance will be
discontinued on 12/18/18. There was no monitored utilizing the following quality
corresponding physician order in the resident's assurance system:
medical record and there was no documented • As per the Directed Plan of Correction, a
evidence the Xarelto 15 mg twice daily was QA&A Committee meeting was held on
started per the NP verbal order. May 2, 2019 to examine this deficiency.
• All medication orders will be audited
A physician progress note dated 1/8/19 weekly for three (3) months to ensure that
documented the resident was seen for a routine any suspected significant medication errors
follow up and there had been no significant have been investigated and reported, as
change in his status. appropriate
• All medication error forms will be audited
A list of the resident's physician orders was weekly for three (3) months to ensure that
printed on 1/8/19 and included Xarelto 15 mg any significant medication errors are

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 31 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 760 Continued From page 31 F 760


twice daily. The list documented the original identified, investigated and reported to the
order date for the Xarelto was 1/8/19. NYSDOH if warranted
• All medication orders will be audited
The 1/20/19 MAR documented Xarelto 15 mg weekly for three (3) months to ensure that
twice daily was started on 1/8/19. There was no orders were transcribed accurately and a
evidence of a corresponding physician order in second nurse check has been completed
the resident's medical record. • All medication orders will be audited
weekly for three (3) months to ensure that
During an interview with the attending physician physician has reviewed and signed off
on 2/14/19 at 10:45 AM, he stated if a resident • Audit results will be reported to the
had a blood clot and was not treated with the QA&A Committee monthly for three
prescribed anticoagulant medication, the months. Frequency of on-going audits will
resident was at risk of developing a pulmonary be determined by the Committee based on
embolism (a blood clot to the lung). He audit results.
performed a routine evaluation of Resident #403 • Consultant will participate in QA&A
on 1/8/19 and had not been made aware the Committee Meeting monthly for 3 months
Xarelto had been discontinued. When he Completion Date: June 11, 2019
evaluated residents, he would review their Responsibility: Director of Nursing
medications from the printed physician order list.
He reviewed the resident's physician orders and
stated the Xarelto was on the order sheet. He
had not noticed prior to this date the order had
not been started until 1/8/19. The order should
have been started on 12/18/19 when it was
discovered the resident had a DVT. The
resident did not receive the anticoagulant
medication for 3 weeks and he should have. He
stated verbal orders were given either face to
face or by telephone. The nurse should
document the order on a physician order sheet
and the order would be signed when he came to
the facility.

During an interview with Director of Nursing


(DON) #7 on 2/14/19 at 11:30 AM, she stated
physician orders were documented on a
physician order sheet by the nurse taking the
verbal order then faxed to the pharmacy. She
did not know if there was a policy on double
checking orders and thought the double checks
were documented in the computer. She said the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 32 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 760 Continued From page 32 F 760


pharmacy would keep a copy of the physician
orders that were faxed, and she would call them
to request a copy of the physician orders for the
Resident #403.

During an interview with LPN Unit Manager #4


on 2/14/19 at 11:40 AM, she stated Resident
#403 had a blood clot in his leg. A doppler study
was done and showed a blood clot and the
physician increased his Xarelto to twice daily. A
verbal order was written on a physician order
sheet and then faxed to the pharmacy. The
pharmacy was responsible for putting the order
in the electronic medication administration
system (EMAR). After faxing the order to the
pharmacy, LPN #4 would place the written order
on the supervisor's clip board and the supervisor
would do the second check. The nurse doing the
second check would put their initials on the
written order indicating the order was checked
and it was correct in the EMAR. She would also
do a double check of the physician order herself,
later in the shift and check the computer to make
sure it was in the EMAR correctly. She stated
the resident's Xarelto 20 mg was discontinued
on 12/18/19 and Xarelto 15 mg twice daily was
supposed to start on the same day. She
reviewed the physician order print out sheet
from 1/8/19 and stated the Xarelto 15 mg twice
daily was not started until 3 weeks later and she
did not know why. She stated the LPNs on the
units did not have any communication with
physicians as that was her responsibility to
contact them and take verbal orders. In her
absence the supervisor would contact the
physician and take verbal orders.

During an interview with the DON on 2/14/19 at


12:30 PM, she provided the surveyor with a
copy of the physician orders for the resident and
stated she had received the copy of the order

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 33 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 760 Continued From page 33 F 760


from the pharmacy. The physician order
documented Xarelto 15 mg twice daily x 3
weeks then resume Xarelto 20 mg daily. The
physician order contained the signature of LPN
#4 and was not signed by a physician. The DON
reviewed the physician order list printed out on
1/8/2019. She stated the error should have been
picked up by the person doing the second check
as they would see the Xarelto 15 mg twice daily
was not in the EMAR. She reviewed a pharmacy
computer generated report and stated it was
LPN #4 who did the second check in the
computer of her own verbal order. She was not
sure how the nursing staff were doing the double
checks and she would have to look into it.

The pharmacy printout containing the Xarelto


order documented Xarelto 20 mg was
discontinued on 12/18/18 and the Xarelto 15 mg
twice daily was to be initiated on 1/8/19. Both
orders were documented as reviewed by LPN
#4.

On 2/14/19 at 1:00 PM, LPN #4 was shown the


written physician order and stated she had
signed the order indicating she had taken the
verbal order from the physician but there were
no initials on the written order that it was double
checked. She remembered faxing the order to
the pharmacy but did not remember if she went
into the computer later to make sure the order
had been inputted correctly.

During an interview with RN #3 on 2/19/19 at


11:40 AM, she stated when there was a new
physician order, it was written on the paper
order and faxed to pharmacy who would put it in
the EMAR. Most of the LPNs in the facility were
not involved with double checking orders. They
would know there was a new order if there was
green flag next to the order or if it was grayed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 34 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


303 EAST RIVER ROAD
PONTIAC NURSING HOME OSWEGO, NY 13126

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

F 760 Continued From page 34 F 760


out if discontinued. The facility did not have a
process for double checking orders. There was
a supervisor's clip board, but orders were not
placed on there for double checking.

A second request for a policy regarding double


checking physician orders was made on 2/19/19
at 10:45 PM and the DON stated she did not
know what the facility process was for double
checking orders and was having trouble finding
a current policy. She had found an old and
outdated policy but did not know what process
the nursing staff were following. She was waiting
for LPN #4 who was out sick to tell her what the
facility policy and process was.

10NYCRR 415.12(m)(2)

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 35 of 35

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