Hamilton Park Nursing And Rehabilitation Center

F-F760 - Residents Are Free of Significant Medication Errors

The findings are:

According to the New York State Educational Law Article 139, Section 6902, the practice of the profession of nursing includes the executing of medical regimens prescribed by a licensed physician. It further states that nursing regimen shall be consistent with and shall not vary any existing medical regimen.

Resident #102 had diagnoses of Bipolar Disorder, Anxiety, and Major Depressive Disorder.

The Minimum Data Set assessment dated [DATE REDACTED] documented Resident #102 had intact cognition.

A physician's order dated 03/19/2022 documented Venlafaxine HCl ER Capsule Extended Release 24 Hour 150 Milligrams, give 1 capsule by mouth one time a day, for Major Depressive Disorder, give together with Venlafaxine 75 milligram for a total dose of 225 milligram.

The electronic Medication Administration Record from 02/01/2025 through 02/20/2025 documented that Venlafaxine was not administered at 9:00 AM on 02/07/2025, 02/08/2025, 02/17/2025, 02/18/2025, 02/19/2025, and 02/20/2025.

The nurses' progress notes dated 02/07/2025 at 2:34 PM, 02/08/2025 at 2:03 PM, and 02/18/2025 at 8:58 AM, and 02/19/2025 at 8:42 AM documented that Venlafaxine was on order.

A nurse's progress note dated 02/18/2025 at 8:58 AM documented waiting for pharmacy.

A physician's order dated 01/05/2024 documented Venlafaxine HCl ER Capsule Extended Release 24 Hour 75 milligram, give 1 capsule by mouth at bedtime for Depression.

The electronic Medication Administration Record from 02/01/2025 through 02/20/2025 documented that Venlafaxine was not administered at 9:00 PM on 02/18/2025.

A nurse's progress note dated 02/18/2025 at 8:19 PM documented awaiting pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 A review of the Physician's Progress Notes did not reveal any indication that the physician was informed of

the missed Venlafaxine doses. Level of Harm - Minimal harm or potential for actual harm A review of Resident #102's nurses' progress notes revealed no documented evidence that Resident #102 was assessed for adverse effects related to the missed Venlafaxine doses. Residents Affected - Some There was no documented evidence that a Medication Error report was completed for the missed Venlafaxine doses.

On 02/21/2025 at 11:49 AM, Licensed Practical Nurse #3, was interviewed and stated they were the medication nurse for the day shift on 02/07/2025, 02/08/2025, 02/18/2025, 02/19/2025, and 02/20/2025.

They stated Resident #102 was not administered Venlafaxine because the medication was not in the cart. Licensed Practical Nurse #3 stated Venlafaxine had been missed for over 3 or 4 days. Licensed Practical Nurse #3 stated they did not inform the Charge Nurse and the physician that Venlafaxine was not available, and that they reported it to the nursing supervisor and the Assistant Director of Nursing on 02/20/2025.

On 02/24/2025 at 09:55 AM, License Practical Nurse #2 was interviewed and stated they were the medication nurse for the day shift on 02/17/2025. They stated Resident #102's Venlafaxine was not administered because it was not available in the medication cart. They stated they told the charge nurse on 02/17/2025 but cannot recall if they followed up with the pharmacy or if they endorsed it to the next shift. License Practical Nurse #2 stated they did not monitor Resident #102 for adverse reactions to missed Venlafaxine dose.

On 02/24/25 at 03:19 PM, License Practical Nurse #1 was interviewed and stated they were the medication nurse for the evening shift on 02/18/2025. Licensed Practical Nurse #1 stated Resident #102's Venlafaxine was not administered because it was not available and was not in the medication cart. Licensed Practical Nurse #1 stated they did not notify the physician that Venlafaxine was not available and did not monitor Resident #102 for negative effects of missed Venlafaxine dose.

On 02/25/2025 at 10:38 AM, Physician #1 was interviewed and stated they were made aware a few days ago that Resident #102 was not administered Venlafaxine, and they instructed the staff to call the pharmacy to get a STAT delivery. Physician #1 stated they had not received a call on the earlier dates that Venlafaxine was not available.

On 02/25/2025 at 09:39 AM, the Director of Nursing was interviewed and stated they were not aware that Resident #102's Venlafaxine was not administered due to not being available. The Director of Nursing stated nursing supervisors are trained to inform the physician when a medication is not available to see if an alternative can be suggested.

10 NYCRR 415.11(c)(3)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41709 potential for actual harm Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to Residents Affected - Some 02/25/2025 the facility did not ensure residents are free of any significant medication errors. This was evident

in 1 (Resident #102) of 5 residents reviewed for psychotropic medications out of 38 total sampled residents. Specifically, Resident #102 was not administered 7 doses of Venlafaxine (an anti-depressant) as ordered by

a physician.

The findings are:

The facility Policy titled Administering Medications with a revised date of 01/2025 documented medications must be administered in safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at

a time other than the schedule time, the individual administering the medication shall initial and enter corresponding code into the Medication Administration Record space provided for the drug and dose.

Resident #102 had diagnoses of Bipolar Disorder, Anxiety, and Major Depressive Disorder.

The Minimum Data Set assessment dated [DATE REDACTED] documented Resident #102 had intact cognition.

A Comprehensive Care Plan for use of antidepressant, Venlafaxine related to Major Depressive Disorder was initiated on 01/02/2021. The facility interventions include administering medication as ordered by a physician and to monitor and document side effects and effectiveness every shift.

A physician's order dated 03/19/2022 documented Venlafaxine HCl ER Capsule Extended Release 24 Hour 150 Milligrams, give 1 capsule by mouth one time a day, for Major Depressive Disorder, give together with Venlafaxine 75 milligram for a total dose of 225 milligram.

The electronic Medication Administration Record from 02/01/2025 through 02/20/2025 documented that Venlafaxine was not administered at 9:00 AM on 02/07/2025, 02/08/2025, 02/17/2025, 02/18/2025, 02/19/2025, and 02/20/2025.

The nurses' progress notes dated 02/07/2025 at 2:34 PM, 02/08/2025 at 2:03 PM, 02/18/2025 at 8:58 AM, and 02/19/2025 at 8:42 AM documented that Venlafaxine was on order.

A nurse's progress note dated 02/18/2025 at 8:58 AM documented waiting for pharmacy.

A physician's order dated 01/05/2024 documented Venlafaxine HCl ER Capsule Extended Release 24 Hour 75 milligram, give 1 capsule by mouth at bedtime for Depression.

The electronic Medication Administration Record from 02/01/2025 through 02/20/2025 documented that Venlafaxine was not administered at 9:00 PM on 02/18/2025.

A nurse's progress note dated 02/18/2025 at 8:19 PM documented awaiting pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 A review of Resident #102's progress notes revealed no documented evidence that the physician was notified of the missed doses and that Resident #102 was assessed for adverse effects related to the missed Level of Harm - Minimal harm or Venlafaxine doses. potential for actual harm

On 02/21/2025 at 11:49 AM, Licensed Practical Nurse #3, was interviewed and stated they were the Residents Affected - Some medication nurse for the day shift on 02/07/2025, 02/08/2025, 02/18/2025, 02/19/2025, and 02/20/2025.

They stated Resident #102 did not receive Venlafaxine because the medication was not in the cart. Licensed Practical Nurse #3 stated they re-ordered the medication on 02/19/2025 and was told it will be delivered in

the evening. They stated they followed up with the pharmacy on 02/20/2025 but was placed on hold and they had to hung up because they need to finish the medication pass. Licensed Practical Nurse #3 stated Venlafaxine had been missed for over 3 or 4 days. Licensed Practical Nurse #3 stated they did not inform the Charge Nurse and the physician that Venlafaxine was not available, and that they reported it to the nursing supervisor and the Assistant Director of Nursing on 02/20/2025.

On 02/24/2025 at 09:55 AM, License Practical Nurse #2 was interviewed and stated they were the medication nurse for the day shift on 02/17/2025. They stated Resident #102's Venlafaxine was not administered because it was not available in the medication cart. They stated they told the charge nurse on 02/17/2025 but cannot recall if they followed up with the pharmacy or if they endorsed it to the next shift.

On 02/24/25 at 03:19 PM, License Practical Nurse #1 was interviewed and stated they were the medication nurse for the evening shift on 02/18/2025. Licensed Practical Nurse #1 stated Resident #102's Venlafaxine was not administered because it was not available and was not in the medication cart. Licensed Practical Nurse #1 stated they contacted the pharmacy on 02/18/2025 and reported to the nursing supervisor that the medication as not available. Licensed Practical Nurse #1 stated they did not notify the physician that Venlafaxine was not available.

On 02/21/2025 at 11:56 AM, Registered Nurse #1 was interviewed and stated they were not aware that Resident #102 had not been administered Venlafaxine. They stated that on 02/20/2025, Licensed Practical Nurse #3 asked them if any medications were delivered to the unit but was not told that the medication was not available or missing.

On 02/21/2025 at 02:09 PM, the Assistant Director of Nursing was interviewed and stated they were made aware today that Resident #102's Venlafaxine was not available and that it is now en route from the pharmacy as a STAT (immediate delivery) order. They stated there was a glitch in the pharmacy system causing delays in dispensing the medications.

On 02/25/2025 at 10:10 AM, the Pharmacist was interviewed and stated they had computer outage on 02/19/2025 and was unable to timely process some of the orders but it was resolved the next day. The Pharmacist stated there was no reason for the resident to not receive Venlafaxine because they refilled the medication. The Pharmacist stated Venlafaxine HCL ER 75 milligram was refilled on 01/21/2025 (14 day supply), on 02/16/2025 (14 day supply), and on 02/21/2025 (14 day supply); Venlafaxine 150 milligram was refilled on 02/09/2025 (14 day supply), on 02/21/2025 (7 day supply), and on 02/23/2025 (30 day supply).

The Pharmacist stated medications were sent as ordered and is possible the medications were misplaced.

The Pharmacist stated the resident not receiving their medication has nothing to do with the glitch in the system since the glitch was resolved the next day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 On 02/25/2025 at 10:38 AM, Physician #1 was interviewed and stated they were made aware a few days ago that Resident #102 was not administered Venlafaxine, and they instructed the staff to call the pharmacy Level of Harm - Minimal harm or to get a STAT delivery. Physician #1 stated they had not received a call on the earlier dates that Venlafaxine potential for actual harm was not available.

Residents Affected - Some On 02/25/2025 at 09:39 AM, the Director of Nursing was interviewed and stated they were not aware that Resident #102's Venlafaxine was not administered due to not being available. They stated nurses must re-order the medications when they are running low. The Director of Nursing stated nursing supervisors are trained to inform the physician when a medication is not available to see if an alternative can be suggested.

10 NYCRR 415.12(m)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41709

Residents Affected - Few Based on observation, record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents were served food that accommodated their allergies and intolerances. This was evident in 1 (Resident #343) of 38 total sampled residents. Specifically, Resident #343, who had a documented allergy to Mushroom, received a lunch tray containing mushroom soup.

The findings are:

The facility document titled Allergy Policy with a revised date of 01/2025 documented all food allergies will be communicated to the Food Service Director for immediate identification on the resident food profile. Tickets should reflect the resident's known food allergies.

Resident #343 had diagnoses of Heart Failure, Dementia, and Hypertension.

The Minimum Data Set assessment dated [DATE REDACTED] documented #343 had moderately impaired cognition and required supervision or touch assistance for eating.

During dining observation on 02/18/2025 at 12:31 PM, Resident #342 was in the unit dining area sitting with their next of kin. The Resident's lunch tray had a container of mushroom soup. Resident #343's lunch meal ticket dated 2/18/2025 documented pureed cream of mushroom soup. The bottom of the meal ticket documented that Resident #343 had allergy to mushrooms and it was highlighted in red. The Resident's next of kin removed the mushroom soup from the Resident's tray.

The Dietary Admission Nutrition Risk assessment dated [DATE REDACTED] documented that Resident #343 had food allergies to Mushroom.

A medical progress note dated 02/18/2025 documented Resident #343 had allergies to pork and mushroom.

A care plan on allergies was initiated for Resident #841 on 10/21/2024. The facility interventions include alerting appropriate discipline for any drug and food allergy.

On 02/18/2025 at 12:32 PM, Resident #343's next of kin was interviewed and stated that Resident is allergic to mushroom.

On 02/18/2025 at 02:13 PM, Certified Nursing Assistant #1 was interviewed and stated they were not trained to read the allergies in the meal tickets and that it is the nurse who checks for allergies.

On 02/18/2025 at 02:18 PM, Certified Nursing Assistant #2 was interviewed and stated they gave the lunch tray to Resident #343 but did not look at the diet or the allergies listed on the meal ticket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 On 02/25/2025 at 10:54 AM, Dietary Aide #1 was interviewed and stated they were the lead person responsible for checking the tray line and placing the meal tickets on all the trays. The Dietary Aide stated Level of Harm - Minimal harm or they were the final checker and was responsible for making sure the trays are complete, but they did not see potential for actual harm the allergies listed at the bottom of the meal ticket.

Residents Affected - Few On 02/24/25 at 10:19 AM, The Dietary Director was interviewed and stated everyone on the tray line is responsible for checking and putting specific items on the resident's tray by reading the meal ticket. The Dietary Director stated the residents' allergies are listed at the bottom of the meal ticket and are highlighted

in red and it was still missed. The Director stated multiple staff double checked the resident's tray and meal ticket and everyone including the final checker missed the allergy.

10 NYCRR 415.14(d)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 42101

Residents Affected - Few Based on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during dining

observation on the 6th Floor. Specifically, Certified Nursing Assistant #4 was observed touching a lettuce with their bare hands while preparing Resident #95's sandwich.

The findings are:

The facility policy titled Food Preparation and Handling with a revised date of 01/2005 documented all food will be prepared and handled using safe and sanitary methods. All staff will avoid bare-hand contact with ready to eat foods, as well as wear single use gloves and use serving utensils.

On 02/18/2025 at 12:55 PM, Certified Nursing Assistant #4 was observed assisting Resident #95 with their sandiwch during lunch. Certified Nursing Assistant #4 was observed holding a piece of lettuce with their bare hand while they were assembling the sandwich and cutting the sandwich in 4 pieces with a knife.

During an interview on 02/18/2025 at 01:07 PM, Certified Nursing Assistant #4 stated they did not touch the lettuce and bun with their bare hands. They stated they used wipes to clean their hands and that they washed their hands before they touch the bread and cut the sandwich for Resident #95.

During an interview on 02/24/2025 at 03:04 PM, Registered Nurse # 3 stated staff should not touch food with their bare hands because it is unsanitary even if they washed their hands.

During an interview on 02/25/2025 at 11:40 AM, the Infection Preventionist stated gloves must be used when handling sandwich. They stated sandwiches are assembled and wrapped in the kitchen and staff must put on gloves when handling them.

10 NYCRR 415.14 (h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 335710 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services 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 335710 B. Wing 02/25/2025

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

Hamilton Park Nursing and Rehabilitation Center 691 92nd Street Brooklyn, NY 11228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44842 potential for actual harm Based on observation, record review, and interview during the Recertification Survey conducted from Residents Affected - Few 02/18/2025 to 02/25/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #130) out of 38 total sampled residents. Specifically, Licensed Practical Nurse #4 failed to practice hand hygiene and glove changes during wound care.

The findings are:

The facility's policy titled Wound Dressings, Dry/Clean with a revised date of 01/2025 documented the purpose of the policy was to provide guidelines for the application of dry, clean dressings.

Resident #130 had diagnoses of Stage 3 Pressure Ulcer of Sacral Region, Type 2 Diabetes Mellitus, and Malnutrition.

The Minimum Data Set assessment dated [DATE REDACTED] documented Resident #130 had intact cognition and Stage 3 pressure ulcers.

The physician's order dated 02/12/2025 documented Triad Hydrophilic Wound Dress External Paste, apply to sacrum topically every shift for pressure ulcer; cleanse wound with normal saline, pat dry, apply Triad paste and cover with foam dressing.

On 02/24/2025 at 10:18 AM, wound care observation was conducted for Resident #130 with Licensed Practical Nurse #4. Licensed Practical Nurse #4 came into the room, placed down the supplies, and washed their hands. Licensed Practical Nurse #4 donned gloves, then removed Resident #130's soiled dressing from

the wound on their Sacrum. Without removing the soiled gloves and without performing hand hygiene, Licensed Practical Nurse #4 proceeded to clean the wound. After cleaning the wound, Licensed Practical Nurse #4 removed their gloves performed hand hygiene, donned clean gloves, then applied the treatment and placed the clean dressing on the wound. Licensed Practical Nurse then removed their gloves and performed hand hygiene.

On 02/24/2025 at 10:30 AM, Licensed Practical Nurse #4 was interviewed and stated they were instructed to remove the soiled dressing, cleanse the wound, then remove gloves and perform hand hygiene before applying treatment.

On 02/24/2025 at 10:43 AM, Registered Nurse #4 was interviewed and stated that hand hygiene is supposed to be performed after removing the soiled dressing and before cleaning the wound.

On 02/25/2025 at 12:54 PM, the Director of Nursing was interviewed and stated that hand hygiene is supposed to be performed after removing the soiled dressing, then again after cleaning the wound and also

before applying the treatment and clean dressing.

10 NYCRR 415.19(b)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 335710