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F0836
E

Non-Compliance with State Building Standards for Resident Room Layouts

Rochester, New York Survey Completed on 05-09-2025

Penalty

Fine: $182,722
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During an extended recertification survey, it was observed that the facility failed to comply with state building construction standards for nursing homes, specifically Subpart 713-1, for units South One, South Three, and North Two. Beds in multiple resident rooms were found to be less than three feet from adjacent radiators and windows, with some beds as close as six inches to a radiator or one foot from a windowsill. In several rooms, beds were also placed less than three feet apart from each other. Additionally, one resident room lacked an outside window, instead having a cutout in the wall leading to a sunporch, with the connecting door padlocked. Windowsills in several rooms were measured at 3 feet 10 inches above the floor, exceeding the allowed height. These findings were based on direct observations of room layouts and measurements taken during the survey. Interviews with staff, including an LPN, confirmed that the arrangement of beds made it difficult for emergency medical services to access residents and for staff to use mechanical lifts in four-person rooms. The lack of space also limited the ability of families to visit comfortably. The deficiencies were identified in multiple rooms across the affected units, with specific measurements and room conditions documented by surveyors.

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