Saratoga County Maplewood Manor

Based on observation and interview the facility did not ensure that food was stored, prepared and served under sanitary conditions in one of one kitchens during the recertification survey. Specifically, foods were not prepared under sanitary conditions, dishes and utensils were not stored under sanitary conditions, and food preparation equipment was not clean in the main kitchen. This resulted in no actual harm with a potential for minimum harm . This is evidenced by:

Finding #1
On 9/20/11 at 3:19 pm, the large mechanical potato peeler had a plastic bag over it. The machine was dirty with dried food particles all over it. There was also dried food on the shoot where the potatoes come out.

During an interview on 9/20/11 at 3:19 pm the Head Cook stated the potato peeler should be cleaned after each use. He did not know why it was not cleaned thoroughly after the last use. The Head Cook said that it was used a couple of times a week.

During an interview the Food Service Director (FSD) on 9/21/11 at 1:00 pm stated the potato peeler should be cleaned after each use and the plastic put on it.

During an observation on 9/21/11 at 9:10 am, the plate warmer was observed to be dirty with crumbs on it. There was a rolling serving cart with sheet trays of pizza dough sitting on it. This cart was dirty with food spills and crumbs on it. The cooler across from the ovens was observed with a dirty glass front panel. The bottom grill had food crumbs stuck to it with dust and some spills. The ovens were soiled with grease and crumbs.

During an interview the cook at 9:10 am on 9/21/11, stated that the kitchen was cleaned daily in the afternoon.

During an interview the FSD on 9/21/11 at 1:00 pm stated that the ovens should be degreased and that the steam table should have been cleaned after breakfast and ready for use for lunch.

Finding #2
During an observation on 9/21/11 at 9:07 am, pizza dough was noted on sheet trays sitting on a serving cart The dough was not covered, and remained uncovered until cooked. The floor was being swept next to the cart with the pizza dough on it. A hotel pan with pizza dough on it was observed sitting on the pizza dough in a sheet tray on the bottom shelf of the cart. The pizza dough was observed uncovered for approximately 40 minutes.
.
During an interview the cook on 9/21/11 at 11:15 pm stated the pizza dough should have been covered.

During an interview the FSD on 9/21/11 at 1:00 pm stated the pizza dough should have been covered.

Finding #3
During an observation on 9/20/11 at 3:13 pm, 12 hotel pans of assorted sizes were stored wet. At 3:14 pm, the Head Cook stated he would have the pans rewashed and dried. He stated these should not have been put away wet. He stated the pans should be dried separately and then put away when dry.

10 NYCRR 415.14 (h)

Based on staff interview and record review the facility did not ensure that a comprehensive care plan (CCP) was developed that included measurable objectives and timetables to meet the residents specific care needs for 2 (#'s 19 and 240) of 9 residents reviewed during Stage II of the recertification survey. Specifically, for resident #19, the facility did not develop a CCP for the Hospice care that the resident was receiving and for resident #240 there was no CCP for the specialized services that the resident received outside the facility. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

1. Resident #19
The facility did not develop a comprehensive care plan for the Hospice care the resident was receiving in the facility.

The resident was admitted to the facility on 03/07/2007 with diagnoses including
Cerebral Vascular Accident, hypertension, and dementia.

A nursing note dated 06/08/2011 stated that the resident's daughter had requested a referral for Hospice care.

A physician's order dated 06/08/2011 requested a Hospice evaluation. A physician progress note dated 06/16/2011 stated continued decline, Hospice evaluation requested.

Review of the medical record revealed that the resident was admitted to Hospice on 06/21/2011. The physician's order for Hospice care was dated 06/22/2011. The orders included that Hospice would provide Home Health Aide services five days a week for personal care and feeding. These orders were last renewed and signed on 09/08/2011.

The facility CCP for the resident did not identify documented evidence that a care plan, that included the involvement of Hospice and the collaboration of care required by the facility for the Hospice services, was developed. A review of the Hospice record identified a CCP developed by hospice services dated 06/21/2011.

During an interview on 09/21/2011 @ 11:00am the Registered Nurse Head Nurse (HN), when asked if the residents CCP included the plan of care for the collaboration with the Hospice services, she replied that there should be one. Upon review of the CCP, she was not able to identify a facility care plan for the Hospice services.

During an interview on 09/21/2011 at approximately 2:30 pm the Director of Nursing (DON) stated there should be a facility developed care plan to document the collaboration of care for that resident and Hospice services.

On 09/26/2011 at approximately 10:00am, the DON submitted a copy of a facility developed Hospice Care Plan for the resident dated 09/22/2011.

2. Resident # 240
The facility did not develop a CCP for the specialized services that the resident received outside the facility.

The resident was admitted to the facility on 09/02/2009, with diagnoses including Cerebral Palsy with Mental Retardation, seizure disorder, and recurrent falls. The resident resided in a group home prior to admission to an acute care facility and transfer to the facility.

The Pre-Admission Screen Resident Review (PASRR) screen ( form DOH-695) dated 09/01/2009, revealed that a Level II evaluation was deferred at that time secondary to the medical status of the resident, who was non ambulatory and participating in sub-acute rehabilitation.

Interview with the Social Worker (SW) on 09/21/2011 at approximately 11:30am, revealed that a second PASRR was completed for the resident to facilitate a
Level II review for specialized services. She stated that the resident currently attends an outside specialized service program three times a week.

The physician's orders revealed an initial order dated 12/20/2010 for the resident to attend the specialized service program three times a week, which has been renewed on a routine basis. Additional physician's orders last dated 08/23/2011 included physical (PT) and occupational therapy (OT) services to be provided by the specialized service program.

A review of resident #240 comprehensive care plan did not find evidence of a care plan that included the collaboration of care for the resident to attend the specialized service program three times a week. The CCP mad one mention of the specialized program attendance three times a week in the care plan titled #7 Psychosocial wellbeing, dated 08/16/2010. The specialized service program three days a week was listed as an approach and dated 07/12/2011. The CCP did not include specific information to facilitate attendance and collaboration of services, such as:
The times of the program attendance
The method of transportation
The PT and OT services
The need for a bag lunch
The communication book

On 09/22/2011 at approximately 10:00am, the unit HN stated that the resident's plan of care should include the information specific to the coordination of care for the resident and the specific specialized services that she receives three days a week outside of the facility. When asked to identify the care plan that addressed the specialized services, she was not able to find documented evidence that a care plan had been completed.

During an interview on 09/22/2011 at approximately 2:30 pm the DON stated there should be a facility developed care plan to document the collaboration of care for that resident and the specific specialized services that were being rendered.

On 09/26/2011 at approximately 10:00am, the DON submitted a copy of a facility developed Specialized Services Care Plan for resident #240, dated 09/23/2011.

10 NYCRR 415.11 (c)(1)

Based on medical record review and staff interview the facility did not ensure the Pre-Admission Screen Resident Review (PASRR) screen ( form DOH-695) was completed prior to or upon admission to the facility for 1 (#101) of 30 residents reviewed during the standard recertification survey. Specifically, resident #101 was admitted to the facility on 06/03/2011 with an incomplete PASRR from the transferring acute care facility. The PASRR form submitted with the resident had only items #1-5 and the screeners name completed. The facility did not complete a PASRR until 06/07/2011, four days after the residents admission. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

1. Resident #101

The facility did not ensure that a PASRR screen form was completed when the resident was admitted to the facility.

The resident was admitted to the facility on 06/03/2011 with diagnoses including Alzheimer's dementia, hypertension, and bradycardia.

Review of the medical record revealed an incomplete PASRR screen form. The form had items #1 through #5 completed, which included identifying information for the transferring facility, the resident name, and the name of the screener. The entire assessment area, items # 6 through #37 were blank.

On 09/20/2011 at approximately 2:15 pm, during an interview with the Head Nurse, she reported that the Social Worker (SW) would have information about the screen.

The SW was interviewed on 09/20/2011 at approximately 2:30 pm, she stated that the facility Admissions Coordinator (AC) was responsible to review all of the required admission paperwork, which includes the completed PASRR. She went on to say that if a resident was admitted without a completed PASRR, the facility would then complete a screen upon admission. She stated that the facility did complete a screen for this resident.

Review of the completed screen revealed that it was dated 06/07/2011, 4 days after the resident's admission to the facility.

During an interview on 09/21/2011 at 2:30 pm the AC with the Director of Nursing (DON) present , stated that the screen is not usually completed when the facility receives the paperwork for review. The screen is usually completed and submitted with the resident at the time of admission. If the resident does not have a completed screen when they arrive, then the facility completes one. There is only one employee that works at the facility that is certified to complete the screens.

During an interview on 09/21/2011 at 2:30 pm the DON stated that the facility does only have one certified screener.

During an interview on 09/26/2011 at 10:00 am, the Registered Nurse, certified screener for the facility stated she did not recall issues or circumstances specific to the completion of a PASRR screen for this resident. She went on to say that if a resident was admitted to the facility without a completed PASRR screen, she would be notified so one could be completed. She stated that the PASRR screen form should be completed upon admission to the facility, which is usually the day of admission.

10NYCRR 415.11(e)

Based on record review and staff interview during the standard recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72, National Fire Alarm Codenone 1999 edition section 7-3.2 requires annual tests for all fire alarm system initiating devices. Specifically, the heat detectors, photo smoke detectors, and pull stations-single action on 1 of 2 wings and the center core, a total of 163 devices, were not tested annually within the past 12 months. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The facility's fire alarm testing records from 2010 and 2011 were reviewed on 09/21/2011 at 2:00 pm. The records revealed that the 25 heat detectors, 117 photo smoke detectors and 21 pull stations-single action were last tested on 08/19/2010, a period of time greater than 13 months ago.

The maintenance mechanic stated in an interview conducted on 09/22/2011 at 10:20 am that the fire alarm system testing company missed the required testing that should have been conducted during 08/2011.

2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-3.2; 1997 NFPA 101: 7-6.1.4; 1996 NFPA 72: 7-3.2; 10 NYCRR 415.29, 711.2(a)(1)

Based on record review and staff interview during the standard recertification survey, it was determined that the facility did not test the kitchen fire suppression system in accordance with adopted regulations. NFPA 17A Standard for Wet Chemical Extinguishing Systemsnone 1998 edition section 5-3.1.1 requires semi-annual testing of the extinguishing system components including the operation of all detection system signals and releasing devices and associated equipment. Specifically, one of the last 2 required kitchen fire suppression system test reports indicated that not all releasing devices and signaling devices were tested. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The inspection reports of the facility kitchen fire suppression system were reviewed on 09/21/2011. These reports reveal that the operation of the micro-switch (box 19) and the operation of the appliance shutdown (box 20) were not checked during the 07/11/2011 semi-annual test.

The maintenance mechanic stated in an interview conducted on 09/22/2011 at 10:20 am that the company contracted to test the kitchen fire suppression system cannot account as to why boxes 19 and 20 were checked " No " which indicates that these devices were not tested.

2000 NFPA 101 19.3.2.6, 9.2.3; 1998 NFPA 96 8.2, 1998 NFPA 17A 5-3.1.1(e)

Based on staff interview and review of inspection records it was determined that the automatic sprinkler system was not tested in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systemsnone 1998 edition section 2-3.3 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, 1 of the past 4 required sprinkler system tests was not conducted. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The sprinkler system inspection records were reviewed on 09/21/2011. The records showed that the flow alarm devices were not tested during the first quarter of 2011.

The maintenance mechanic stated in an interview conducted on 09/22/2011 at 10:20 am that quarterly testing of the sprinkler system was not conducted during the first quarter of 2011.

2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 2-3.3; 1997 NFPA 101 7-7.6; 1995 NFPA 25 2-3.3; 10 NYCRR 415.29, 711.2(a)(1)

Based on observation and staff interview during the standard recertification survey, it was determined that the facility did not maintain the integrity of floor-ceiling assemblies. NFPA 101 Life Safety Codenone 2000 edition section 8.2.5 requires that the spaces around items that penetrate floors and ceilings shall be filled with a material that maintains the fire resistance rating of the floor-ceiling assembly. Specifically, the space around the pipe that penetrates 1 of 1 floor-ceiling assemblies observed was not sealed. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

The second-third floor-ceiling assembly above the tiled ceiling in resident room A207 was inspected on 09/22/2011 at 11:05 am. The space around a 4-inch black pipe passing through a 6-inch hole in the floor-ceiling assembly was not sealed.

The maintenance mechanic stated in an interview conducted on 09/22/2011 at 11:05 am that sealing the space noted above might have been overlooked when the third floor was added to the building.

2000 NFPA 101 19.3.1.1, 8.2.5; 1997 NFPA 101 13-3.1.1, 6-2.4; 10 NYCRR 415.29, 711.2(a)(1)