Non-Compliance with Fire Code: Inadequate Carbon Monoxide Alarm Testing
Summary
The facility was found to be non-compliant with the 2020 Fire Code of New York State, specifically Section 915, which mandates carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances. Observations revealed that the facility had installed battery-operated combination photoelectric smoke and carbon monoxide alarms with a voice message system on all three resident use floors and in the basement. However, the facility failed to adhere to the manufacturer's guidelines for weekly testing of these alarms, as they were only tested monthly. The facility's logs confirmed that the alarms were checked monthly from January to October 2024, which does not meet the required testing frequency. The deficiency affected all three resident use floors and the basement, where natural gas fuel-burning appliances were installed. During an interview, the Maintenance Supervisor confirmed the monthly testing schedule and provided logs as evidence. However, the user guide provided by the facility was incomplete, lacking information on the required testing procedures. This oversight in maintenance and testing of carbon monoxide alarms represents a failure to comply with both state fire codes and professional standards, potentially compromising resident safety.
Penalty
Resources
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A resident had discontinued respiratory orders that were not signed and dated by the physician. The record showed an order to discontinue the vent and downsize the trach, as well as a verbal order to titrate O2 to maintain saturation, but neither document showed physician signature. The Administrator stated the facility did not have a system for physicians to sign discontinued orders, and the Administrator and DON acknowledged the findings.
Failure to Report Kitchen Closure to CDPH: The facility did not notify CDPH of a cockroach infestation in the kitchen that led to a 24-hour closure by local public health. The RD stated she believed local public health would notify CDPH, and the ADM later confirmed there was no verification that the closure was reported. The facility policy required unusual occurrences affecting resident, employee, or visitor welfare to be reported to the appropriate agencies within 24 hours.
Expired Food Service License: Surveyors found that the facility did not have a current food operating license displayed in the kitchen, and staff reported learning from local news that the license had expired. The Local Health Department confirmed the license had lapsed and was not renewed for more than two months. The DON and Administrator stated the kitchen had been a QAPI concern and that food services were outsourced, while the Administrator confirmed the kitchen operated without a valid license during that period.
The facility failed to renew its food service license on time. The Administrator sent the renewal application to corporate for payment, but the fee was not paid initially, and the license expired for a few days before the new license was issued. The Dietary Manager said he did not realize he was responsible for the license because he thought corporate handled it.
Expired Infectious Medical Waste Permit: The facility's Infectious Medical Waste Program permit was posted in the building but had expired. The administrator confirmed the lapse and said the invoice had been sent to corporate for payment but had not yet been paid at the time of the survey.
Unqualified Social Services Staffing and Supervision: The facility failed to ensure the social services department was staffed and supervised by qualified personnel, and all residents received social services from unqualified staff. HR reviewed the SSD job description and could not determine the minimum educational requirements, while also stating applicants were not checked for qualification. The SSD was the only social services staff member, and the ADM confirmed there was no qualified social worker overseeing the department.
Unsigned Discontinued Respiratory Orders
Penalty
Summary
Resident 4 had discontinued respiratory orders that were not signed and dated by the physician. Medical record review showed a new physician order on 3/10/26 to discontinue the vent and downsize the trach to an uncuffed Portex 6, but the Clinical Note Summary did not show the discontinued order was signed and dated by the physician. The record also showed a verbal physician order on 3/20/26 to titrate oxygen to maintain oxygen saturation, and the document did not show the physician signed the order. The facility's P&P titled Readmission, Handwritten Orders, and Written Transfer Orders directed staff to enter orders into the EMR, where the physician electronically signs the order. During interviews on 5/29/26, the Administrator stated the facility did not have a system for physicians to sign discontinued orders. The Administrator and DON were informed of and acknowledged the findings.
Failure to Report Kitchen Closure to CDPH
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH) of a cockroach infestation in the facility kitchen that resulted in a 24-hour kitchen closure by local public health. During an interview on 5/22/26 at 12:30 p.m., the Registered Dietician stated the facility did not report the kitchen closure to CDPH because she thought local public health would notify CDPH. During a concurrent interview and record review on 5/26/26 at 4:00 p.m., the Administrator reviewed files of incidents reported to CDPH and stated he could not locate verification that the kitchen closure had been reported. He stated the last facility-reported incident to CDPH was on 3/19/26, and that the kitchen closure qualified as an unusual occurrence with the potential to harm residents. The facility policy titled Unusual Occurrences stated that unusual occurrences affecting the health, safety, or welfare of residents, employees, or visitors are to be reported to appropriate agencies within 24 hours, with a written report sent within 48 hours or as required by law.
Expired Food Service License
Penalty
Summary
The facility failed to comply with applicable State and local licensure laws by allowing its food service license to lapse for more than two months. During a kitchen tour on 05/04/26, surveyors observed that no current food operating license was displayed. Dietary Aide #672 and [NAME] #672 stated during interview that they learned from local news that the facility's food operating license had expired in March 2026. The Local Health Department later confirmed that the food service license expired on 02/28/26 and was not renewed until 05/04/26. The DON and Administrator stated that the kitchen had been identified as a QAPI concern in late 2025 and that food services were outsourced to a third-party company in February 2026. The Administrator confirmed the kitchen operated without a valid food service license from 02/26/26 through 05/04/26 and described the kitchen as a work in progress.
Late Renewal of Food Service License
Penalty
Summary
The facility failed to ensure its food service license was renewed on time. An email from the Administrator to Corporate Accounts Payable dated 02/12/26 showed the Administrator sent the food license application to the corporate office and requested payment be sent to the local health department for renewal of the building's food service license. Review of the Food Service Operation License showed it was issued on 03/06/26 and would expire on 03/01/27, and an additional food license application showed it was completed on 03/11/26 with a late fee of $110.00 applied because the initial renewal application fee was not paid. The local health department confirmed in interview on 04/20/26 that the facility went without a license for three days, with the original license expiring on 03/02/26 and the new license issued on 03/06/26. In interview on 04/21/26, the Dietary Manager stated he had not been aware the food license was something he had to take care of because he thought the company completed it, and he confirmed the license had expired for a few days.
Expired Infectious Medical Waste Permit
Penalty
Summary
The facility failed to comply with applicable state laws, regulations, and codes because its Bureau for Public Health, Office of Environmental Health Services, Infectious Medical Waste Program permit was expired. The permit was posted on the wall in the facility and had been issued on one date and expired on another date. During the survey, the administrator confirmed that the permit had expired and stated that she had submitted the invoice to corporate for payment, but it had not yet been paid. Later the same day, the administrator stated that she had just paid the invoice to renew the facility's Infectious Medical Waste Program permit and provided the receipt showing the invoice had been paid.
Unqualified Social Services Staffing and Supervision
Penalty
Summary
The facility failed to ensure the social services department was staffed and supervised by qualified staff for a census of 59 residents, resulting in all residents receiving social services from unqualified staff. During interview, the Social Services Director stated they had worked at the facility since 2022. Human Resources reviewed two versions of the Social Services Director job description and stated the revised version listed the qualifications section as preferred rather than required, leaving the minimum educational requirements unclear, although the ability to read and solve practical problems was identified as a requirement. Human Resources also reviewed the Social Services Director's employment application, which showed completion of high school and licensure as a vocational nurse. HR stated they did not check whether applicants were qualified for the position and that department managers were responsible for ensuring employees were qualified. HR further stated the Social Services Director was the only staff member in the social services department and did not have another supervisor. The Administrator stated they were the overall supervisor for all staff, including the Social Services Director, and confirmed there was no qualified social worker overseeing the social services department. Facility policy stated the director of social services is responsible for supervising social services personnel, and state regulations reviewed indicated the social work service unit shall be organized, directed, and supervised by a social worker.
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