Inspection Reports for
The Pines at Poughkeepsie Center for Nursing & Rehabilitation
100 Franklin Street, Poughkeepsie, NY, 12601
Back to Facility Profile5 Reports
Inspection Report — Aug 20, 2024
Annual Inspection CMS
Date: Aug 20, 2024
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans within 48 hours of admission, inadequate pressure ulcer care, insufficient supervision to prevent accidents, lack of physician orders for oxygen therapy, inadequate dialysis care communication, missing certified nurse aide performance reviews, improper use and monitoring of psychotropic medications, and unsafe food storage and handling practices.
Citations (8)
F 0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for 2 residents, delaying care planning and assessments.
F 0686: The facility did not ensure pressure ulcers were prevented for 1 resident by failing to offload heels as ordered.
F 0689: The facility failed to provide adequate supervision and maintain a safe environment to prevent accidents for 1 resident with a history of falls.
F 0695: The facility did not ensure oxygen therapy was provided with a physician's order for 1 resident for 4 days.
F 0698: The facility failed to ensure ongoing assessments and communication with the dialysis center for 1 resident receiving hemodialysis.
F 0730: The facility did not complete annual performance reviews for 4 of 5 certified nurse aides as required.
F 0758: The facility failed to implement gradual dose reductions and behavioral monitoring for residents on psychotropic medications, and did not follow pharmacist recommendations to taper medications.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled, undated, expired food, improper hygiene, and incomplete temperature logs.
Report Facts
Days oxygen therapy without physician order: 4
Certified nurse aides missing annual reviews: 4
Expired food items: Multiple expired and undated food items found in walk-in refrigerator, dry storage, and pantry.
Temperature log missing shifts: 3
Ice accumulation lumps: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #24 | Licensed Practical Nurse | Performed nursing admission evaluation for Resident #241. |
| Director of Nursing | Provided statements on baseline care plan requirements and supervision. | |
| Director of Clinical Operations | Discussed baseline care plan initiation and nursing admission evaluations. | |
| Registered Nurse Manager #25 | Registered Nurse Manager | Initiated baseline care plan for Resident #241 after admission delay. |
| Nurse Practitioner | Nurse Practitioner | Evaluated Resident #241 and Resident #170; provided psychiatric consultation. |
| Registered Nurse #30 | Registered Nurse | Noted oxygen therapy without physician order for Resident #392. |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Discussed dialysis communication form usage. |
| Assistant Director of Nursing | Discussed dialysis communication and documentation. | |
| Director of Clinical Operation | Acknowledged missing nurse aide performance reviews. | |
| Psychiatric Nurse Practitioner Consultant | Psychiatric Nurse Practitioner | Evaluated Resident #170 and commented on psychotropic medication use. |
| Medical Director | Commented on inappropriate use of Seroquel for Resident #170. | |
| Director of Food Services | Discussed food safety, hygiene, labeling, and temperature monitoring deficiencies. | |
| Dietary Aide #27 | Dietary Aide | Observed not wearing hair net and beard covering in kitchen. |
Inspection Report — Aug 20, 2024
Complaint Investigation State
Date: Aug 20, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from June 2022 to May 2026 with citation and complaint history including enforcement actions.
Complaint Details
The facility received 112 complaints with 11 on-site inspections resulting in 1 citation from complaints during the reporting period.
Findings
Across 4 inspections, 2 had no citations while 2 resulted in 18 total citations split evenly between standard health and Life Safety Code violations. The facility had 112 complaints with 11 on-site inspections and 1 enforcement action recorded.
Citations (18)
Standard Health Citation — quality of care: Baseline Care Plan was deficient.
Standard Health Citation — quality of care: Dialysis care was deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and sanitary conditions were deficient.
Standard Health Citation — quality of care: Use of psychotropic medications was not properly managed.
Standard Health Citation — quality of care: Facility failed to ensure freedom from accident hazards and proper supervision.
Standard Health Citation — quality of care: Nurse aide performance review and in-service training were inadequate.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Treatment and services to prevent or heal pressure ulcers were deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system were deficient.
Life Safety Code Citation — NFPA requirements: EP testing requirements were deficient.
Life Safety Code Citation — NFPA requirements: Fire drills were deficient.
Life Safety Code Citation — NFPA requirements: Gas equipment cylinder and container storage were deficient.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: Standards of construction for new and existing nursing homes were deficient.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 18
Inspections with violations: 2
Inspections without violations: 2
Total complaints: 112
On-site complaint inspections: 11
Citations from complaints: 1
Enforcement actions: 1
Total fines: 2000
Inspection Report — Mar 13, 2024
Abbreviated Survey CMS
Date: Mar 13, 2024
Visit Reason
The visit was an abbreviated survey conducted to assess medication administration practices and ensure residents were free from significant medication errors.
Findings
The facility failed to ensure that residents were free from significant medication errors, specifically one resident was not administered an intravenous antibiotic as prescribed on three occasions.
Citations (1)
F 0760: The facility did not ensure Resident #1 received intravenous Ceftriaxone antibiotic as ordered on 4/30/2022, 5/1/2022, and 5/3/2022. Medication administration records lacked documentation of these doses.
Report Facts
Medication omissions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration and policy | |
| Registered Nurse Manager | Notified medical provider of medication omissions and discussed administration | |
| Registered Nurse Supervisor | Responsible for administering antibiotic via PICC line and interviewed about medication administration | |
| Medical Director | Reviewed Medication Administration Records and confirmed omissions | |
| Administrator | Interviewed about awareness of medication omissions and incident reporting |
Inspection Report — Oct 12, 2021
Annual Inspection CMS
Date: Oct 12, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations regarding medication storage and infection prevention and control protocols.
Findings
The facility failed to ensure safe and secure storage of medications on two occasions and did not provide proper hand hygiene to a resident after crawling on the floor and before meals, violating infection control protocols.
Citations (2)
F 0761: The facility did not provide safe and secure storage of medications on two occasions; a bottle of aspirin and stool softener were left unattended on a medication cart, and 33 blister packs of medications were left unattended at the nurses station.
F 0880: The facility failed to provide and implement an infection prevention and control program; Resident #98 was not given hand hygiene after crawling on the floor and before eating, despite staff supervision.
Report Facts
Medication blister packs left unattended: 33
Dates of medication storage observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #6) | Verified medications left unattended on medication cart | |
| Licensed Practical Nurse (LPN #5) | Stated it was a mistake to leave medications unattended | |
| Certified Nursing Assistant (CNA #4) | Failed to provide hand hygiene to Resident #98 after floor contact | |
| Certified Nursing Assistant (CNA #5) | Forgot to offer hand hygiene to Resident #98 before meal | |
| Licensed Practical Nurse (LPN #7) | Supervised dining and acknowledged oversight in hand hygiene | |
| Director of Nursing (DON) | Stated resident should have had hand hygiene after floor contact | |
| Registered Nurse Unit Manager (RNUM #1) | Stated resident's hands should have been cleaned after floor contact |
Inspection Report — Dec 6, 2018
Complaint Investigation CMS
Date: Dec 6, 2018
Visit Reason
Complaint investigation regarding care planning, fluid intake monitoring, positioning, catheter care, medication management, infection control, and food safety at The Pines at Poughkeepsie Center for Nursing & Rehab.
Complaint Details
Complaint #NY00230539 regarding inadequate care planning, fluid intake monitoring, positioning, catheter care, medication management, infection control, and food safety.
Findings
The facility failed to develop and implement complete care plans for hospice and fluid intake monitoring, ensure proper positioning and wheelchair maintenance, discontinue urinary catheters timely, justify psychotropic medication use, maintain medication error rates below 5%, label and store medications properly, ensure food safety and cooling logs, and follow infection control protocols including hand hygiene.
Citations (8)
F 0656: The facility did not develop a person-centered care plan for hospice care and fluid intake monitoring for residents with indwelling catheters or at risk for dehydration.
F 0684: Residents #42 and #108 did not receive appropriate care for positioning and mobility; wheelchair foot rests were inadequate or in disrepair.
F 0689: Resident #47 was not provided adequate supervision or assistive devices to prevent recurrent falls; interventions were ineffective and not reassessed.
F 0690: Resident #169's indwelling catheter was not discontinued after pressure ulcers healed, lacking reassessment for continued need.
F 0758: Resident #146 was prescribed Zyprexa without documented justification; behavior monitoring was inadequate and gradual dose reduction was not considered.
F 0761: Medication storage was improper with expired medications and unlabeled individually packaged pills found in medication carts and rooms.
F 0812: Food safety violations included lack of cooling logs for TCS foods and unit refrigerators containing unlabeled, undated, or expired foods and supplements.
F 0880: Infection control failures included improper hand hygiene and glove use during wound care and meal assistance, risking cross contamination.
Report Facts
Medication error rate: 6.4
Falls: 11
Fluid intake: 1500
Fluid intake: 2000
Medication expiration dates: 3
Hi Cal supplement expiration: 48
Wandering episodes: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse Manager | Observed improper wound care technique and contamination of medication cart. |
| LPN #3 | Licensed Practical Nurse | Administered insulin late and documented blood sugar incorrectly. |
| RN #4 | Registered Nurse | Administered incorrect eye medication. |
| RN #2 | Nurse Manager/Registered Nurse | Interviewed about fall prevention and Dycem mat use. |
| Physical Therapist | Interviewed about wheelchair positioning and fall prevention. | |
| Director of Nursing | Director of Nursing | Interviewed about care planning and fall prevention processes. |
| Medical Director | Medical Director | Interviewed about psychotropic medication use and insulin administration. |
| FSD | Food Service Director | Interviewed about food safety and unit refrigerator management. |
| CNA #1 | Certified Nursing Assistant | Observed not washing hands during meal assistance. |
| Activity Staff Member #1 | Observed not washing hands after dropping badge and touching resident. |
Viewing
Loading inspection reports...
