St Anns Community
July 8, 2016 Certification Survey

Standard Health Citations

FF09 483.20(g) - (j):ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

REGULATION: The assessment must accurately reflect the resident's status. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. A registered nurse must sign and certify that the assessment is completed. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Under Medicare and Medicaid, an individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or an individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment. Clinical disagreement does not constitute a material and false statement.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 8, 2016
Corrected date: September 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for 5 of 29 residents reviewed for accuracy of the Minimum Data Set (MDS) Assessments, the facility did not accurately complete the MDS Assessments. Specifically, Section V (the Care Area Assessment summary or CAA) included areas that were triggered to proceed to care planning where the care planning decision was marked not to proceed (Residents #4, #5, #15, and #32), and inaccurate coding of vision status (Resident #62). This is evidenced by, but not limited to, the following: 1. Resident #32 has [DIAGNOSES REDACTED]. Review of the 1/14/16 significant change assessment MDS Assessment, Section V, CAA summary revealed the following care areas triggered in column A: [MEDICAL CONDITION], cognitive loss/dementia, visual function, communication, urinary incontinence/indwelling catheter, mood state, behavioral symptoms, falls, nutritional status, dehydration/fluid maintenance, and pressure ulcers. In column B the only care area that was checked with a 1 to address in the care plan was urinary incontinence and indwelling catheter. All the other care areas triggered were marked with a 0, indicating they will not be addressed in the care plan. When interviewed on 7/7/16 at 11:09 a.m., the Registered Nurse (RN) Reimbursement Nurse said she did not know what the 0 under care planning decision represented. She said she did not realize that she needed to change the 0 to a 1 if the area proceeded with care planning. The RN Reimbursement Nurse reported that she does not meet with the care planning team and does not know what their decisions are regarding care planning. In an interview on 7/8/16 at 11:08 a.m., the RN Manager also said she did not know that the care planning decision should be marked on the CAAs with a 1 or a 0 in Section V. She said the CAAs are reviewed to be sure they are captured on the care plan. However, the MDS Coordinator does the CAA notes. She said the team does not alert the RN Reimbursement Nurse when triggered areas on the CAAs are included in the care plan. 2. Resident #62 has [DIAGNOSES REDACTED]. Review of the MDS Assessment, dated 4/26/16, revealed that the resident had severe cognitive impairment, impaired vision indicating the ability to see large print, and does not have corrective lens. In the Care Plan, with the effective date 3/18/14 to the present, the Social Worker documented that the resident is visually impaired, had glasses, but rarely chose to wear them. On a medical visit form, dated 3/16/16, the Nurse Practioner (NP) did not document any vision impairment and/or use of glasses. The Resident Care Summary, dated 6/1/16, does not include a vision impairment and/or glasses. During an interview on 7/6/16 at 11:02 a.m., the CNA stated the resident watches television, but she is not sure how much the resident understands. The CNA stated the resident did not have any trouble seeing. During an observation on 7/6/16 at 11:10 a.m. and 2:00 p.m., the resident was in a common area sitting in a recliner chair watching the television. Interviews conducted on 7/7/16 included the following: a. At 10:26 a.m., the LPN stated the resident did not have any problems with vision. She stated if the resident did have a problem with vision, it should be on the care card. b. At 11:31 a.m., the Reimbursement Specialist, a RN who completed the MDS Assessment, stated she did not test the resident's vision. She stated she interviewed two CNAs on the day shift, who stated they believed the resident's vision to be minimally impaired. The RN stated the CNAs do not have assessment skills, but she felt comfortable with their responses as they know the resident. The MDS Assessment instruction manual, dated (MONTH) (YEAR), provided direction for assessing a resident's vision that included the following: a. Ask direct care staff over all shifts, if possible, about the resident's usual vision patterns during the seven day look-back period (e.g., is the resident able to see newsprint, menus, and greeting cards?). b. Ask the resident about his or her visual abilities. c. Test the accuracy of your findings: 1) Ensure that the resident's customary visual appliance for close vision is in place (e.g., eyeglasses, magnifying glass). Ask the resident to look at regular-size print in a book or newspaper. Then ask the resident to read aloud, starting with larger headlines and ending with the finest, smallest print. If the resident is unable to read a newspaper, provide material with larger print, such as a flyer or large textbook. 2) When the resident is unable to read out loud (e.g., due to [MEDICAL CONDITION], illiteracy), you should test this by another means such as, but not limited to, substituting numbers or pictures for words that are displayed in the appropriate print size (regular-size print in a book or newspaper). (10 NYCRR 415.11(b))

Plan of Correction: ApprovedAugust 25, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate action taken:
1. Resident #32 deceased [DATE], therefore, no immediate action needed. Though the CAA was marked with 0, care plan was created for all triggered areas.
2. Care plan updated to reflect that resident #62 does not in fact wear glasses. Completion date: [DATE]
Education to all staff on Resident #62 of vision impairment. Confirmed that Resident does not wear corrective lenses.
Completion date: [DATE]
Resident #4 deceased on [DATE]. No immediate action taken.
Resident #5 has a care plan in place for all triggered areas.
Completed: [DATE]
Resident #15 has a care plan in place for all triggered areas.
Completed: [DATE]

Identification of other residents that could be affected:
Reimbursement Nurse will ensure all areas triggered in column A will proceed to care plan by changing column B from a 0 to a 1
Responsible Party: Reimbursement Nurse
Completion date: [DATE]

Systemic Plan:
Education to Reimbursement Nurse and care plan team to review process on triggered CAA's
Responsible Party: Director of Nursing
Completion date:[DATE]
Quality Assurance:
Audits of a minimum of 8 residents CAA summary each month to ensure areas triggered are care planned for three months. Finding will be reported a monthly at Quality Assurance.
Responsible Party: Nurse Manager/ICDP team
First Audit will be completed by [DATE]

FF09 483.60(b), (d), (e):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 8, 2016
Corrected date: August 25, 2016

Citation Details

Based on observations and interviews, it was determined that for one of three residential units, the facility did not ensure the safe storage of medications. The issue involved the lack of timely disposal of expired medication. This is evidenced by the following: During a medication administration observation on the 3200 Unit on 7/7/16 at 8:57 a.m., Licensed Practical Nurse (LPN) #1 removed a bottle of Aspirin 81 milligrams (mgs) from the medication cart to prepare for a medication pass. LPN #1 handed the bottle of Aspirin to the surveyor, who then observed the expiration date on this medication as (MONTH) (YEAR). LPN #1 said she did not know who was responsible for checking for expired medications on the medication cart. Further review of medications on the cart revealed a large bottle of Ferrous Sulfate 325 mgs, which was marked opened 6/10/15, with an expiration date of (MONTH) (YEAR). Observations of the third floor medication room revealed one bottle of unopened Aspirin 325 mgs with a (MONTH) (YEAR) expiration date, three unopened bottles of enteric coated Aspirin 325 mgs, with a (MONTH) (YEAR) expiration date, one opened bottle of enteric coated Aspirin 325 mgs marked as opened 9/8/15 and as expired (MONTH) (YEAR), and a large bottle of opened liquid Tylenol with an expiration date of (MONTH) (YEAR). During an interview on 7/7/16 at 1:10 p.m., the Registered Nurse Manager said that as the nurses pass medications and restock their medication cart, they should be checking for any expired medications. In an interview at 3:27 p.m. that day, the Director of Nursing stated every nurse is responsible for checking for expired medication. The facility's policy, Medication Preparation and Administration, dated 7/3/14, includes to check all expiration dates on medications prior to administration. (10 NYCRR 415.18(d))

Plan of Correction: ApprovedAugust 24, 2016

Immediate action taken
1. Nurse removed all expired medications from the medication cart and medication room and was reeducated on policy TX 87 regarding checking for medication expiration dates.
Completed 7/7/2016
Identification of other residents what could be affected:
Director of Nursing and Nurse Manager checked all medications rooms and carts for expired medications.
Completed 7/7/2016
Responsible Party: Director of Nursing
Systemic Plan:
Reeducation provided to all nursing staff on six rights and review of policy TX 87, Administration of Medications.
Completed by 8/25/2016
New policy established requiring evening nurse on each floor to check medication room and medication cart for expired medications on the first of each month and properly discard to pharmacy.
Responsible Party: Director of Nursing and Nurse Manager
Quality Assurance:
Audits of all med rooms and carts will be completed monthly audited monthly. Audits will be reported to Quality Assurance committee for three months.
First audit will be completed by 9/7/2016

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 8, 2016
Corrected date: August 25, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, it was determined that for four (Residents #15, #22, #36, and #62) of five residents reviewed for accidents, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue involved rails utilized for bed mobility that were not secured to beds. This was evidenced by, but not limited to, the following: 1. Resident #15 has [DIAGNOSES REDACTED]. The 5/9/16 Falls Risk Assessment revealed the resident is at moderate risk for falling. The 6/21/16 Minimum Data Set (MDS) Assessment included that the resident has moderately impaired cognition. The current Comprehensive Care Plan (CCP) included that the resident has a history of falls and is at risk for injury. Interventions included two bed assist rails, monitor environment for safety hazards, and monitor that equipment is in proper working order. When observed on 7/6/16 at 1:21 p.m., the resident was in bed. One end of the right side bed assist rail was loose and not secured to the bed, which allowed it to swing away from the bed. At that time, the resident said she uses the bed assist rail to move herself a little in bed to relieve the pressure on her buttocks when she is alone and uses them to turn when the staff are with her. The resident said the rail should not be loose, and she attempted to slam it against the bed to lock it in place several times unsuccessfully. When interviewed on 7/6/16 at 1:29 p.m., Certified Nursing Assistant (CNA) #1 said the resident can use the bed assist rails. She noticed that morning that she was unable to lock the bed assist rails in place on the bed but did not report it to anyone. CNA #1 then made four attempts to snap the bed assist rail into place unsuccessfully. She said she would have to call maintenance to fix it. When interviewed on 7/8/16 at 11:08 a.m., the Registered Nurse (RN) Manager stated that the bed assist rail should be attached to the bed and locked in place when the resident is in the bed. She said Resident #15 can use the rail because her upper body strength is great. She said she was not aware of the problem with this rail but she would expect the CNA to report this to her so she could be sure that follow up occurred. 2. Resident #22 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/9/16, described the resident with moderate cognitive impairment, requiring the extensive assist of two staff for bed mobility, and as receiving hospice care. Documentation on the CCP, currently in place, included that the resident was at risk for falls and uses two bed assist handles/rails. Staff are to monitor the environment for safety hazards and to ensure that equipment is kept in proper working order. When observed on 7/5/16 at 10:48 a.m., the resident was in bed with two rails. Neither were secured to the bed, allowing them to swing out. During an interview on 7/6/16 at 2:15 p.m., the Director of Nursing (DON) stated that the facility has enablers not rails on the beds. She stated the enablers swing out while the bed is being made and are latched in place for the residents that use them. For the residents that do not use the enablers, they may be moved away and not latched. In an interview on 7/7/16 at 10:13 a.m., a CNA stated the rails on all of the beds lock into the sides of the beds. She stated the rails are locked into the beds when a resident is lying in bed. The CNA stated staff are responsible for checking and making sure the rails are secured whether they are in the up or down position. At 2:00 p.m. that day, the Nurse Manager stated they did not have bed rails, they used bed assist handles. In an observation on 7/7/16 at 2:29 p.m., the resident was in bed, turned towards the left side hanging on to the left rail, which was not secured to the bed. The right rail was not secured to the bed. During an observation on 7/8/16 at 9:28 a.m., the resident was in bed and CNA #2 was providing care. The resident was turned towards the left and was hanging on to the rail, which was not secured to the bed. The bed was in the high position. CNA #2 stated at that time that she could not get the rail locked. She stated she had noticed the rail not locking that morning. CNA #2 stated other staff were able to latch the rail but she was not and would call maintenance. CNA #2 reported that she had been having problems with the rail locking in place. 3. Resident #36 has [DIAGNOSES REDACTED]. Review of the MDS Assessment, dated 5/9/16, revealed that the resident is cognitively intact. An Occupational Therapy Discharge summary, dated 5/18/16, documented the resident utilized a bed assist rail for rolling side-to-side, supine to sit, and sit to supine. The most recent Resident Care Summary indicated the resident was independent with transfers and ambulation. During an observation on 7/5/16 at 10:23 a.m., the resident was sitting up in the chair. The bed was made, and both rails were not secured to the bed, allowing them to swing out. During an interview on 7/6/16 at 11:24 a.m., the resident stated she uses the rails at night time. When interviewed on 7/7/16 at 10:13 a.m., CNA #2 stated the rails are used for residents to get in and out of bed, and not all residents are able to use them. During an interview on 7/8/16 at 10:00 a.m., the DON stated that all the beds have assist rails, which are not included in care plans. Also, maintenance does not routinely check the assist bars on the bed for functioning. Review of the facility's policy, Bed Rail Usage, dated 9/13/06, revealed that the interdisciplinary team assesses the potential benefits and risks of using bed rails/bed canes. The bed rail tool will be completed if bed rails are in use. Also, assist rails are installed on beds in the facility unless otherwise ordered by medical. The policy does not require the bed rail tool to be completed for assist rails. (10 NYCRR 415.12)

Plan of Correction: ApprovedAugust 24, 2016

Immediate Action:
Bed enablers for resident #15 was repaired by maintenance on 7/6/2016 and for resident #22 on 7/8/2016.
Bed enablers for resident #36 and #62 were secured on 7/8/2016
Identification of other Residents what could have been affected:
1. Preventative maintenance check will be completed by 8/25/2016 for each bed enabler.
Responsible Party: Facilities Supervisor
2. Nursing staff will ensure enables are secured at all times or call maintenance if the enabler is in need of repair.
Completed 8/1/2016
Responsible Party: DON/Nursing Supervisor
Systemic Plan:
1. Re-education provided to all nursing staff on how to properly secure bed enablers. Education will include ensuring each enabler is secured before staff exit the room while the resident is in or out of the room.
Completion date of 8/25/2016
2. Re-education on how to submit a maintenance request to be provided to all nursing staff.
Completion date of 8/25/2016
Responsible Party: Director of Nursing and Nurse Manager
Quality Assurance:
Random audits will be conducted by environmental rounds team on an ongoing basis. Audit findings will be reported at the monthly Quality Assurance Meeting for three months.
First audit will be completed by 9/7/16

Standard Life Safety Code Citations

K302 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, 18.3.5.1.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 8, 2016
Corrected date: August 25, 2016

Citation Details

Based on observations made during the Life Safety Code Survey, it was determined that for one (third floor) of three resident use floors, the facility did not properly protect hazardous areas. Specifically, a room used to store large amounts of combustible materials lacked a self-closing door and was not fully enclosed in one-hour fire rated construction. The findings are: 1. Observations on 7/5/16 at 10:05 a.m. revealed the corridor door to the third floor activities storage room/office was not self-closing. The room was greater than 50 square feet in size and housed the following combustible materials: cardboard boxes, baskets, dozens of plastic totes, papers, books, supplies, and shelving units of combustible items. 2. Observations above the suspended ceiling on 7/6/16 at 9:30 a.m. revealed one of the enclosure walls inside the third floor activities storage room/office had approximately 12 unsealed openings. The openings were located where the gypsum board contacted the corrugated decking and measured approximately 3 inches x 5 inches. The openings were filled with a white fiberglass material only. There was no labeling on this wall to indicate that it was a firerated partition. (10 NYCRR 415.29(a) (2), 711.2(a) (1); 2000 NFPA 101 LSC: 18.3.2.1, 8.4.1.1, 8.4.1.3)

Plan of Correction: ApprovedJuly 29, 2016

Immediate Action
1. A self closure has been installed on the recreation office door on 7/5/2016.
Responsible Party: Facilities Supervisor
Identification of other areas potentially affected:
Facilities staff will audit areas of potential hazard to ensure proper self closure.
Audits to begin 8/25/2016
Responsible Party: Facilities Supervisor
Systemic Plan:
Education to be provided to all staff on proper door closure in potentially hazardous areas.
Education to be completed by 8/25/2016
Responsible Party: Facilities Supervisor/Administrator
Quality Assurance
Facilities staff will check doors for proper closure monthly for three months and report findings at Quality Assurance.
First audit to be complete by 8/25/2015
Responsible Party: Facilities Supervisor
2. The 12 openings will be sealed and the wall will be upgraded to a one hour fire-rated barrier no later than (MONTH) 25th.
Responsible Party:
Facilities Supervisor
Identification of other areas potentially affected:
Facilities staff will conduct random audits on each floor monthly.
Audits to begin 8/25/2016
Responsible Party:
Facilities Supervisor
Systemic Plan:
Education to be provided to Facilities staff on proper audits and sealing of penetrations.
Completion date: 8/25/2016
Responsible Party:
Facilities Supervisor
Quality Assurance
Facilities staff will audit fire walls for penetrations monthly for three months and report findings at Quality Assurance.
First Audit will begin no later thank 9/7/2016
Responsible Party: Facilities Supervisor

K302 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 8, 2016
Corrected date: August 12, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for two (first and second) of three resident use floors and one of one main kitchen, the facility did not properly maintain electrical installations. Specifically, there were extension cords and a three-receptacle plug extender that lacked overcurrent protection, electrical panels were obstructed, and power strips were being used connected in a series. The findings are: 1. Observations on 7/5/16 from 8:30 a.m. to 12:02 p.m. revealed the following: a. Two electrical circuit breaker panels (labeled PK) located in the main kitchen were obstructed by a stack of crates and a recycling bin that were placed directly in front of the panels. b. There was a three-receptacle plug extender attached to a duplex electrical outlet in use in the lounge behind a large television adjacent to room [ROOM NUMBER] (first floor). c. Two power strips were connected to each other and in use in the office adjacent to the pharmacy (first floor). d. Two power strips were connected to each other and in use in the first floor finance office. 2. Observations on 7/6/16 at 8:17 a.m. revealed two white extension cords connected to each other and to decorative lights located on potted plant arrangements sitting in the hallway just outside the second floor porch. In an interview at that time, a Registered Nurse stated that they thought the lights were added around Christmas time. The 1999 edition of NFPA 70, National Electric Code, states: 1) Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The minimum clear distance of working space shall be 3 feet. 2) Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against over-current. 3) Temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes. 4) Flexible cords and cables and their associated fittings shall be suitable for the conditions of use and location. (10 NYCRR 415.29(a) (2), 711.2(a) (1); 2000 NFPA 101: 18.5.1.1, 9.1.2; 1999 NFPA 70: Article 110-26, Article 240-4, Article 305-3, Article 400-3; CMS S&C 14-46)

Plan of Correction: ApprovedJuly 29, 2016

Immediate Action Taken
a. The stack of crates and recycling bins blocking the electrical panels were removed on 7/5.
Systemic Plan
Staff education provided to the entire Dining Services Team to ensure that the electrical panels are free from obstruction.
To be completed by 8/12/2016
Responsible Party: Food Service Director
Quality Assurance:
The area will be monitored monthly to ensure the electrical panels are free from obstruction.
First audit will be completed by 8/12/2016
Responsible Party: Food Service Director
b. The three-receptacle plug extender was removed from the television on the Heritage household on 7/5
c. The power strips in the first floor nursing office was removed on 7/5.
d. The power strips in the first floor finance office was removed on 7/5.

2. The decorative lights and extension cords around the potted plants was removed on 7/5.
Systemic Plan:
Provide education to all staff regarding the use of proper electric equipment including power strips. Staff will also be reminded that extension cords and plug extenders are not permitted for use.
To be complete by 8/25/2016.
Quality Assurance:
Each area will be monitored as part of the floor audit monthly to ensure proper use of power strips and no use of extension cords or plug extenders. Findings will be reported at Quality Assurance.
First Audit to begin no later than 8/8/2016
Responsible Party: Environment Rounds Team