Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Absolut Center For Nursing And Rehabilitation At T during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies. A resident with Covid-19 was not placed on proper precautions, and staff were observed without appropriate PPE. Another resident with a pressure ulcer was not on enhanced barrier precautions, and staff did not wear gowns during care. The facility's infection control policies were not reviewed annually, contributing to these deficiencies.
The facility failed to comply with pneumococcal vaccine protocols for eight employees, lacking documentation of vaccine eligibility, education, and annual offering. Employees D, A, and B were last offered the vaccine in 2020 and 2022, while forms for Employees E, H, I, and J were incomplete. The Infection Preventionist and Administrator were unaware of the annual requirement, indicating a need for policy revision.
The facility did not conduct or document semi-annual visual inspections of its fire alarm system initiating devices, including smoke detectors, heat detectors, and pull stations, for the year 2024. The Environmental Services Director was unaware of the requirement, relying solely on the vendor for inspections. This resulted in non-compliance with NFPA 72 standards.
A Life Safety Code Survey found that the facility did not ensure proper illumination of egress pathways for four of seven exits. Observations revealed a lack of exterior lighting on several sections of the pathways. The Environmental Services Director was unaware of the deficiency but acknowledged the need for additional lighting.
A resident with dementia and impaired cognition fell out of bed during care provided by one CNA instead of the required two-person assistance. The incident, which resulted in a skin tear and bruising, was not reported to the Department of Health as required. Despite concerns about the CNA's conduct, the facility's DON and Administrator did not consider the incident reportable, citing the injury as not serious.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent nail care, as required by the facility's policy. Observations showed the resident with brown debris on their fingers and nails on multiple occasions, despite needing total assistance with personal hygiene. Staff interviews revealed a lack of communication and documentation regarding the resident's nail care.
A resident with edema did not receive prescribed ace wraps for their lower extremities, as observed during a survey. Despite physician's orders and a care plan directive, there was no documentation of the wraps being applied or any refusals recorded. Interviews revealed the resident occasionally refused care, but no refusals were documented. The DON stated refusals should be documented if care is refused after re-approach attempts.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease, as they did not have physician orders or a care plan for the resident's tunneled catheter, nor did they monitor it for complications. The care plan and physician orders were inconsistent, and the facility did not follow the vascular physician's recommendations. Staff interviews revealed a lack of awareness regarding the resident's dialysis care needs, and there was no documented evidence of monitoring by the Infection Preventionist nurse.
The facility did not ensure proper maintenance of electric beds as per the manufacturer's guidelines. During a survey, it was found that electrically operated beds were not inspected at the required intervals, and there was no documentation of formal inspections or maintenance. The Environmental Services Director acknowledged the lack of unique identifiers for beds and stated that beds were checked annually using a room audit form, but specific beds were not identified. This failure to adhere to maintenance requirements constituted a deficiency in compliance with NFPA 99 standards.
The facility failed to conduct a fire drill for the second shift during the fourth quarter of 2024 and did not document staff participation in a November drill. The Environmental Services Director admitted to not using a schedule and acknowledged the oversight.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a recertification survey. Resident #45, who tested positive for Covid-19, was not placed on enhanced droplet/contact precautions, and staff were observed within six feet of the resident without wearing appropriate personal protective equipment (PPE). Additionally, Resident #100, who also tested positive for Covid-19, was placed on contact precautions instead of the required airborne precautions, and staff were observed handling the resident's environment without proper PPE. Resident #79, admitted with an open area on their leg and later developing a pressure ulcer, was not placed on enhanced barrier precautions. Staff were observed changing the dressing on the resident's heel ulcer without wearing a gown. Similarly, Resident #104, admitted with an unstageable pressure ulcer, was not placed on enhanced barrier precautions. Resident #16, who was on enhanced barrier precautions due to a multi-drug-resistant organism, was assisted by staff who only wore gloves during high-contact personal care, contrary to the requirement to wear gowns and gloves. The facility's Infection Prevention and Control Program policies and procedures were not reviewed annually as required. The Registered Nurse Educator/Infection Preventionist acknowledged the lapses in precaution signage and PPE usage, and the Director of Nursing confirmed that residents with certain conditions should have been on enhanced barrier precautions. The facility's failure to adhere to infection control protocols and ensure staff compliance with PPE requirements contributed to the deficiencies observed during the survey.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F880 Corrective Action - To assure the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. On 2/27/25 Resident #45 was placed on enhanced droplet/contact precautions for Covid-19 and the proper precaution sign was posted. CNA #4 was educated on proper PPE for enhanced droplet/contact precautions including wearing a mask/face shield. On 2/27/25 Resident #79 was placed on enhanced barrier precautions and the proper precaution sign was posted. The RN Educator and the Nurse practitioner were educated on proper PPE/gown use. On 2/27/25 Resident #100 was placed on enhanced droplet/contact precautions and CNA #3 was educated on proper PPE for precautions. Resident #104 was placed on enhanced barrier precautions. Additionally, the facility will ensure that Infection Prevention and Control Program policies are reviewed annually. Resident #16’s care plan was reviewed to assure the resident's enhanced barrier precautions remained appropriate and the proper precaution sign was posted. CNA #1 and #2 were educated on proper PPE precautions. 2. All residents who have respiratory symptoms and are being tested for COVID-19 have the potential to be affected by this deficient practice. A list of residents who have respiratory symptoms and are being tested for COVID-19 will be audited to ensure they are on enhanced droplet/contact precautions per policy, their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. All residents who have a wound with an expected healing time of greater than 4 weeks as per policy have the potential to be affected by this deficient practice. A list of residents with wounds will be generated and audited to determine if enhanced barrier precautions are necessary and their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. 3. The facility policies for its Infection Control Program including: Infection Prevention and Control - General Statement, Policy on Use of Criteria for Infection Identification, Antibiotic Stewardship Program, Policy on Influenza Immunization (Seasonal/H1N1), Pneumococcal Vaccination Program - Residents, Policy on Surveillance, PPE Donning and Doffing, Enhanced Barrier Precautions and Coronavirus Policies will be reviewed and updated (if necessary), as well as annually. All facility staff will be educated on PPE Donning and Doffing. And all licensed nursing staff (RN/LPNs) will be educated on all our Infection Control Program policies listed above. The Director of Nursing/Designee will oversee the completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform 10 audits per month for 3 months, and then as needed based on findings. Audits will verify that residents on precautions (EBP, contact/droplet/airborne) have appropriate precaution signs on doors and that appropriate PPE is worn by staff during direct care. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F 880.
Inadequate Pneumococcal Vaccine Protocols for Employees
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of compliance with pneumococcal vaccine protocols for eight out of ten employees reviewed. Specifically, the facility did not determine eligibility for the pneumococcal vaccine, provide education on its risks and benefits, or offer the vaccine annually to all employees who have direct care and/or close contact with residents. Documentation was missing for Employee F regarding vaccine eligibility and education. Employees D, A, and B were last offered the vaccine in 2020 and 2022, respectively, but declined it. Additionally, the consent/declination forms for Employees E, H, I, and J were not dated or signed by a facility representative, indicating a lack of proper documentation and attestation that the vaccine was offered and education provided. During interviews, the Infection Preventionist and the Administrator admitted to being unaware of the requirement to offer the pneumococcal vaccine annually to all employees. This oversight indicates a need for revision in the facility's policy and procedure to ensure compliance with New York State Department of Health regulations.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I210 Corrective Action- To assure the facility determines eligibility for the pneumococcal vaccine, provides education on the risks/benefits of the pneumococcal vaccine, and offers the vaccine to all employees annually. 1. Employees (A-J) will have their eligibility for the Pneumococcal Vaccination determined, and if able, they will be offered, educated on, and have consent/declination forms signed. Those who are eligible and have consented, will have the vaccination administered. 2. All employees at the facility have the potential to be affected by this practice. The facility will complete a full house audit of staff. The audit will include eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine (if appropriate). 3. The facility’s pneumococcal vaccination policy for employees will be reviewed and revised (if necessary). All Registered Nurses and HR staff in the facility will be reeducated on this policy. 4. To ensure prevention of future deficit in this practice, the Staff Educator/Designee will perform 10 audits per month for 3 months, then as needed based on the audit findings. Audits will verify that eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F I210.
Failure to Conduct Semi-Annual Fire Alarm Inspections
Penalty
Summary
The facility failed to properly maintain and inspect its fire alarm system initiating devices, as required by the 2010 edition of the National Fire Protection Association 72, National Fire Alarm and Signaling Code. During a Life Safety Code Survey, it was observed that the facility did not conduct or document semi-annual visual inspections for smoke detectors, heat detectors, and pull stations throughout the building for the calendar year 2024. Although annual functional testing was documented, the semi-annual visual inspections were not performed. The Environmental Services Director was unaware of the requirement for semi-annual visual inspections, relying solely on the vendor for inspection and testing. This oversight led to a deficiency in compliance with the NFPA 72 standards, which mandate that visual inspections occur twice per year, with a minimum of four months and a maximum of eight months between inspections.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K345 Corrective Action- The facility will ensure that it meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Alarm System Testing and Maintenance. 1. The facility’s contracted Fire Alarm Inspection company has been contacted to perform the semi-annual visual inspection for all fire alarm system initiating devices. 2. The semi-annual visual inspection for fire alarm system initiating devices will be added to the facility’s electronic work order system. 3. The Administrator will oversee in-services to all maintenance department staff in regards to the NFPA 101 Fire Alarm System Testing and Maintenance requirements including the importance of the visual inspection for initiating devices. 4. To prevent future deficit in this practice, the Maintenance director will perform 1 audit per month for 3 months to ensure the visual inspection requirements have been met and documentation is in place. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K345.
Inadequate Illumination of Egress Pathways
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was observed that the facility failed to ensure proper illumination of the means of egress for four of seven exits. Specifically, the outdoor exit discharge pathways lacked sufficient lighting to the public way. Observations made on February 24, 2025, between 1:11 PM and 1:24 PM revealed that there was no exterior lighting present to illuminate several sections of the exterior egress pathways. These included a 100-foot-long section between the exits from the A1 and D2 corridors, a 50-foot-long section between the exits from the D2 corridor and physical therapy, a 100-foot-long section between the exits from the D1 and C2 corridors, and a 50-foot-long section between the exits from the C2 corridor and the main entrance. During an interview conducted on the same day at 1:24 PM, the Environmental Services Director stated they were unaware of the lack of lighting between exits or the need for additional lighting. The director acknowledged the presence of lighting at the exits but indicated that additional lighting could be added for the pathways.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K281 Corrective Action - To ensure the facility meets the requirements of illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall either be continuously in operation or capable of automatic operation without manual intervention. 1) The facility will install lighting: in the 100 foot long section of exterior egress pathway between the exits from A1 and D2 corridors; the 50 foot long section of exterior egress pathway between the exits from D2 and D2 physical therapy; the 100 foot long section of exterior egress pathway between the exits from D1 and C2 corridors; and the 50 foot long section of exterior egress pathway between the exits from the C2 corridors and the main entrance so that the egress paths are illuminated in compliance with the Life Safety Code. 2) The Director of maintenance will conduct a complete inspection of all means of egress to identify any additional areas that may require increased lighting in compliance with the Life Safety Code. Annual inspection of egress path lighting will be added to the facility’s electronic work order system. 3) The Administrator will oversee in-services to all maintenance department staff in regard to the life safety requirements for means of egress lighting. 4) All means of egress will be audited monthly for 3 months and as needed based on the audits findings. Audits will verify all egress lighting meets the requirement of the Life Safety Code. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K281.
Failure to Report Resident Fall and Potential Neglect
Penalty
Summary
The facility failed to report an incident involving a resident, identified as Resident #66, who fell out of bed during incontinence care. The care was being provided by one Certified Nursing Assistant (CNA) instead of the two-person assistance required by the resident's Comprehensive Care Plan. This incident was not reported to the New York State Department of Health as required by state law, despite the resident sustaining a skin tear and bruising. The facility's policy mandates reporting any accident or incident where negligence is suspected, but the Director of Nursing and the Administrator did not consider the incident reportable, as they believed the injury was not serious. Resident #66 had a history of dementia, congestive heart failure, and atrial fibrillation, with severely impaired cognition as documented in their Minimum Data Set Resident Assessment. The incident occurred when the CNA instructed the resident to roll back, but the resident rolled the wrong way and fell. Statements from staff indicated that the CNA may have been rough with the resident, and another staff member expressed concerns about the CNA's conduct. Despite these concerns, the incident was not escalated to the Department of Health, highlighting a failure to adhere to reporting protocols for potential neglect or mistreatment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F609 Corrective Action- To assure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator and to other officials in accordance with State law through established procedures. 1. As noted, the investigation regarding resident #66, dated 2/19/25, was made aware to the state DOH during survey 2/24/25 through 2/28/25. C.N.A. # 7, was educated/counseled on properly following the residents care plan. 2. All residents with alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source and misappropriation of resident property have the potential to be affected by this deficient practice. A retrospective review of all residents who have had such incidents in the past 30 days will be created and reviewed to assure that proper notification took place (if necessary). 3. The facility’s “Accident/Incident Investigation and Prevention” and “Facility Incident/abuse investigation and reporting” policies will be reviewed and revised if necessary to assure compliance. All staff will be in-serviced on these policies and the NYSDOH reporting guidelines. The Director of Nursing/Designee will oversee all education for staff. 4. To prevent further deficiency in this practice, the Director of Nursing / Administrator will perform audits of 10 resident accident and incident investigations each month for the next 3 months and then as needed based on the audit findings. Audits will verify that the facility is appropriately reporting all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are being reported immediately to the administrator of the facility and to other officials in accordance with State Law through established procedure. The administrator will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F609.
Inconsistent Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide consistent assistance with nail care for Resident #15, who was dependent on staff for personal hygiene due to severe cognitive impairment and other medical conditions. The facility's policy required routine nail care following baths or showers, but observations during the survey revealed that Resident #15 had brown debris on their fingers, nails, and cuticles on multiple occasions. Despite the resident's need for total assistance with personal hygiene, there was no documented evidence of nail care being refused or performed, as required by the facility's policy. Resident #15, diagnosed with vascular dementia, congestive heart failure, and traumatic brain injury, was observed with soiled hands and nails on several occasions, indicating a lack of proper hygiene care. The resident's care plan required total assistance with bathing and nail care, yet observations showed the resident with brown debris under their nails and on their hands, even while eating. Interviews with staff revealed a lack of communication and documentation regarding the resident's nail care, contributing to the deficiency in maintaining the resident's personal hygiene.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F677 Corrective Action- To assure all residents who were unable to carry out activities of daily living (ADLs) receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. On 3/17/2, Resident #15 had proper nail care performed. Resident #15’s Care plan was reviewed for level of assistance required for hygiene and remains appropriate. 2. All residents residing in the facility who require assistance for nail care have the potential to be affected by this practice. A list of all residents who are dependent on staff for nail care will be created. These listed residents will then be audited for appropriate nail care. 3. To ensure this practice does not reoccur, the facility policy on Nail Care will be reviewed and revised if necessary. Education will be provided to all nursing staff (RNs, LPNs, and CNAs). The Director of Nursing/Designee will oversee in-services for all nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing/Designee will perform 10 resident audits per month for 3 months, and then as needed based on the audit findings. Audits will verify that proper nail care has been completed. The DON will monitor this process and review results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F677.
Failure to Apply Prescribed Ace Wraps for Edema Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as evidenced by the lack of application of ace wraps to the resident's lower extremities. The resident, who had diagnoses including congestive heart failure, atrial fibrillation, and edema, was observed multiple times without the prescribed ace wraps, despite having orders for their use to manage edema. The resident's care plan also included instructions to encourage the use of ace wraps and document any refusals, yet there was no documentation of the ace wraps being applied or any refusals recorded for the month of February. Interviews with facility staff revealed that the resident occasionally refused care, particularly from male caregivers, but there was no documented evidence of such refusals regarding the ace wraps. The Director of Nursing stated that refusals should be documented by nursing staff if a resident continues to refuse care after re-approach attempts. The lack of documentation and adherence to the care plan and physician's orders resulted in the resident not receiving the necessary treatment for their condition, as observed during the survey.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F684 Corrective Action- To assure that Residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents’ choices. 1. On 2/27/25, the provider reviewed and revised resident #51’s order for ace wraps, requiring progress notes for all refusals. On 3/17/25, resident #51’s care plan was reviewed and remains appropriate in regards to ace wraps. 2. All residents who have orders for ace wraps have the potential to be affected by this practice. A list of all residents requiring ace wraps will be created and audited to ensure that ace wraps are applied as directed and documented appropriately. 3. To ensure this practice does not reoccur, the facility policy on “Medication/Treatment administration: Documentation” will be reviewed and revised if necessary. All licensed nursing staff (RN, LPN) will be re-educated on this policy. The Director of Nursing/designee will oversee in-services for all licensed nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing/designee will perform 10 audits per month for 3 months, and then as needed based on the audit findings. Audits will verify ace wraps are applied as ordered, and that all refusals are documented. The Director of Nursing will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of nursing will assume overall responsibility for correction of F684.
Deficient Dialysis Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease, muscle weakness, and diabetes. The resident had a clotted dialysis fistula and a tunneled catheter was placed for dialysis treatments. However, the facility did not have physician orders or a care plan for the tunneled catheter, nor did they monitor the catheter and dressing for potential complications. The facility also did not follow the vascular physician's recommendations regarding blood draws and needle pokes in the resident's right arm. The resident's care plan and physician orders were inconsistent and incomplete. The care plan did not include the presence of the tunneled catheter or interventions for its care, and the physician orders did not address monitoring the catheter. Additionally, the facility's records showed inconsistent documentation of the resident's 24-hour fluid restriction, with daily fluid intake totals ranging from zero to 2160 milliliters, which did not align with the ordered 1500 milliliters per day. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dialysis care needs. Licensed Practical Nurses were unsure about the resident's fluid restriction and tunneled catheter, and the Dialysis Clinical Coordinator confirmed that the tunneled catheter was used for dialysis treatments. The Director of Nursing and Quality Assurance Nurse acknowledged that all dialysis access sites should be monitored, and the care plan should include the tunneled catheter, but there was no documented evidence of monitoring by the Infection Preventionist nurse.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F698 Corrective Action- To assure that residents requiring [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. 1. Resident #36 orders were reviewed and updated for: 24-hour fluid restriction, and monitoring of the right chest tunneled catheter dressing. The left AV fistula orders were reviewed and discontinued and the interventions have been resolved. The care plan was reviewed and updated to include the right chest wall tunneled [MEDICAL TREATMENT] catheter, interventions for monitoring, and the 11/26/2024 vascular physician recommendations were reviewed by the provider and added to the care plan. The resident is scheduled to have a right arm fistula or graft completed on 4/7/2025. 2. All residents who receive [MEDICAL TREATMENT] treatment have potential to be affected by this practice. A list of all Residents on [MEDICAL TREATMENT] will be created and audited to assure fluid restrictions are monitored 24 hours a day, physician orders [REDACTED]. 3. To ensure this does not reoccur, the facility policy on [MEDICAL TREATMENT] will be reviewed and updated as needed. LPN and RN staff will be educated on said policy and written test to be provided to ensure competency. The Director of Nursing will oversee completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform audits of all [MEDICAL TREATMENT] residents each month for 3 months, and then as needed based on findings. Audits will include monitoring of any fluid restrictions, monitoring of physician orders [REDACTED]. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings as needed. If continued improvement is needed the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F698.
Failure to Maintain Electric Beds as per Manufacturer's Guidelines
Penalty
Summary
The facility failed to ensure that patient care-related electrical equipment, specifically electric beds, was properly maintained according to the manufacturer's specifications. During the Life Safety Code Survey, it was observed that electrically operated beds were in use throughout the facility without documented formal inspections or maintenance. The facility's policy on medical equipment management required that all medical and electrical patient care equipment be evaluated prior to use and maintained according to specific criteria. However, there was no inventory or unique identification for the electrically operated beds, and no preventative maintenance forms were available to indicate that electrical safety checks were conducted routinely as required by the manufacturer. The survey revealed that the M.C. Rexx brand bed manual specified that each bed should be inspected at least once a year by qualified technicians, with a detailed checklist provided for the inspection. Despite this, the facility did not maintain records of such inspections. The Environmental Services Director confirmed that beds were checked annually using a room audit form, but there were no unique identifiers for the beds, and specific beds were not identified during these audits. This lack of documentation and adherence to the manufacturer's maintenance requirements constituted a deficiency in the facility's compliance with the 2012 edition of NFPA 99, Health Care Facilities Code, which mandates the establishment of policies and protocols for testing patient care-related electrical equipment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K921 Corrective Action- To ensure the facility meets all the requirements for NFPA 101 Electrical Equipment Testing and Maintenance in regards to the testing of portable patient care related electrical equipment (PCREE), specifically patient electric beds. 1. The Maintenance Director has obtained manufacturers recommendations for each type of in-house electrical bed, and created an auditing system to monitor testing of each type of bed per manufacturer recommendations. 2. The Maintenance Director will complete a full house audit of resident beds to ensure all bed types are inspected per manufacturer recommendations, and documented as required by the NFPA 101. 3. The Administrator will oversee in-services to all maintenance department staff in regard to the NFPA 101 guidelines for patient care related electrical equipment testing and maintenance requirements. 4. To prevent future deficit in this practice, the Maintenance Director will perform 1 audit per month for 3 months to ensure bed inspections have been performed and documented according to the manufacturers recommendations. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K921.
Failure to Conduct and Document Fire Drills for Second Shift
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was found that the facility failed to ensure fire drills were properly performed for one of the three staff work shifts. Specifically, the facility did not conduct a fire drill for the second shift (2:00 PM to 10:00 PM) during the fourth quarter of 2024. The fire drill reports for the fourth quarter listed drills conducted on October 31 at 8:43 AM, November 1 at 9:30 AM, and December 27 at 4:00 AM, none of which covered the second shift. Additionally, the fire drill report dated November 1, 2024, lacked staff signatures or documentation of staff participation, with the attendance section left blank. The Environmental Services Director admitted to not using a schedule for fire drills and acknowledged the oversight in conducting the second shift drill and obtaining staff signatures.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K712 Corrective Action- To ensure that the facility meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Drills. 1. On 3/6/25 a 2nd shift fire drill was performed to compensate for the missed second shift fire drill from the fourth quarter of Calendar Year 2024. 2. The Maintenance Director will complete an audit of fire drills for Calendar Year 2025, to ensure fire drills are properly documented (including sign in sheets) and performed on each shift as required by The Life Safety Code of the NFPA. 3. The Administrator will oversee in-services to all maintenance department staff in regards the importance maintaining compliance with the NFPA Fire Drill requirements. 4. To prevent future deficit in this practice, the Maintenance director / designee will perform 1 audit per month for 3 months to ensure fire drills have been performed and documented quarterly on each of 3 shifts. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K712.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Painted Post
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corning Center For Rehabilitation And Healthcare | 4 mi | ★★★★★ | 0 | 0 |
| Elcor Nursing And Rehabilitation Center | 13.9 mi | ★★★★★ | 6 | 0 |
| Bethany Nursing Home & Health Related Facility Inc | 15.1 mi | ★★★★★ | 0 | 0 |
| Steuben Center For Rehabilitation And Healthcare | 16.9 mi | ★★★★★ | 2 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 17.1 mi | ★★★★★ | 3 | 0 |
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