St Patricks Home
October 25, 2016 Certification Survey

Standard Health Citations

FF09 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: December 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility did not ensure that a Comprehensive Care Plan (CCP) was developed for a resident. Specifically: there was no care plan developed for a resident with impaired vision and a history of [MEDICAL CONDITION]. This was evident for 1 of 20 residents reviewed for assessments and plans of care. (Resident # 289) The findings are: Resident #289 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/16 at 10 AM the resident was observed alert, awake and sitting on a geri-chair in the day room with other residents. On 10/25/15 at 11:25 AM a pair of eyeglasses were observed on the resident's bedside table. The initial Physician assessment dated [DATE] documented [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The Minimum Data Sets (MDS) 3.0 Significant change assessment dated [DATE] documented: impaired cognition, impaired vision with no corrective lenses. The MDS further documented the resident required extensive assistance of two persons for Activities of Daily Living (ADL). The Care Area Assessment (CAA) triggered for Visual Function and to proceed for care planning. There was also no documented evidence that a care plan was developed to address the residents vision. There was also no documented evidence that the consult to evaluate the residents vision was done. On 10/25/16 at 11:20 AM an interview conducted with the Certified Nursing Assistant (CNA) who stated that the resident has a pair of eye glasses brought in by a family member. She further stated that the resident used to wear glasses almost every day in the past, but recently became confused and often removes the glasses. The CNA also stated that the residents husband always tells the staff to make sure the resident wears her glasses, especially when she is watching television. On 10/25/16 at 11:30 AM an interview was conducted with the Charge Nurse who stated the nursing staff are unaware that the resident had vision problems or wears glasses. The charge nurse further stated that all the residents admitted to the facility are usually seen for a vision screening. There are always physician orders [REDACTED]. The nurse stated she was not sure if the resident was seen for vision screening and was unable to locate a vision screen in the medical record. On 10/25/16 at 1:26 PM an interview conducted with MDS coordinator who stated that he initiates the comprehensive care plans immediately after a resident is admitted to the facility and ensures that the other disciplines have completed theirs. He further stated that he missed the vision care plan for this resident. 415.11(c)(1)

Plan of Correction: ApprovedDecember 16, 2016

Based on the record review the delay in the screening did not negatively impact the resident's Quality of Life.
1. Resident #289 had a vision screen performed on 11/14/2016. A follow-up will occur in three months as recommended by her physician.
2. It was determined that a staff member missed the vision consult order and the screening was not performed. The policy for vision screening was not modified but staff have been in-serviced on the need to comprehensively review all orders for new admissions and re-admissions.
For all new admissions and re-admissions the nursing staff will review admission orders [REDACTED].
3. During all care plan reviews, residents identified as having vision deficits will have their care plans reviewed to determine if all interventions have been put in place and follow-up have been provided.
4. An audit tool has been developed that will review all admissions and re-admissions to determine if orders related to vision screenings have been followed.
The audit threshold is set at 100%. Based on the results of the initial audit, the audit will be repeated until the 100% audit threshold is met. The audit will be on-going for all new admissions and re-admissions.
Nurse Managers will monitor care plans for residents with identified vision issues to determine if the interventions are being carried out. The findings and actions will be reported and reviewed at QA monthly and QAA quarterly.
5. Responsible Person: Nursing Supervisor/Designee
Date Completed: 12/21/2016

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: December 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility did not ensure that each residents drug regimen was free from unnecessary drugs. Specifically: 1) the the nursing staff did not provide ongoing monitoring of the residents behavior from 9/2015 through 7/2016; 2) non-pharmacological behavioral interventions were not developed to address the residents periodic verbal behaviors and 3) a gradual dose reduction was not attempted to determine if the residents behavioral symptoms could be managed on a lower dosage. This was evident for 1 of 5 sampled residents reviewed for Unnecessary Medication Use. (Residents #154) The findings are: Resident #154 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/2016 9:14 AM, the resident was observed calmly sitting in her wheelchair in her room watching TV and was neatly groomed. The resident stated, I just finished eating rice krispies with milk and added I feel good today. On 10/24/2016 2:14 PM the resident was observed calmly sitting in her w/c in the day room watching TV. On 10/25/2016 at 2:12 PM the resident was observed sitting quietly in her room in her w/c. The resident is neatly groomed and watching a movie on her TV. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented: moderate hearing difficulty-uses a hearing aide, intact cognition and no behavior, mood, [MEDICAL CONDITION] or delusions. The MDS further documented extensive assistance for ADL (Activities of Daily Living) and Antipsychotic, Antidepressant, and Anticoagulant medications received in the last 7 days. The MDS 3.0 Quarterly assessment dated [DATE] documented: moderate cognitive impairment. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 10/2016 documents: Resident receives [MEDICATION NAME] and [MEDICATION NAME]. [DIAGNOSES REDACTED]. Alert MD for improvement and confer if medication can be reduced or discontinued. Physician's monthly orders dated 9/2015 to 10/2016 document: [MEDICATION NAME] 0.5 mg - 1.5 tablets- 0.75 mg (milligram) 2 times a day. Diagnosis: [REDACTED]. Medication Administration Record [REDACTED] [MEDICATION NAME] 0.5 mg - 1.5 tablets (0.75 mg) 2 times a day. Senile dementia uncomplicated. Pharmacy Drug Regimen Review note to Attending Physician dated 8/30/16 documents: Currently receiving [MEDICATION NAME] 1.5 mg once daily for behaviors associated with dementia. No recent behavior problems noted appears to be at baseline behaviors. Please evaluate current dosing, consider trial taper to 1 mg once a day if appropriate. The Social Service Note dated 9/12/16 documents: Resident is alert and oriented x 3 (times three), does exhibit jealousy at times towards other residents who are able to have more independence. She does receive Psychological services and this behavior has improved tremendously. physician progress notes [REDACTED]. Pharmacy wants to decrease dose because [MEDICAL CONDITION] and agitation under control. Plan: Patient is well behaved. No agitation. Plan: would not decrease med's (medication) as she is stable, however psych can follow up and if they want, can decrease med's. The Psychology Consult dated 9/21/16 documents: Resident's mood was dysphoric, frustrated with foibles of residents she doesn't like. She focused at length on behaviors that anger her. e.g. one resident pacing. Will follow for chronic dysphoria, anxiety, hypersensitivity to slight and periodic angry verbal outbursts. Psychiatric Consult dated 10/9/2016 documents: On interview alert and calm. Somewhat sad. No paranoia. SI/HI (Suicidal Ideation/Homicidal Ideation). No EPS/TD (Extrapyramidal Symptoms/Tardive Dyskinesia). Impression: Dementia, irritability, delusions and depression. Doing okay at present. Recommendations: continue current [MEDICAL CONDITION] medication regimen. Effort to lower dosages now would be premature in light of recurrent behavioral issues in recent past. There was no documented evidence that the nursing staff provided ongoing monitoring of the residents behavior from 9/2015 through 7/2016. There was also no documented evidence that non-pharmacological behavioral interventions were developed to address the residents periodic verbal behaviors. Additionally, there was no documented evidence that a gradual dose reduction was attempted to determine if the residents behavioral symptoms could be managed on a lower dosage. On 10/24/2016 at 10:54 AM the (7-3 PM) Certified Nursing Assistant (CNA) was interviewed and stated that at times the resident is not in a good mood. She has never hit me or any other resident. She eats breakfast in her room and for lunch she goes downstairs to the dining room and eats independently. If there is an activity, she might go. On 10/24/2016 at 9:48 AM the Registered Nurse (RN) Unit Manager was interviewed and stated that the resident exhibited behavioral issues in the past but not during (YEAR). There has been no physical aggression towards staff or other residents. There was an instance when the resident got upset by yelling when the TV channel was changed in the dayroom this year, but that's about it. On 10/25/2016 at 9:04 AM the RN Supervisor was interviewed and stated that we have used a new electronic medical record system since 8/2016 and the nurses have not been documenting behavioral notes in the computer. The behavioral notes template is still in the process of transferring to this new system from the old software. On 10/25/2016 at 9:15 AM the facility Medical Director was interviewed and stated the conditions that the resident is receiving the [MEDICATION NAME] for as written by the Psychiatrist, are dementia with irritability, delusions and depression. The FDA approves the use of [MEDICATION NAME] for psychotic conditions such as [MEDICAL CONDITIONS] disorder [MEDICAL CONDITION] disorders sometimes irritability with autism. This resident does not have any of these clinical indications based on the medical indications of the Psychiatrist. I am familiar with the black box warnings for [MEDICATION NAME] and added that I do not know the exact time frame that a GDR (Gradual Dose Reduction) needs to be done. I do know that you are supposed to try it and you see how the resident responds. If the residents behavior can be managed on a lower dose then we should prescribe the lowest dose possible. When the Sa (State Agency) pointed out that in the computer software there is a black box warning embedded in the physician's orders [REDACTED]. I am not sure if the Attending Physician's or the Psychiatrist are aware of this. On 10/25/2016 10:15 AM the RN supervisor was interviewed and stated that the nurses are responsible for observing the residents behavior and for side effects of antipsychotic medication. If the resident displays a behavioral issue, the nurse is supposed to write a behavior note in the behavior section of the progress notes. I don't see any behavior notes written from (MONTH) (YEAR) until 10/23/16 and added that we do not write behavior notes in the paper chart. 415.12(1)(1)

Plan of Correction: ApprovedDecember 16, 2016

1. Resident #154 the Medical Director has reviewed with both the Psychiatrist and the Psychologist the issues identified and related to the use of antipsychotic medications.
Developed a Behavior Management Sheet that will identity and record behavior.
The Nurse Managers will continue to monitor that direct care staff are completing documentation related to Resident #154 in identifying behavioral issues.
2. All residents on antipsychotic medications were reviewed to determine if the medication was appropriate and behaviors supporting the use of the medication has been documented. Where a resident had been receiving an antipsychotic and had a care plan in place to address behaviors the staff has been re-educated on the importance of documenting behaviors as not only a part of the care plan and assessment process but of the facility's continuing efforts to improve the quality of life and quality of care for all residents.
3. The facility has developed a Behavior Management sheet that will facilitate the identification and recording of behaviors. Staff has been in-serviced on the tool. The facility will continue to monitor their antipsychotic drug use and specific medications to individual residents. All individuals on antipsychotics will continue to be reviewed by the Inter-Disciplinary Team (IDT) and whether current behavioral data supports the use of the medication and whether current interventions are successful.
The Policy and Procedure for Behavior Management was reviewed and revised to include the Behavior Management tool. The staff was in-serviced on the completion of this tool.
Nurse Managers will continue to monitor that direct care staff are providing the interventions and completing documentation related to residents with identified behavioral issues.
4. The facility has developed an audit tool which will be conducted monthly with a focus on four (4) residents identified for Gradual Dose Reduction (GDR) on antipsychotics and whether the behaviors for which the medications is being prescribed are present. The findings of the audits will be reviewed and the results provided to the QA monthly and to the QAA Quarterly.
The audit threshold is set at 100%. Based on the results of the initial audit, the audit will be repeated until the 100% audit threshold is met. The audit will be on-going for all new admissions and re-admissions.
An audit tool was initiated for residents on antipsychotic medications which includes Nurses notes on behaviors and evidence of Behavior Management tool.
Additionally, the Medical Director who is a member of the QAA Team will discuss with the Psychiatrist and Psychologist weekly any issues and trends that are identified as the results of the audits.
The use of antipsychotics will continued to be part of the QAPI activity.
5. Responsible Person: Attending Physician/Nurse Manager
Date Completed: 12/21/2016

FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: December 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that the Attending Physician reviewed the resident's total plan of care. Specifically, the Attending Physician did not implement the consultant Pharmacist's recommendation for a gradual dose reduction to determine if the resident's behavioral symptoms could be managed on a lower dose. This was evident for 1 of 5 sampled residents reviewed for Unnecessary Medication Use. (Resident #154) The findings are: Resident #154 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/2016 9:14 AM, the resident was observed calmly sitting in her wheelchair in her room watching TV and was neatly groomed. The resident stated, I just finished eating rice krispies with milk and added I feel good today. On 10/24/2016 2:14 PM the resident was observed calmly sitting in her w/c in the day room watching TV. On 10/25/2016 at 2:12 PM the resident was observed sitting quietly in her room in her w/c. The resident is neatly groomed and watching a movie on her TV. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented: moderate hearing difficulty-uses a hearing aide, intact cognition and no behavior, mood, [MEDICAL CONDITION] or delusions. The MDS further documented extensive assistance for ADL (Activities of Daily Living) and Antipsychotic, Antidepressant, and Anticoagulant medications received in the last 7 days. Pharmacy Drug Regimen Review note to the Attending Physician dated 8/30/16 documents: Currently receiving [MEDICATION NAME] 1.5 mg once daily for behaviors associated with dementia. No recent behavior problems noted appears to be at baseline behaviors. Please evaluate current dosing, consider trial taper to 1 mg once a day if appropriate. The MDS 3.0 Quarterly assessment dated [DATE] documented: moderate cognitive impairment. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 10/2016 documents: Resident receives [MEDICATION NAME] and [MEDICATION NAME]. [DIAGNOSES REDACTED]. Alert MD for improvement and confer if medication can be reduced or discontinued. Physician's monthly orders dated 9/2015 to 10/2016 document: [MEDICATION NAME] 0.5 mg - 1.5 tablets- 0.75 mg (milligram) 2 times a day. Diagnosis: [REDACTED]. physician progress notes [REDACTED]. Pharmacy wants to decrease dose because [MEDICAL CONDITION] and agitation under control. Plan: Patient is well behaved. No agitation. Plan: would not decrease med's (medication) as she is stable, however psych can follow up and if they want, can decrease med's. Psychiatric Consult dated 10/9/2016 documents: On interview alert and calm. Somewhat sad. No paranoia. SI/HI (Suicidal Ideation/Homicidal Ideation). No EPS/TD (Extrapyramidal Symptoms/Tardive Dyskinesia). Impression: Dementia, irritability, delusions and depression. Doing okay at present. Recommendations: continue current [MEDICAL CONDITION] medication regimen. Effort to lower dosages now would be premature in light of recurrent behavioral issues in recent past. There was no documented evidence that a gradual dose reduction was attempted to determine if the residents behavioral symptoms could be managed on a lower dosage. On 10/25/2016 at 9:15 AM the facility Medical Director was interviewed and stated the conditions that the resident is receiving the [MEDICATION NAME] for as written by the Psychiatrist, are dementia with irritability, delusions and depression. The FDA approves the use of [MEDICATION NAME] for psychotic conditions such as [MEDICAL CONDITIONS] disorder [MEDICAL CONDITION] disorders sometimes irritability with autism. This resident does not have any of these clinical indications based on the medical indications of the Psychiatrist. I am familiar with the black box warnings for [MEDICATION NAME] and added that I do not know the exact time frame that a GDR (Gradual Dose Reduction) needs to be done. I do know that you are supposed to try it and you see how the resident responds. If the residents behavior can be managed on a lower dose then we should prescribe the lowest dose possible. When the Sa (State Agency) pointed out that in the computer software there is a black box warning embedded in the Physician's order fro [MEDICATION NAME], the Director stated, I know the icon is there. I am not sure if the Attending Physician's or the Psychiatrist are aware of this. 415.15(b)(2)(iii)

Plan of Correction: ApprovedDecember 16, 2016

1. The Attending Physician has reviewed the MEDICATION ORDERS FOR [REDACTED].
The Behavior Management Sheet has been put into place and will be reviewed as needed.
2. All residents on antipsychotic medications were reviewed to determine if the medication was appropriate and behaviors supporting the use of the medication has been documented. Where a resident had been receiving an antipsychotic and had a care plan in place to address behaviors the staff has been re-educated on the importance of documenting behaviors as not only a part of the care plan and assessment process but of the facility's continuing efforts to improve the quality of life and quality of care for all residents.
3. The facility has developed a Behavior Management sheet that will facilitate the identification and recording of behaviors. Staff has been in-serviced on the tool. The facility will continue to monitor their antipsychotic drug use and specific medications to individual residents. All individuals on antipsychotics will continue to be reviewed by the Inter-Disciplinary Team (IDT) and whether current behavioral data supports the use of the medications and whether current interventions are successful.
The Policy and Procedure for Behavior Management was reviewed and revised to include the Behavior Management tool. The staff was in-serviced on the completion of this tool.
The Attending Physicians will continue to review the Pharmacist Consultant recommendations.
The Medical Director has reviewed and in-serviced the Attending Physicians, the Psychiatrists and the Psychologists on the issues identified and related to the use of antipsychotic medications. Nurse Managers will continue to monitor that direct care staff are providing the interventions and completing documentation related to residents with identified behavioral issues.
4. The facility has developed an audit tool which will be conducted monthly with a focus on four (4) residents identified for Gradual Dose Reduction (GDR) on antipsychotics and whether the behaviors for which the medication is being prescribed are present. The findings of the audits will reviewed and the results provided to the QA monthly and the QAA quarterly.
The audit threshold is set at 100%. Based on the results of the initial audit, the audit will be repeated until the 100% audit threshold is met. The audit will be on-going for all new admissions and re-admissions.
The audit tool was initiated for residents on antipsychotic medications which includes Nurses notes on behaviors and evidence of Behavior Management tool.
Additionally, the Medical Director who is a member of the QAA Team will discuss with the Psychiatrist and Psychologist weekly any issues and trends that are identified as the result of the audits.
The use of antipsychotics will continue to be part of the QAPI activity.
5. Responsible Person: Attending Physician/Nurse Manager
Date Completed: 12/21/2016

FF09 483.20(k)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: December 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility did not ensure that services were provided in accordance with the resident's written plan of care. Specifically, a Physician ordered vision consult was not done for a resident admitted to the facility with [DIAGNOSES REDACTED]. This was evident for one resident reviewed for Vision Care and Services. (Resident # 289) The findings are: Resident #289 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/16 at 10 AM the resident was observed alert, awake and sitting on a geri-chair in the day room with other residents. On 10/25/15 at 11:25 AM a pair of eyeglasses were observed on the resident's bedside table. The initial Physician assessment dated [DATE] documented [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The Minimum Data Sets (MDS) 3.0 Significant change assessment dated [DATE] documented: impaired cognition, impaired vision with no corrective lenses. The MDS further documented the resident required extensive assistance of two persons for Activities of Daily Living (ADL). The Care Area Assessment (CAA) triggered for Visual Function and to proceed for care planning. There was also no documented evidence that the consult ordered by the Physician to evaluate the residents vision was done. On 10/25/16 at 11:20 AM an interview conducted with the Certified Nursing Assistant (CNA) who stated that the resident has a pair of eye glasses brought in by a family member. She further stated that the resident used to wear glasses almost every day in the past, but recently became confused and often removes the glasses. The CNA also stated that the residents husband always tells the staff to make sure the resident wears her glasses, especially when she is watching television. On 10/25/16 at 11:30 AM an interview was conducted with the Charge Nurse who stated the nursing staff are unaware that the resident had vision problems or wears glasses. The charge nurse further stated that all the residents admitted to the facility are usually seen for a vision screening. There are always physician orders [REDACTED]. The nurse stated she was not sure if the resident was seen for vision screening and was unable to locate a vision screen in the medical record. On 10/25/16, at 11:35 AM an interview was conducted with the Medical Director who stated that all residents have vision screenings at the time of admission. He further stated that a resident with a history of [MEDICAL CONDITION], if untreated can lead to [MEDICAL CONDITION], and was unable to explain the reason why the resident was not provided with a vision screening. 415.11(c) (3)(ii)

Plan of Correction: ApprovedDecember 16, 2016

Based on the record review the delay in the screening did not negatively impact the resident's Quality of Life.
1. Resident #289 a care plan was developed to address vision and an appointment for a vision screen was scheduled.
2. All residents records were reviewed to determine if any other vision screenings had been missed. No other residents were identified as having a missed vision screenings. The policy for vision screenings were not modified but staff has been in-serviced on the need to comprehensively review all orders for new admissions.
3. For all new admissions and re-admissions the nursing staff will review admission orders [REDACTED].
During all care plan reviews, residents identified as having vision deficits will have their care plans reviewed to determined if all interventions have been put into place and follow-ups have been provided.
4. An audit tool has been developed that will review all admissions and re-admissions to determine if orders related to vision screenings have been identified and followed.
The audit threshold is set at 100%. Based on the results of the initial audit, the audit will be repeated until the 100% audit threshold is met. The audit will be on-going for all new admissions and re-admissions.
Nurse Mangers will monitor care plans for residents with identified vision issues to determine if the interventions are being carried out. The findings of all audits will be analyzed with the results provided to QA monthly and QAA quarterly.
5. Responsible Person: Nurse Manager/Nursing Supervisor
Date Completed: 12/21/2016

FF09 483.25(b):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: December 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility did not ensure that the resident received the proper treatment to maintain vision abilities. Specifically, a Physician ordered vision consult was not done for a resident admitted to the facility with [DIAGNOSES REDACTED]. This was evident for one resident reviewed for Vision Care and Services. (Resident # 289) The findings are: Resident #289 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/16 at 10 AM the resident was observed alert, awake and sitting on a geri-chair in the day room with other residents. On 10/25/15 at 11:25 AM a pair of eyeglasses were observed on the resident's bedside table. The initial Physician assessment dated [DATE] documented [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The Minimum Data Sets (MDS) 3.0 Significant change assessment dated [DATE] documented: impaired cognition, impaired vision with no corrective lenses. The MDS further documented the resident required extensive assistance of two persons for Activities of Daily Living (ADL). The Care Area Assessment (CAA) triggered for Visual Function and to proceed for care planning. There was also no documented evidence that the consult ordered by the Physician to evaluate the residents vision was done. On 10/25/16 at 11:20 AM an interview conducted with the Certified Nursing Assistant (CNA) who stated that the resident has a pair of eye glasses brought in by a family member. She further stated that the resident used to wear glasses almost every day in the past, but recently became confused and often removes the glasses. The CNA also stated that the residents husband always tells the staff to make sure the resident wears her glasses, especially when she is watching television. On 10/25/16 at 11:30 AM an interview was conducted with the Charge Nurse who stated the nursing staff are unaware that the resident had vision problems or wears glasses. The charge nurse further stated that all the residents admitted to the facility are usually seen for a vision screening. There are always physician orders [REDACTED]. The nurse stated she was not sure if the resident was seen for vision screening and was unable to locate a vision screen in the medical record. On 10/25/16, at 11:35 AM an interview was conducted with the Medical Director who stated that all residents have vision screenings at the time of admission. He further stated that a resident with a history of [MEDICAL CONDITION], if untreated can lead to [MEDICAL CONDITION], and was unable to explain the reason why the resident was not provided with a vision screening. 415.12(3)(b)

Plan of Correction: ApprovedDecember 16, 2016

Based on the record review the delay in the screening did not negatively impact the resident's Quality of Life.
1. Resident #289 was seen by Vision Care and a vision screen was completed in-house on 11/14/2016.
2. All residents records were reviewed to determine if any other vision screenings had been missed. No other residents were identified as having vision screenings. The policy for vision screenings was not modified but staff has been in-serviced on the need to comprehensively review all orders for new admissions.
3. For all new admissions and re-admissions the nursing staff will review admission orders [REDACTED].
During all care plan reviews, residents identified as having vision deficits will have their care plans reviewed to determined if all interventions have been put into place and follow-ups have been provided.
4. An audit tool has been developed that will review all admissions and re-admissions to determine if orders related to vision screenings have been identified and followed.
The audit threshold is set at 100%. Based on the results of the initial audit, the audit will be repeated until the 100% audit threshold is met. The audit will be on-going for all new admissions and re-admissions.
Nurse Mangers will monitor care plans for residents with identified vision issues to determine if the interventions are being carried out. The findings of all audits will be analyzed with the results provided to QA monthly and QAA quarterly.
5. Responsible Person: Nurse Manager/Nursing Supervisor
Date Completed: 12/21/2016

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: November 30, 2016

Citation Details

Where required by section 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. Based on observation and interview, it was determined that the facility did not ensure that all areas in the facility were protected by an approved automatic sprinkler system in accordance with NFPA 101. Reference is made to the area beneath the 5 1/2 ft. wide low ceiling in the security office and the closet within the 2nd Fl staff development room, that were not provided with sprinkler coverage. The findings are: On 10/20/16 and 10/21/16 during the life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that the area beneath a low ceiling of approximately 5 1/2 ft. wide located in the facility's security office was not sprinkler protected. In addition, the 2nd FL staff development room had a storage closet that also lacked sprinkler protection. In an interview on 10/21/16 at approximately 11:45 am, the Director of Engineering of the facility stated that the identified areas will be provided with sprinkler coverage. 2000NFPA 101- 19.1.6 9.7 1999 NFPA 13 711.2(a) (1)

Plan of Correction: ApprovedNovember 16, 2016

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Law.
Areas noted without proper sprinkler coverage. No residents were affected by this deficient practice.
Security Office located on the 1st Floor one additional sprinkler head has been installed under the lower ceiling.
Completed: 11/11/2016
Staff Development Office located on the 2nd Floor one sprinkler head has been installed in the closet.
Completed: 11/11/2016
Engineering personnel will conduct routine audits regarding various aspects of the automatic sprinkler system to ensure compliance with the Life Safety Code requirements.
Completed:11/21/2016
Responsible Person: Director of Engineering/Designee
Routine audits will be reported to the Monthly QA/Quarterly QAA Meetings and be reviewed for any follow-up action needed to ensure regulatory compliance. Frequency of ongoing audits will be adjusted, as appropriate.
Completed:11/17/2016
Responsible Person: Director of Engineering/Designee

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: November 30, 2016

Citation Details

NFPA 101 2000 LIFE SAFETY CODE STANDARD 7.1.10 Means of Egress Reliability. 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation and interview, it was determined that the facility did not ensure that all means of egress were continuously maintained free of all obstructions as evidenced by the facility's emergency exit from the ground floor to the parking lot that had combustible items such as cardboard boxes with mattresses and soiled linen carts stored in the corridor/exit access. The findings are: On 10/20/16 and 10/21/16 during the life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that 5 cardboard boxes with mattresses and 3 carts with soiled linen were stored in the corridor / exit access to the emergency exit to parking lot area. In an interview on 10/20/16 at approximately 1:15 pm, the Director of Engineering stated that the observed items will be removed immediately. 2000 NFPA 101- 7.1.10 711.2(a) (1)

Plan of Correction: ApprovedNovember 16, 2016

Preparation and execution of this Plan of Correction does not constitute admission of agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Law.
No Residents were impacted by this deficient practice.
Emergency Exit from the Ground Floor to the Parking Lot all items have been removed from the egress area.
Completed: 10/26/2016
The facility will ensure and maintain the means of egress to be continuously free of all obstructions.
Personnel have been re-educated regarding code/requirement for emergency egress.
Completed:11/30/2016
Responsible Person: Director of Housekeeping/Laundry/Designee

Emergency exits will be monitored during Environmental/Safety Rounds.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings. Frequency of ongoing audits will be adjusted as appropriate at that time.
Completed: 11/17/2016
Responsible Person: Director of Engineering/Designee

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: November 30, 2016

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that doors protecting hazardous areas were made self-closing and maintained to self-close as evidenced by doors to the food storage room and recreation room that did not self-close when tested . The findings are: On 10/20/16 and 10/21/16 during the life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that doors to hazardous areas in the facility were not self-closing when tested . Examples include but are not limited to: 1. The ground floor food storage room: the door to the corridor was self closing and equipped with a magnetic hold open device, however the door dragged on the floor when tested and didn't self close. 2. The recreation room on the 1st floor: the room had numerous items of combustible storage such as cardboard boxes and plastic totes with decoration and recreation items and an operational stove. Also, two corridor doors were used as exits and only one door was equipped with self closing devices that didn't self-close the door when tested . In an interview on 10/21/16 at approximately 1:45 pm with the Director of Engineering of the facility, he stated that the doors to hazardous areas will be fixed or equipped with self closing devices. 2000 NFPA 101 19.3.2.1 711.2(a) (1)

Plan of Correction: ApprovedNovember 16, 2016

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
Both areas noted are doors leading to a corridor. No residents were affected by this deficient practice.
1. Food Storage Room located on the Ground Floor door has been repaired and closes properly with the self-closing device.
Completed: 10/26/2016
2. Recreation Room located on the 1st Floor installed new self-closing devices on each door. Both doors close properly.
Completed: 11/2/2016

The facility has implemented a bi-annual door maintenance program for corridor doors and doors to hazardous areas. The inspection components will include positive latching devices and self-closing devices where applicable.
Completed: 10/26/2016
Responsible Person: Director of Engineering/Designee
Engineering personnel have been re-educated regarding code/requirement for doors leading to the corridor to positively latch/close.
Completed: 11/21/2016
Responsible Person: Director of Engineering/Designee
Doors leading to the corridors will be monitored during Environmental/Safety Rounds.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings. Frequency of ongoing audits will be adjusted as appropriate at that time.
Completed:11/17/2016
Responsible Person: Director of Engineering/Designee

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Clearance between bottom of door and floor covering is not exceeding 1 inch. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.2.3.2.1. Roller latches are prohibited by CMS regulations in all health care facilities. 19.3.6.3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2016
Corrected date: November 30, 2016

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that doors protecting the corridor positively latched in their frames in accordance with NFPA 101. Reference is made to doors to facility's chapel and male and female locker rooms that didn't positively latch when tested . The findings are: On 10/20/16 and 10/21/16 during the annual life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that the doors to the male and female locker rooms located on the facility's ground floor didn't positively latch in their frames when tested . In an observation on 10/21/16 at approximately 11:15 am, it was noted that the facility's chapel was provided with one set of double doors and two single-leaf doors that opened to the corridor. The doors were held open with approved magnets however they lacked latching hardware. In an interview on 10/21/16, the facility's Director of Engineering stated that the door to the locker rooms will be fixed immediately. In addition, the Director of Engineering stated that the doors to the chapel were installed when the facility was opened and that he had the impression that they were in compliance with the code. 2000 NFPA 101 19.3.6.3 NYCRR 711.2(a) (1)

Plan of Correction: ApprovedNovember 23, 2016

Preparation and execution of this Plan of Correction does not constitute admission or agreement by the Provider. The Plan of Correction is prepared and executed solely because it is required by the provisions of Federal and State Laws.
Both areas noted are doors leading to a corridor. No residents were affected by this deficient practice.
Both the Female and Male Locker Room located on the Ground Floor entrance doors have been repaired. The passage lock set does positively latch in the frame.
Completed: 10/26/2016
The Chapel located on the 1st Floor self-closing devices were adjusted and magnetic door holders were installed on all four doors leading to the corridor to maintain the doors in the closed position in accordance with NFPA [PHONE NUMBER] Section 19.3.6.3.2.
Completed:11/23/2016
The facility has implemented a bi-annual door maintenance program for corridor doors and doors to hazardous areas. The inspection components will include positive latching devices and self-closing devices where applicable.
Completed: 10/26/2016
Responsible Person: Director of Engineering/Designee
Engineering personnel have been re-educated regarding code/requirements for doors leading to the corridor to positively latch/close.
Completed:11/21/2016
Responsible Person: Director of Engineering/Designee
Doors leading to the corridors will be monitored during Environmental/Safety Rounds.
Findings will be reviewed at the Monthly QA/Quarterly QAA Meetings. Frequency of ongoing audits will be adjusted as appropriate at that time.
Completed:11/17/2016
Responsible Person: Director of Engineering/Designee