Mercy Living Center
October 27, 2016 Certification Survey

Standard Health Citations

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2016
Corrected date: December 24, 2016

Citation Details

Based on observation, record review and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that food contact surfaces are to be cleaned after use. Specifically, various food contact equipment was not clean. This is evidenced as follows: An inspection tour of the kitchen was conducted on 10/26/2016 at 9:00 am. The slicer and table mixer were not cleaned after their last use. The Director of Nutrition Services stated in an interview conducted on 10/26/2016 9:00 am, that the slicer was probably last used two days ago and that both pieces of equipment will be cleaned immediately. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110

Plan of Correction: ApprovedNovember 23, 2016

The Facility shall comply with 483.35(i) FOOD PR(NAME)URE, STORE/PREPARE/SERVE - SANITARY specifically the facility will ensure that the food contact equipment will be clean.
The plan of correction for this citation is as follows:
1)The slicer and table mixer were cleaned immediately upon notification on 10/26/16.
2)Policy and Procedure will be created to address sanitation of all food contact equipment.
3)All dietary staff will be educated on the new policy
4) The Cook or designee will perform a check at the start of each shift daily of all food contact equipment per new policy. Anything not satisfactory will be cleaned immediately and reported to Food Services Director.
5)The Food Service Director or designee will perform an audit of the cleanliness of the food contact equipment daily times 2 weeks, weekly times 1 month, then monthly times 3 months and ongoing as needed.
5) Results of this audit will be reported monthly to the facility QAPI committee who will determine the need for future frequency.
Responsible Party: Food Services Director

FF09 483.25:PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2016
Corrected date: December 24, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure it provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of 3 resident's reviewed comprehensively during the recertification survey. Specifically: there was lack of monitoring of medication side effects. This is evidenced by: Resident #1: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident understands, was understood and had a Brief Interview of Mental Status (BIMS) of 12/15 or moderately impaired decision making ability. Physician orders [REDACTED]. A physician's orders [REDACTED]. Interaction: Co-administration of [MEDICATION NAME] and [MEDICATION NAME] may increase the risk of [MEDICAL CONDITION] and [MEDICAL CONDITION]. A Nurse Practitioner Note on 8/18/16 at 4:05 pm, documented: the resident will start on [MEDICATION NAME] 10 mg daily, starting on 8/20/16. Please observe for [MEDICAL CONDITION]. Progress notes documented that neurological checks were done for the resident on 8/26 and 8/27/16, however, there was no documentation of the blood pressure results. A physician progress notes [REDACTED]. The note documented under Plan to monitor blood pressure and heart rate; to consider titrating [MEDICATION NAME] due to the beneficial hypertensive side effect of [MEDICATION NAME] and current [MEDICAL CONDITION]. The Medication Administration Record [REDACTED]. Start date of 8/30/16. A blood pressure of 98/62 and heart rate of 51 were documented on 8/31/16. There were no blood pressures or heart rates documented prior to 8/31/16. A physician progress notes [REDACTED]. The note documented under Plan to monitor blood pressure and heart rate; to consider titrating [MEDICATION NAME] due to the beneficial hypertensive side effect of [MEDICATION NAME] and current [MEDICAL CONDITION]. A Licensed Practical Nurse (LPN) note on 8/31/16, documented the resident's blood pressure was 98/62 this morning when first taken and her pulse was 51. The resident was lying down sleeping in bed while they were taken, the writer re-checked BP and Pulse before she took her [MEDICATION NAME]. BP was then 122/67 with pulse at 66. The 24 Hour Report Sheet for 8/30/16 documented: Vitals every day times 1 week. (Vitals include blood pressure and pulse.) An LPN Note on 9/1/16 at 2:51 pm, documented: blood pressure below normal limits Physician orders [REDACTED]. On 9/1/16, an order for [REDACTED]. Notify MD if held. On 9/1/16, an order to discontinue [MEDICATION NAME] 10 mg one time a day for the reason the resident is becoming more agitated and irritable on [MEDICATION NAME]. During an interview on 10/20/16 at 10:35 am, the Registered Nurse Manager (RNM) stated the Nurse Practitioner placed the order for the [MEDICATION NAME] and did not order for the blood pressure to be monitored. The RNM stated that she saw the interaction warning also and should have ordered for the blood pressure to be monitored. During an interview on 10/27/16 the Director of Nursing (DON) stated the Nurse Practitioners (NP) put their own orders in the computer. The NP should have put the monitoring of the blood pressure and pulse in the orders. 10NYCRR415.12

Plan of Correction: ApprovedNovember 23, 2016

The facility shall comply with 483.25 Provide Care/Services for Highest Wellbeing: specifically that the facility shall monitor medication side effects.
1) For resident #1: This resident was discharged from the facility.
Identification of other residents having the potential to be affected by this deficient practice and corrective action to be taken:
1)All current resident's orders will be audited to identify potential drug interactions and potentially harmful adverse side effects, with the assistance of the pharmacy consultant.
2)All residents identified by pharmacy consultant as having potential for adverse side effects will be reviewed by provider for appropriate interventions.
Measures put in place to ensure that this deficiency does not recur:
1)on 11/15/16 Point Click Care was updated so that all black box warnings which include side effects and potential drug to drug interactions must be acknowledged, signed off, and a progress note must be written for the order to be initiated.
2)Training will be provided to nursing on the changes to Point Click Care. Training is scheduled for 11/30/16 and 12/2/16. This training will be added to new orientation checklist for nursing.
3)Nurse Managers will be educated on necessity of reviewing provider's progress notes and are responsible for clarification on need for increased monitoring.
4)Providers, including Medical Director will be educated on the changes to Point Click Care.
5)Audits of all new orders will be performed to ensure that monitoring is initiated for any potential medication side effects when deemed appropriate by provider, or if intervention not initiated, provider has acknowledged risks vs benefits.
6)Audits will be conducted daily times 2 weeks, weekly times 1 month, then monthly times 3 months.
7)Results of this audit will be reported monthly to facility QAPI committee who will determine need for future frequency.
Responsible Party: Director of Nursing

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 27, 2016
Corrected date: December 24, 2016

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2000 edition section 8.2.5 requires that vertical openings be continuous from floor to roof. Specifically, penetrations in the IT-chase were not sealed. This is evidenced as follows. The IT-chase was inspected on 10/27/2016 at 11:30 am. Three 3-inch unsealed holes for wiring were found between the second and third floors, and one 3-inch unsealed hole for wiring was found between the first and second floor. The Manager of Plant Operations stated in an interview conducted on 10/27/2016 at 11:30 am, that the unsealed holes look like they are for new wiring. 42 CFR 483.70 (a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedNovember 22, 2016

The facility shall comply with NFPA 101 Life Safety Code 2000 edition section 8.2.5 requires that vertical openings be continuous from floor. Specifically, penetrations in the IT-chase were not sealed.
Measures put into place to ensure this deficiency does not recur are:
1)Plant Ops director will review and revise policy to ensure it meets NFPA 101 Life Safety Code 2000 standard.
2)The work to the IT-chase will be completed by 12/12/16 according to code.
3)Plant Ops will audit other sections of the building once per month until facility is completed ensuring areas of the building subject to this code meet the requirements of fire resistance ratings of at least one hour with no penetration. This includes areas of new construction or after running of cables.
4)Results of this audit will be reported at the facility QAPI committee monthly initially, with the committee to determine need for future frequency.
Responsible Party: Plant Operations Director