Elm Manor Nursing and Rehabilitation Center
November 18, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(a)(3):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 18, 2016
Corrected date: December 23, 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 two of four residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain personal hygiene. Issues involved a lack of timely showering and a lack of thorough oral care and nail care (Resident #5), and a lack of thorough oral care which included placement of a lower denture plate (Resident #55). This is evidenced by the following: 1. Resident #5 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 9/12/16, revealed the resident's cognition is moderately impaired, requires the physical assistance of one staff person for personal hygiene needs, and rejection of care (one to three days). A Comprehensive Care Plan (CP), dated 9/27/16, for self-care deficit directs to assist with ADLs per the Nursing Aide Assignment Sheet. Review of a Certified Nursing Assistant (CNA) Resident--Specific Assignment Sheet, dated 11/14/16, directs to give a shower on Sunday and Thursday and for staff to assist with grooming needs (nails, facial hair, and oral care). A review of Nursing Progress Notes (PN), dated 8/12/16 to 11/15/16, revealed the resident refused a shower on 9/11/16. During an interview on 11/14/16, starting at 11:03 a.m., the resident said she gets one shower a week and would like at least one more. She also said she does not always get the help she needs for dressing, toileting or oral care. She was observed to have a build-up of creamy white debris caked around the bottom of her lower teeth. During observations on 11/15/16 at 2:42 p.m. and 11/16/16 at 10:20 a.m., the resident was observed with creamy-colored debris caked around the bottom of her lower teeth. All of the resident's fingernails had chipped or missing nail polish and were discolored below the nails with orange/brown flecks. When asked if she had help brushing her teeth, she said, I have to brush my own teeth. Interviews conducted on 11/16/16 included the following: a. At 10:32 a.m., Licensed Practical Nurse (LPN) #1 said CNAs are to document any resident showers given in the notebooks which are kept at the nurses' station. At that time, a review of a CNA-ADL Tracking Form, dated (MONTH) (YEAR), revealed staff have not documented giving any showers or nail care, and oral care is documented as being done for 4 of 16 opportunities in the morning and 14 of 16 opportunities in the evening. Additionally, the Nurse/Nursing Assistant Accountability Sheet, dated (MONTH) (YEAR), did not include any documentation that a shower had been given. b. At 10:58 a.m., CNA #1/Days/Primary said she documents giving a shower on the Nursing Assistant Accountability Sheet and CNA-ADL Tracking Form. CNA #1 said the resident is to get two showers a week, on Sundays and Thursdays. CNA #1 said the resident refused a shower this last Sunday and she reported it to the nurse. CNA #1 then reviewed the logs and said she had not documented that refusal. CNA #1 said the resident needs to be encouraged to do morning cares, including brushing her teeth. She said the activities staff perform nail care. CNA #1 said the resident likes her nails a little longer and likes to have staff use an orange stick to clean below her nails. c. At 12:39 p.m., LPN #1 observed the oral cavity and said she could see the build-up of debris. At that time, the resident said she would like some dental floss to clean her teeth. d. At 12:56 p.m., the Director of Nursing (DON) said staff are to document after giving a shower. She said this resident requires one person assist with personal hygiene and that means if she can't do it--staff should. The DON said if a resident refuses cares, staff are to tell a nurse and then re-approach later. e. At 1:15 p.m., the DON said she had reviewed shower audits and said, The last day the resident had a shower, that I can actually verify, was 10/26/16. f. At 2:33 p.m., the resident had been given dental floss and was trying to use it. She said, I didn't realize it was so bad! During an observation and interview on 11/17/16 at 10:08 a.m., CNA #1 looked at the resident's fingernails and said that the nails had chipped and missing polish and needed to be manicured. The resident said she would like to have that done. CNA #1 also looked at the nails and said Oh, I see that stuff under her nails. They need to be soaked and cleaned. She has a shower today and I will use an orange stick. There was visible build-up of an orange colored debris, with some darker spots and brown specks under five of ten nails. 2. Resident #55 has [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 6/2/16, revealed the gums, tongue and mucosa are intact. The entire section for Dentition was blank. A Dental Evaluation, dated 7/7/16, documented that the resident uses a partial lower denture which does not fit well, but should be able to use. A Dental Evaluation, dated 8/18/16, revealed better oral care is needed, slight bleeding while brushing, oral tissue is red and irritated, brush twice daily. A MDS Assessment, dated 9/1/16, revealed the resident has moderately impaired cognitive skills and requires extensive assist of one person for personal hygiene needs. A CNA Resident-Specific Assignment sheet, dated 9/14/16, directs the resident requires the assistance of one staff member for grooming needs. A CP for Self-Care Deficit for ADLs, dated 9/19/16, directs to provide care per Nursing Assistant Accountability Sheet. In an observation on 11/15/16 at 9:25 a.m., the resident had no lower partial in place. In an interview on 11/15/16 at 2:33 p.m., Evening CNA #2 said staff brush the resident's teeth. She said the resident has her own teeth but they are not in the greatest condition, but actually rotting. CNA #2 said she brushes the resident's teeth using a toothbrush and mouthwash. In an observation on 11/17/16 at 11:01 a.m., the resident was in bed and had no lower partial in place. In an interview on 11/17/16 at 11:17 a.m., CNA #1/Days said the resident could answer some questions with a thumbs up or thumbs down gesture. CNA #1 said the resident has a lower partial denture and she thought it was kept in the bedside stand. When asked if she had a lower partial and would like to wear it, the resident used a thumbs up gesture. At that time, CNA #1 said, I get her up in the morning but she cannot always brush her teeth on her own. I mix some toothpaste and mouthwash together and clean her mouth. CNA #1 said, Honestly, I have never used the partial or put it in her mouth. At 1:33 p.m., LPN #2 was assisting the resident with her lunch. LPN #2 said she did not know if the resident was wearing her partial or not but would guess not because her straw is pushed right between her lower teeth. On 11/18/16 at 9:00 a.m., the resident was again, observed without her lower partial in place. Review of a facility policy, AM Care, dated 3/17/10, directs that every resident shall receive AM care on a daily basis. Minimum Standards for AM care shall include bathing face, hands, axillae and perineal/peri-anal care; mouth care, including care of dentures, dressing in own clothes, grooming (brushing and combing hair, shaving). Nail care is given with complete baths and as needed in between. Review of a facility policy, Care of Fingernails/Toenails, dated (MONTH) 2007, directs that nail care includes daily cleaning and regular trimming. (10 NYCRR 415.12(a)(3))

Plan of Correction: ApprovedDecember 7, 2016

F 312
Preparation and/or execution of the ?Plan of Correction? does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?Statement of Deficiencies.? The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and
Federal Laws.
? Resident #5 shower schedule, oral care assistance and nail care assistance reviewed by DON with resident. Oral care, nail care provided. Resident # 55 use of lower partial plate reviewed by DON with the resident and adjusted plan of care.
Completion date: 11/21/16
? DON reviewed Nursing Assistance Assignment sheet for assistance for oral care and nail care for all residents with Revisions made if indicated. DON reviewed shower schedule preferences for all residents, and plans of care adjusted accordingly.
Completion date: 12/08/16
? All Staff to be in serviced on providing showers, oral care and nail care as outlined on the Nursing Assistance Assignment sheet and plan of care
Completion date: 12/23/16
? A Quality Assurance Audit was developed by the DON to ensure oral care, nail care and showers are being completed. Audits will be completed by DON/Designee monthly for 3 months and regularly thereafter with the results presented to the Quality Assurance committee for action, if needed.
Completion date: 12/23/16
Overall responsibility for F312 Director of Nursing

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: November 18, 2016
Corrected date: December 23, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, it was determined that for 1 (Resident #55) of 19 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure the MDS Assessment accurately reflected the resident's dental status. The issue involved incorrect coding for dental issues. This is evidenced by the following: Resident #55 has [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 6/2/16, revealed the resident's gums, tongue and mucosa are intact. The entire section for dentition was blank. An initial MDS Assessment, dated 6/9/16, documented the resident had no dental issues. During an observation on 11/15/16 at 9:25 a.m., the resident had no lower partial in place. During an interview on 11/17/16 at 11:52 a.m., a Registered Nurse (RN)/MDS said she did not look into the resident's mouth to complete the dental section of the MDS Assessment. She said she would have reviewed the Nursing Admission Assessment. The RN/MDS then reviewed the Nursing Admission Assessment and said gums, tongue, and mucosa are checked intact and the entire dentition section is blank. At that time, a Licensed Practical Nurse (LPN) joined the conversation and said she had completed the Nursing Admission Assessment. The LPN said she did not honestly remember if she had looked into the resident's mouth to complete the assessment. In an interview on 11/18/16 at 10:49 a.m., the RN/MDS said she is in charge of completing the MDS Assessment so she should be following the MDS manual instructions. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.13, (MONTH) (YEAR), chapter 3 Section L v1.13, pages L-1 through L-3, directs: For completion of Section L0200, ask the resident about the presence of chewing problems or mouth or facial pain/discomfort and conduct an exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces. Check L0200D, obvious or likely cavity or broken natural teeth if any cavity or broken tooth is seen. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedDecember 7, 2016

F 278
Preparation and/or execution of the ?Plan of Correction? does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?Statement of Deficiencies.? The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and
Federal Laws.
? Resident # 55 oral assessment was completed by JoAnne VanBuren RN for any dental issues and documented, and plan of care updated. MDS correction completed.
Completion date: 12/05/16
? MDS coordinator reviewed all other Residents MDS coding for dental, to ensure RN assessment completed, and accurately reflects the residents dental status, and documented.
Completion date: 12/23/16
? Administrator and MDS coordinator reviewed policies and procedures without revisions. Nursing staff in serviced by MDS Coordinator/Designee, on completing and documenting oral examine on admission.
Completion date: 12/23/16
? A Quality Assurance Audit was developed by Administrator on completing and documenting oral examine on admission, and accurate MDS coding. Audits will be completed by MDS coordinator monthly for 3 months and regularly thereafter with the results presented to the Quality Assurance committee for action, if needed.
Completion date: 12/23/16
Overall responsibility for F278 MDS Coordinator.

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: November 18, 2016
Corrected date: December 23, 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 two of five residents reviewed for Unnecessary Medications, the facility did not ensure that each resident's drug regime was free of unnecessary medications. Issues involved the use of antipsychotic medications without documentation of a clinical reason or demonstration of a clinically pertinent rationale for using medications, a lack of considering a possible underlying medical cause or environmental or psychosocial stressor, and a lack of monitoring for continued use of an antipsychotic (Resident #30), and an antipsychotic medication initiated without adequate indication for use and without use of behavioral interventions (Resident #47). This is evidenced by the following: 1. Resident #47 has [DIAGNOSES REDACTED]. Physician orders, dated 5/20/16, include to discontinue [MEDICATION NAME] (antipsychotic). Physician orders, dated 11/1/16, are to initiate [MEDICATION NAME] daily, and on 11/4/16 increase [MEDICATION NAME] to twice daily with psych evaluation for behavioral issues. Review of progress notes, dated 5/20/16 to 10/31/16 and 11/2/16 to 11/18/16, do not include any documented episodes of inappropriate behaviors, sexually or otherwise. A physician note, dated 6/17/16, revealed the resident tolerated the Gradual Dose Reduction (GDR). A MDS Assessment, dated 10/4/16, revealed no cognitive impairments, no signs/symptoms of depression, no hallucinations, delusions, behavioral symptoms, wandering or rejection of care. An antipsychotic medication was not in use at that time. A CP, dated 10/20/16, revealed the resident had problem behavior, socially inappropriate behaviors, verbally abusive towards others, and resistance to cares. Approaches included to use simple explanations, maintain routines, reality orientation as needed, praise appropriate needs, redirect as needed, psych team evaluation/follow up and see behavior plan. A Behavior Plan, revised 11/2/16, directs that sexually inappropriate behaviors are to be redirected. A CNA Resident-Specific Assignment sheet, dated 11/8/16, for behavior management program is blank. A Nurse Practitioner note, dated 11/9/16, documented [MEDICATION NAME] was discontinued several months ago, although recently restarted due to impulsive behaviors, inappropriately touching other men, and preoccupied with male attention/touch, described as clingy. This has been persistent and resident is not responding to staff redirection. Resident offers no complaints. Recommendations are to offer her comfort, appropriate means of physical touch, and opportunities for support/social contact. During observations on 11/14/16 at 10:19 a.m., on 11/15/16 at 2:41 p.m., and on 11/16/16 at 8:56 a.m., 10:11 a.m., and 2:15 p.m., the resident was in her room, asleep in the recliner. Interviews conducted on 11/18/16 included the following: a. At 9:42 a.m., CNA #3/Days said she has never noticed any behaviors from this resident. CNA #3 said when the resident ate in the front dining room, she had behaviors towards another male resident. CNA #3 said the resident would flirt with him. She said, I don't see that as being a bad behavior but he is married so I guess that is what made it bad. They are now eating in separate dining rooms and she is not flirting with anyone. b. At 10:28 a.m., LPN #4 said she was watching the front dining room the day of the incident (11/1/16) and actually wrote the progress note regarding a sexual interaction with another resident. LPN #4 said, I witnessed it. It was before breakfast in the front dining room. Resident #47 was in her wheelchair, sitting at a table. The male resident was standing over her and she said, Hi sweetie, hi sweetie, come here for a minute. He thinks every woman is his wife, although he thinks Resident #47 is a man. He reached out to shake her hand and she pulled his arm down and planted a kiss on him. He leaned forward and stumbled but did not fall or get hurt. LPN #4 said this was the first time she had witnessed such an event and that there were not any other documented incidents she knew of. LPN #4 said she took Resident #47 out of the dining room, in her wheelchair, and put her in front of the nurses' station. She told her to wheel herself back to the front dining room. LPN #4 said by the time the resident wheeled herself back, she was very pleasant and there were no further issues. c. At 11:17 a.m., the DON said the resident was admitted back in 2014, on [MEDICATION NAME], for dementia with behaviors. She said the behaviors were being impulsive, refusing toileting and incontinence cares, and putting herself on the floor one day because she did not want to walk. When asked what behaviors should have been monitored after [MEDICATION NAME] was discontinued (MONTH) (YEAR), the DON said, refusal of cares, aggression toward anybody. She then added that there is no formal program in place to track behaviors after a GDR and that there were no other documented episodes of sexually inappropriate behaviors. The DON added that the process for reviewing a GDR and following behaviors needs to be tightened up. d. At 12:03 p.m., a physician said he expected that nursing staff document behaviors, whatever those behaviors are, and if behaviors are escalating, they should be documented. He said staff should also document normal behaviors, off medications. He said, In this case, there must have been more than one episode of sexually inappropriate behavior because I do not usually add a medication after just one episode. He said nursing staff, in particular the RN/NM, review behaviors with him and he writes an order on the basis of their assessment. The physician said, It has to be a significant issue or repetitive behaviors for me to reinitiate an antipsychotic. Review of a facility policy, Antipsychotic Medication Use, dated (MONTH) 2011, revealed antipsychotic medication therapy shall be used only when necessary to treat a specific condition. Staff will observe, document, and report to the Licensed Practitioner information regarding the effectiveness of any interventions. Antipsychotics will not be used for wandering and or restlessness. The Interdisciplinary Care Team will identify, document, and discuss non-pharmacological interventions and develop a resident specific care plan. 2. Resident #30 has [DIAGNOSES REDACTED]. A physician order, dated 9/5/16, directs to give [MEDICATION NAME] IM NOW (antipsychotic) and start [MEDICATION NAME] (antipsychotic) twice daily. There were no indications for use included in the order. Current physician orders, dated 10/28/16, direct [MEDICATION NAME] twice daily for dementia with behaviors. A Minimum Data Set (MDS) Assessment, dated 10/10/16, revealed that the resident has moderately impaired cognitive skills, no symptoms of mood disorder, hallucinations, delusions, behavioral symptoms, rejection of care or wandering, and daily use of both an antipsychotic and antidepressant. A Certified Nursing Assistant (CNA) Resident-Specific Assignment/Accountability sheet, dated 10/24/16, for behavior management is blank. A Comprehensive Care Plan (CP), dated 10/24/16, revealed that the resident had problem behavior and is resistant to care. Approaches include to use simple explanations, maintain routines, reality orientation, praise, redirect, and psych team follow-up. The CP does not identify target behaviors or include resident specific non-pharmacological interventions. Integrated progress notes, dated 8/1/16 to 9/4/16, do not reveal any documented behaviors. A review of progress notes, dated 9/6/16 to 11/16/16, do not reveal any documented behaviors. A progress note, dated 9/5/16, revealed the resident required 1:1 supervision from 1:30 p.m. to 2:15 p.m. due to escalating behaviors and did not define those behaviors. Staff approaches were to ambulate the resident to decrease her energy and take her outside. However, when they tried to bring the resident back inside, she began to swat, kick, and head butt at staff. The physician was called and gave an order for [REDACTED]. A Physician Medical Assessment Note, dated 9/9/16, revealed a recent episode [MEDICAL CONDITION] combativeness treated with [MEDICATION NAME] IM and initation of [MEDICATION NAME]. The note did not include a plan to rule out underlying medical, emotional, psychological, and/or environmental causes of behaviors. During observations on 11/15/16 at 2:25 p.m. and on 11/16/16 at 10:48 a.m., the resident was in bed. On 11/17/16 at 12:45 p.m. and 1:22 p.m., the resident was in a chair, eyes closed, and head down. Interviews conducted on 11/17/16 included the following: a. At 10:34 a.m., CNA #1 said the resident is always tired and is up all night. b. At 10:43 a.m., Licensed Practical Nurse (LPN) #1 said the resident is not violent but is antsy, cannot sit still, and tries to get up on her own. LPN #1 said staff will take the resident for a walk or put her back to bed but this does not always work. She said the resident is on [MEDICATION NAME] for anxiety and agitation. c. At 10:48 p.m., a Registered Nurse/Nurse Manger (RN/NM), who wrote the progress note of 9/5/16, was interviewed via telephone. The RN/NM said the resident gets wound up, anxious, agitated, and cannot sit still. The RN/NM said on 9/5/16, she was able to provide nail care, and then took the resident outside for a walk. She added she was not aware of the resident experiencing any behaviors prior to 9/5/16. d. At 12:48 p.m., the Director of Nursing (DON) said this resident's behaviors include standing then ambulating independently and getting out of bed by herself. She said there is no formal process in place to monitor behaviors related to the addition of or decrease in [MEDICAL CONDITION] medication use, including the effects of a change in dose. The DON said when asked, she will set up a behavior log and review it with staff. She said she is not aware of how nursing staff know what to document on behaviors and that there have been misinterpretations of behaviors with use of vague terms, such as agitated. The DON said [MEDICAL CONDITION] medications are reviewed quarterly by the consulting pharmacist, a physician, RN/NM, Social Worker and herself but that documentation of this review is not consistently done. In an interview on 11/18/16 at 12:07 p.m., the physician said he does not order [MEDICATION NAME] lightly and utilizes it as a one-time order if a resident's behaviors put themselves or others at risk. He said he expects that documentation in the medical record reflects the medication use and a decrease in targeted behaviors. The physician said he relies on nursing observations and the nurses ability to assess and document behaviors related to the use of these medications. (10 NYCRR 415.12(l)(1-2))

Plan of Correction: ApprovedDecember 7, 2016

F 329
Preparation and/or execution of the ?Plan of Correction? does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?Statement of Deficiencies.? The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and
Federal Laws.
? Resident #47 reviewed by MD for Medical evaluation for appropriateness of continued use of antipsychotic. Behavioral monitoring log put in place. Resident # 30 reviewed by MD for medical evaluation on 12/02/16 for appropriateness of and or clinical indication of antipsychotic use, and a behavior monitoring log put in place on 12/02/16.
? All residents on antipsychotic medication will be reviewed for appropriateness or reduction if indicated.
Completion date: 12/23/16
? Administrator and DON reviewed and revised policy and procedure for antipsychotic medication use and behavior monitoring. Staff education provided by DON/Designee.
Completion date: 12/23/16
? A Quality Assurance Audit was developed by the DON to ensure no unnecessary medication. Audits will be completed by DON/Designee monthly for 3 months and regularly thereafter with the results presented to the Quality Assurance committee for action, if needed.
Completion date: 12/23/16
Overall responsibility for F329 Director of Nursing

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: November 18, 2016
Corrected date: December 23, 2016

Citation Details

Based on observations, interviews, and record reviews, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Issues included ready to use utensils stored on a shelf below a prep sink and were exposed to food splash/debris from an indirect drain, and caulking applied in the gap between the backsplash on the dish machine table and the wall were not maintained in a sanitary condition. This was evidenced by the following: Observations and interviews in the Main Kitchen on 11/18/16 included the following: a. At 12:23 p.m., a rolling pin and muffin tin were found stored under a sink used for vegetable washing. Material below the drain appeared to have splashed out and contaminated the rolling pin and muffin tin. At that time, the Director of Food Service (DFS) said she could see the material and removed both items and took them to be washed. b. At 12:46 p.m., caulk applied in the gap between the backsplash on the dish machine table and the wall was stained with black, brown, and pink material. The caulk was not smooth and had multiple cracks and low spots. The DFS said they clean it and when the caulk gets too bad, maintenance will replace it. c. At 2:05 p.m., the Administrator said there are no policies for cleaning of surfaces or storage of utensils. (10 NYCRR 415.14(h); 14-1.95 Dish machine with caulking noted with mold, black and pink--along splash guard; 14-1.100 Storage of utensils under sink, muffin tins and metal rolling pin ---exposed to indirect drain splash/splatter)

Plan of Correction: ApprovedDecember 7, 2016

F 371
Preparation and/or execution of the ?Plan of Correction? does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?Statement of Deficiencies.? The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and
Federal Laws.
? A. Immediate removal of rolling pin and muffin tin under sink for cleaning. Immediate verbal education to staff, to not store items under sink areas. Work order submitted to look at drain for necessary repair if needed.
B. Immediate cleaning of gap between back splash, on dish machine and wall. Staff present immediately educated on proper cleaning procedure. Work order submitted for repair.
Completion date: 11/18/16
? All kitchen areas identified and evaluated to ensure no storage under sink areas, and caulked areas are clean, repaired and maintained.
Completion date: 12/13/16
? Director of Dietary reviewed policies and procedures with revisions made to ensure proper storage and cleaning maintained. All staff in serviced by Dietary Director on updated procedures.
Completion date: 12/23/16
? A Quality Assurance Audit was developed by the Dietary Director to ensure no storage under sink areas, and caulked areas are clean, and maintained. Audits will be completed by Dietary Director/Designee monthly for 3 months and regularly thereafter with the results presented to the Quality Assurance committee for action, if needed.
Completion date: 12/23/16
Overall responsibility for F371 Director of Dietary

FF09 483.15(h)(1):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: The facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 18, 2016
Corrected date: January 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that for three of three residential hallways, the facility did not provide a safe, clean, comfortable, and homelike environment. The issue involved carpet in resident hallways that was ripped, torn and/or bubbled that had been repaired with duct tape and/or silver roofing nails tacking the carpet down. This is evidenced by the following: Observations on 11/14/16 through 11/18/16 revealed the carpet in the hallway entering the resident unit, from Rooms #1 through #10, contained multiple areas where the carpet had bubbled and was worn or torn. The areas were repaired with duct tape and/or silver nails were used to tack the carpet in place. The hallway for Rooms #12 through #17 and #19 through #24 had several areas where the carpet had bubbled and was repaired with nails tacking the carpet down. During an interview on 11/14/16 at 2:34 p.m., Resident #19/Resident Council Representative said, I think the carpets are old and worn and they are starting to curl up, so they tack them down. When asked if it was homelike, she laughed and said, Oh, no! But I think they feel it is safe. Interviews conducted on 11/16/16 included the following: a. At 9:42 a.m., a Physical Therapist (PT) stated there have been times a resident has had to move around the areas of bubbled carpeting. She stated it is reported to maintenance and they nail the carpet down. The PT stated nailing down the carpet is not homelike, she would not have tacks on her floor. The PT stated some carpet was just tacked down last week and now there is duct tape too. b. At 10:46 a.m., a family member stated the carpet was disgusting. The family member stated it should be replaced or removed, and she would not have anything like it in her home. c. At 11:46 a.m., family member #2 said the facility is judged on things like the carpet. She said, When you first enter the building, the entrance looks so nice, then you come down the hall to the resident rooms and see that awful carpet. The family member said she tells other family members not to judge the place on the carpet, but it does look bad. In an interview on 11/17/16 at 9:35 a.m., the Director of Environmental Services stated she would guess that the carpet in the hallways was approximately [AGE] years old and that it does not look homelike. During an interview on 11/18/16 at 1:27 p.m., Resident #57 stated he could see the carpet has nails holding it in place and the carpet sticks up in places. The resident stated it is not homelike. (10 NYCRR 415.5(h)(1))

Plan of Correction: ApprovedDecember 14, 2016

F 252
Preparation and/or execution of the ?Plan of Correction? does not constitute admission or agreement by the provider of the truth of facts as alleged or conclusions set forth in the ?Statement of Deficiencies.? The Plan of Correction is prepared and /or executed solely because it is required by provisions of State and
Federal Laws.
? All Carpeting in Nursing Home between rooms 1-24B evaluated for replacement by Spectrum Design Group, proposal received.
Completion date: 11/30/16
? All carpeting on wing one, two and three between rooms 1-24B identified for removal and replacement, Instillation and completion of carpet replacement to be completed by 01/17/17.
Completion date: 01/17/17
? Administrator and Director of Environmental Services and IDT to work with Spectrum Design Group on plan for replacing carpet and resident safety plan , all staff to be educated.
Completion date: 12/29/16
? A Quality Assurance Audit was developed to ensure new carpet remains free from rips, tears, or bubble areas. Audits will be completed by Director of Environmental Services/Designee monthly for 3 months and regularly thereafter with the results presented to the Quality Assurance committee for action, if needed.
Completion date: 01/17/17
Overall responsibility for F252 Director of Environmental Services

Standard Life Safety Code Citations

MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: 2016-11-18
Corrected date: 2016-12-23

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required