Comprehensive Rehab & Nursing Ctr At Williamsville

Penalty

No penalty information released

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

The deficiency involves the facility’s failure to follow required transfer and discharge processes, including written notification to residents, their representatives, and the State Long-Term Care Ombudsman at least 30 days prior to transfer or discharge. The facility’s policy "Discharge Plan - Discharge Instructions" required that each resident with an anticipated discharge date receive necessary information and connections to outside services, and that each department interview the resident and continuing care provider to assess post-discharge needs and develop a plan. Despite this, three residents reviewed for transfer or discharge did not receive proper written notices or complete discharge planning consistent with regulatory requirements. Resident #3 had dementia, type II DM, and depression, and their MDS dated 10/13/2025 documented that they were cognitively intact, always understood, and always understood others, with no active discharge plan indicated. A single progress note by Social Worker #1 on 11/17/2025 stated that the representative had been informed the facility planned a lateral discharge to a more secure locked unit and that the resident would transfer to the first facility with an open bed. Social Worker #1 later stated the resident was discharged because they required a more secure unit due to dementia and wandering, but could not locate documentation of recent wandering behaviors or recent wandering/elopement assessments and could not recall who had reported the elopement risk. The transfer/discharge notice for this resident was dated 11/13/2025, cited that the resident’s needs could not be met at the facility, and indicated a lateral transfer to a secure locked unit, but the resident/representative signature line was blank, and there was no evidence the representative received written notice 30 days in advance. The nutritional section of the IDT discharge instructions dated 11/14/2025 for this resident was not completed. Resident #4 had dementia, bipolar disorder, and anxiety disorder, and their MDS dated 09/12/2025 documented that they were cognitively intact, always understood, and always understood others. This resident was discharged on 11/14/2025, and the discharge notice was completed and dated 11/13/2025 by Social Worker #1, but the resident signature line was blank, with no indication of written notice being provided 30 days prior to discharge. Resident #5 had polyneuropathy, bipolar disorder, and anxiety disorder, with an MDS dated 10/16/2025 showing they were usually understood, always understood others, and were moderately cognitively impaired. A late-entry progress note by Social Worker #1, effective 11/17/2025, documented that the resident was notified of discharge and given the discharge notice and summary upon discharge, although the resident had actually been discharged on 11/14/2025. The discharge notice for this resident was dated 11/13/2025 and the resident signature line was marked "Verbal Consent" instead of containing the resident’s signature. This resident later filed an appeal and was readmitted. In an interview, this resident stated staff did not tell them they were moving, that staff came into the room the morning of the move, packed them, and moved them, and that they had to beg to return. Interviews with facility staff and the Ombudsman further described failures in the notification process. Social Worker #1 stated they believed they spoke with Resident #3’s representative on 11/11/2025 about the planned discharge and allowed time for the representative to research two facilities, but did not call the representative prior to the actual move, despite the representative’s request to be notified so they could be present. Social Worker #1 acknowledged that the representative later complained about not being notified of the timing of the move and not receiving a written transfer/discharge notice. Social Worker #1 also stated they sent transfer/discharge notices to the Ombudsman and that three residents, including Residents #3, #4, and #5, were discharged to the same facility on 11/14/2025. However, the email to the Ombudsman with attached discharge transfer notices was dated 11/18/2025, after the transfers had occurred, and the Ombudsman reported they had not been receiving discharge notices from the facility and had only received one notice since July 2025. The Ombudsman stated that residents and their representatives should receive written notice 30 days prior to transfer or discharge and that the Ombudsman should receive a copy the same day, and also noted that the forms used by the facility prior to 11/17/2025 were outdated and did not meet current regulatory requirements. The Administrator stated that if a resident was agreeable to a move, the facility did not believe a 30-day transfer/discharge notice was required, and that if a resident was responsible for themselves, family would not need to be notified of a transfer. The Administrator also stated that they would only issue a 30-day transfer/discharge notice to a resident who was discontent with leaving the facility. The Ombudsman, who also served at the receiving facility, reported learning of the moves of four residents to the other facility after receiving calls from family members and the receiving facility that the residents were unhappy about the move. Overall, the record review and interviews showed that the facility did not provide timely, complete, and properly documented written transfer/discharge notices to the three residents and their representatives, nor did it send copies to the Ombudsman at least 30 days before the transfers or discharges, as required by 10 NYCRR 415.3(i)(1)(i–vii).

Penalty

No penalty information released

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

The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan, specifically related to an order for compression therapy for leg edema that was never entered or implemented. Resident #1, admitted for short-term rehabilitation with diagnoses including heart failure, heart disease, hypertension, coronary artery disease, atrial fibrillation, and cognitive impairment, had ongoing lower extremity edema documented in nursing progress notes. Notes showed repeated leg elevation and swelling observations, and an order for Lasix was obtained when the legs appeared more swollen than usual. However, there were no documented new orders for any type of compression therapy in the electronic medical record, physician orders, or Treatment Administration Record during the review period. A medical provider progress note by the Physician Assistant on 09/29/2025 documented that compression was ordered as an addition to the resident’s treatment, with the PA later clarifying they intended ace wraps and expected the order to be entered as soon as possible. At the time, providers could not enter their own orders into the facility’s EMR, and the PA did not communicate the compression order directly to nursing staff. Interviews with nursing staff and leadership revealed that Unit Managers or RN Supervisors were expected to receive, clarify, and enter new provider orders by the end of the day or within 24 hours, but the Unit Manager reported often not seeing new orders because providers did not give them directly and acknowledged not reviewing the provider’s note or being aware of the compression order. The DON and Administrator both stated that the order should have been entered and implemented, and the RN Supervisor confirmed that new orders were expected to be put in right away by the Unit Manager or RN Supervisor. As a result, the compression order documented by the PA was never transcribed into the EMR or carried out for Resident #1.

Penalty

No penalty information released

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

A deficiency occurred when a resident's right to be free from misappropriation of property was not maintained. The resident, who had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and general anxiety disorder, and was assessed as having moderately impaired cognition, reported their credit card and driver's license missing after finding their wallet on the floor of their room. The resident had last seen the card after returning from dinner with their daughter and noticed the items missing two days later. The resident's daughter reported the theft to the police and the bank, and fraudulent charges totaling $1,041.41 were made at apparel stores. The resident stated they had a drawer with a lock in their room but never received a key, and would have used it for safekeeping if available. The resident's purse was kept attached to their walker next to their bed. The facility's policy defined misappropriation as theft or unauthorized use of a resident's property, including money and other possessions. There was no documentation in the resident's care plan addressing the safekeeping of personal items. The incident was reported by the former DON, who, along with Human Resources, reviewed video surveillance at the police station and identified a CNA as being involved in the fraudulent use of the credit card. The CNA denied knowingly using a resident's card, stating a coworker had given them the card to make a purchase, and claimed not to have known it belonged to a resident. The police investigation was ongoing at the time of the report. Interviews revealed gaps in facility communication and documentation. The interim DON acknowledged that theft of a credit card constituted misappropriation and abuse. The Administrator was unaware of the incident, stating they had not been informed by the former DON and were unable to locate relevant documentation. The current social worker was not employed at the time of the incident and had no information. The facility was unable to confirm whether the resident's right to be free from misappropriation had been maintained, and the Department of Health had more information than the facility at the time of the survey.

Penalty

No penalty information released

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

The facility failed to thoroughly investigate and report an alleged misappropriation of a resident's credit card, as required by regulation. The incident involved a resident with chronic obstructive pulmonary disease, atrial fibrillation, and general anxiety disorder, who had moderately impaired cognition. The resident discovered their wallet on the floor and noticed their credit card and driver's license were missing. The resident's daughter reported unknown charges on the card, totaling $1,041.41, and filed a police report. The facility's former DON submitted an initial report, but there was no evidence of a completed investigation, incident report, or timely notification to the Administrator. The alleged perpetrator, a CNA, was identified through police investigation, but had already been removed from the schedule due to expired certification prior to the report of the incident. Interviews with facility staff revealed that neither the interim DON nor the Administrator could locate an accident or incident report related to the theft. The Administrator was unaware of the incident and stated that they should have been notified and that an incident report should have been completed. The investigation did not include statements from the resident, potential witnesses, or the alleged perpetrator, and there was no documentation of protective measures for the resident or follow-up actions after the allegation was verified. The CNA involved was not contacted by the facility regarding the incident and only learned of the situation when approached by police. Additionally, the facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property was outdated and lacked specific procedures for investigating allegations, interviewing involved parties, protecting alleged victims, and reporting within required timeframes. The interim DON and Administrator acknowledged that policies were outdated and that policy revisions had not been prioritized over staffing concerns. The lack of a current, comprehensive policy contributed to the facility's failure to respond appropriately to the alleged violation.

Penalty

No penalty information released

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

A deficiency occurred when a resident was re-admitted to the facility and their admission medication orders were not entered into the electronic medical record or implemented until two days after their return. The facility's policy requires that admission or readmission orders from a licensed provider be entered into the electronic system upon a resident's arrival, but this process was not followed. As a result, the resident did not receive any prescribed medications during this period. The resident in question had a medical history including schizophrenia, anxiety disorder, and hypertension, and was discharged from the hospital with a comprehensive list of medications. Upon re-admission, the resident reported not receiving any medications after arrival at the facility, despite having received their morning medications at the hospital. Nursing staff confirmed that no medication orders were present in the electronic system, and the resident's name did not appear in the electronic medication administration record (EMAR), preventing medication administration. Interviews with facility staff revealed a breakdown in communication and process. The unit manager assumed that batch orders in the system were complete, but these did not include the resident's hospital discharge medications. The on-call provider was not notified to review or sign admission orders, and the Director of Nursing confirmed that the responsibility for entering orders was not fulfilled. As a result, the resident did not receive any medications until the orders were finally entered and signed two days after re-admission.

Penalty

No penalty information released

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

The facility failed to ensure that residents were informed about the grievance process and did not have an established grievance policy to ensure the prompt resolution of grievances regarding residents' rights. During a Resident Council meeting, all seven attendees expressed that they were unaware of how to file a grievance or who the Grievance Officer was. The residents also mentioned that the facility did not consistently respond to their concerns, which included staffing and customer service issues. Interviews with staff revealed a lack of awareness about the grievance process, with the Activities Department Director and the Director of Nursing both indicating they were unsure of the grievance policy or the location of grievance forms. Further investigation revealed that the Social Worker, who was responsible for handling grievances, had recently terminated their employment, leaving the facility without a designated Grievance Officer. The Administrator admitted that grievance forms were not readily available at the reception desk and that grievances were not being reviewed or followed up on as required. The grievance binder provided by the Administrator contained forms without department head follow-up or signatures, indicating a failure in the grievance process. The Director of Nursing confirmed that the facility did not have a grievance policy and procedure in place.

Plan Of Correction

Plan of Correction: Approved January 6, 2025 1. Social Worker met with resident 17, 34, 36, 61, 70, 82, and 96 and a copy of the updated policy and procedure was provided to explain the grievance process. Social Worker also explained to residents that the Social Worker is the grievance coordinator. All residents were provided a copy of the grievance policy and procedure with the Grievance Coordinator's name by the Social Worker. A resident council meeting was held with the Social Worker to review the process. Grievance posters and Ombudsman posters are posted on all floors, the front desk, and the chapel. The Ombudsman will be provided the resident council schedule to allow them the ability to participate. Resident rights will be reviewed at the monthly resident council meeting. 2. All residents are at risk for deficient practice of not having a process in place for residents to voice concerns. 3. Administrator created a new policy and procedure for grievances, including who is the grievance coordinator. 4. All residents were given a copy of the new grievance procedure, including who is the grievance coordinator. A family meeting was held on (MONTH) 15, 2025, to discuss the new policy and procedure on grievances. All staff were educated by the RN Educator on the new grievance policy and with all new general orientation for all new hires. 5. Social Worker was educated by the Administrator regarding the new policy and procedure. 6. All grievances will be reviewed monthly at QAPI for trends. Any deficient findings will be corrected. Person Responsible: Social Worker

Penalty

No penalty information released

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

The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies from previous surveys. The deficiencies included issues with developing comprehensive care plans, maintaining a safe and clean environment, and ensuring proper food storage and sanitation. The facility's QAPI program was not effectively implemented or monitored, leading to ongoing noncompliance in these areas. The lack of effective systems to address these deficiencies was highlighted by the repeated citations for the same issues over multiple surveys. The facility also faced challenges with infection prevention and control, as well as activities of daily living (ADL) care for dependent residents. The QAPI committee failed to institute and follow corrective actions to prevent the recurrence of these deficiencies. The facility's inability to maintain compliance was further exacerbated by staff turnover, including the loss of key personnel such as the Nurse Educator and Assistant Director of Nursing, which hindered the facility's ability to audit and educate new staff effectively. Additionally, the facility did not have functioning bathtubs in the shower rooms, posing a safety hazard for residents. The Administrator was unaware of this issue, indicating a lack of oversight and communication within the facility. Furthermore, the facility lacked a specific Grievance Officer and a grievance policy, resulting in resident grievances not being reviewed or addressed properly. The termination of the Social Worker, who was responsible for handling grievances, further contributed to the facility's inability to manage resident complaints effectively.

Removal Plan

• The Assistant Director of Nursing would report to the QAPI committee to determine if any further process changes or approaches were needed for comprehensive care plans.
• The floor charge nurse along with the Assistant Director of Nursing would report their findings for chin hair removal and long fingernails and corrective action will be taken as necessary by the QAPI committee.
• The Food Service Director along with the QAPI committee will submit audit findings for foods unlabeled/outdated in the refrigerators until problems were resolved.
• Audit results for housekeeping and maintenance services will be reported to the Quality Assurance and Performance Improvement committee and the frequency of ongoing audits will be determined based on the audit results.
• Audit results for transmission-based precautions and adequate hand hygiene will be reported to the Quality Assurance and Performance Improvement committee and frequency of ongoing audits will be determined based on the audit results.
• The administrator will meet with the Director of Food Service and Director of Maintenance to review any kitchen/food service-related repairs and assign priority tasks.
• Audits will be performed by the Director of Food service.
• The Consultant will conduct random onsite audits of the food service areas and report findings to the QA&A Committee.
• An audit tool was to be developed to track completion of all audits; audits will be submitted to the administrator/designee for review to ensure compliance.
• Audit results will be reported to the QA&A Committee. Frequency of ongoing audits will be determined by the Committee based on the results.
• The Consultant will conduct random onsite audits of the cited areas and attend the meeting.

Penalty

No penalty information released

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

The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented for several residents, leading to deficiencies in meeting their medical and nursing needs. Resident #10, who had multiple sclerosis, diabetes mellitus type 2, and pressure ulcers, did not have care plan interventions for their pressure ulcers until a month after admission, despite having stage III and unstageable pressure ulcers. The Director of Nursing acknowledged the lack of interventions and added them only after the surveyor's request. Resident #25, diagnosed with dementia and stroke, required assistance with oral hygiene but did not have a care plan for denture care. The care plan lacked documentation of the resident's dentures, which was necessary for proper hygiene and to prevent bacterial growth. Interviews with nursing staff revealed that care plans had not been updated recently, and there was a lack of awareness about the resident's denture needs. Residents #36 and #41 were involved in an alleged altercation, but their care plans did not include interventions to prevent future incidents. The facility's investigation documented the altercation, but no care plan updates were made to address the issue. Additionally, Resident #43's care plan was missing focus areas, goals, and interventions for various diagnoses and treatments, while Resident #65's care plan lacked documentation for bladder incontinence, falls, and other critical areas. The Director of Nursing and other staff members acknowledged the deficiencies and the importance of timely and comprehensive care planning.

Plan Of Correction

Plan of Correction: Approved January 6, 2025 1. Resident #10's careplan was reviewed by IDT Team and was updated to reflect wounds. The admissions nurse was reeducated on having careplan in place upon admission. Resident #25's careplan and closet care plan was reviewed by IDT and careplan was updated to reflect denture care. Resident #36's and resident #41 had careplan reviewed by IDT for behaviors by IDT and plan was updated to reflect residents status. Resident #43's careplan was reviewed by IDT and careplan and closet care plan was updated to reflect current status. Nurse who did residents admission was updated on policy and procedure on careplans by Director of Nursing. Resident #65 careplan and closet careplan was reviewed by IDT and updated to reflect current status. All residents Careplans were reviewed by RN for updated careplans reflecting current status. 2. All residents are at risk for deficient practice of not completing the careplan on admission and updating the careplan during the 21 day admission period as well as Quarterly and Annually to reflect changes occurred by resident. 3. Policy and procedure for baseline careplans and comprehensive careplan was reviewed by Director of Nursing. No changes were made to policy. 4. Outside consultant educated IDT on comprehensive careplan process and baseline careplanning. All licensed nurses were educated on careplan and closet care plan process by RN Educator. The Director of Nursing will be educated on the comprehensive careplan policy and procedure by the Consultant. 5. All new admissions will be audited weekly for 4 weeks and monthly for 6 months to ensure all areas are careplanned and on closet careplan for staff to provide care to residents. CCP will be audited by MDS coordinator to ensure CCP reflects all areas weekly for 1 month and monthly for 6 months. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing

Penalty

No penalty information released

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 a Life Safety Survey, it was observed that corridor doors in a long-term care facility were not properly maintained, leading to obstructions and failure to latch into their frames. On Unit 6, a folding walker and a trash receptacle were found obstructing the doors to Resident Rooms 631 and 633, respectively. On Unit 5, a plastic door chock was wedged under the door of Resident Room 519, and a chair was placed against the door of Resident Room 532, preventing them from closing. Additionally, a three-foot-tall circular floor fan was obstructing the Server room door in the Basement A Wing, which was left open due to a broken air conditioning unit. The Maintenance Director confirmed the fan was used to cool the equipment in the room. Further observations revealed that the corridor door of the Employee Break room in the Basement did not latch due to being hung up on its frame. The Maintenance Director mentioned that a request for an angle grinder to fix the metal door had not been approved. On Unit 6, three-drawer precautions cabinets were found obstructing the doors to Resident Rooms 610 and 617, and a similar cabinet was found against the door of Resident Room 526 on Unit 5. The facility's Annual Door Audit sheets indicated that the corridor doors had been checked in September 2024, but these issues persisted, affecting the safety and functionality of the doors.

Plan Of Correction

Plan of Correction: Approved January 2, 2025 1. 1st Floor - Unit 6 - Folding walker against corridor door to Resident Room 631 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - Trash receptacle against corridor door of Resident Room 633 obstructing the door from closing was removed during survey. 1st Floor - Unit 5 - Plastic Chock wedged under the corridor door of Resident Room 519 obstructing the door from closing. When chock removed, the door did not self-close or latch into its door frame. The door was repaired by Maintenance Director. 1st Floor - Unit 5 chair against the corridor door of Resident Room 532 obstructing the door from closing was removed during survey. Basement - A Wing - Floor Fan against Server Room Corridor door (A5) obstructing the door from closing was removed during survey. Basement - corridor door (B6) of the Employee Break room did not latch into its doorframe. The door was repaired by Maintenance Director. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 610 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 617 obstructing the door from closing was removed during survey. 1st Floor - Unit 5 - precaution cabinet stored in front and against the corridor door of Resident Room 526 obstructing the door from closing was removed during survey. 2. All Residents are at risk for deficient practice of obstructed doors and doors not closing and latching in their frames. 3. A 100% audit of all Units/corridor doors was conducted on 12/26/2024 to ensure that all doors are unobstructed. Any deficient findings were corrected immediately. 4. A 100% audit of all doors/latches and doorframes was conducted on 12/26/2024 to identify any doors not properly functioning. Any deficient findings were corrected immediately. 5. Administrator reviewed policy and procedure on corridor doors. No changes were made to the policy. Administrator educated Maintenance Director and Maintenance Tech on the policy and procedure of obstructed doors and doors latching properly. 6. All staff will be in-serviced with a post-test for competency by the Consultant regarding properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. 7. The Director of Maintenance will conduct a monthly survey of all corridor doors and report findings to the QAPI Monthly Meeting. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that extension cords and a power strip were improperly used to provide a permanent power supply to various equipment in the facility. On the First Floor, a power strip connected to an extension cord was supplying power to a television in the Chapel. The Maintenance Director, upon being interviewed, was unaware of this setup and mentioned that residents typically watched television near the Chapel entrance or in their rooms or lounges. Additionally, in the Basement, an extension cord was found supplying power to a computer in the Housekeeping and Laundry Director's office, which the Maintenance Director was also unaware of. Further observations on the First Floor in Unit 6 revealed two extension cords supplying power to two televisions in a resident room. The Maintenance Director stated they were not aware of the extension cords being used in this room either. Despite having documentation for checks, the facility's audit of power strips in resident rooms, conducted on a previous date, did not prevent these deficiencies. The survey identified these issues as non-compliance with specific NFPA standards and state regulations.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Extension cord was being used to supply a permanent source of power to a television in the Chapel was removed by Maintenance Director. Extension cord was being used to supply a permanent source of power to a computer in the Housekeeping and Laundry Director's office was removed by Maintenance Director. Extension cords were being used to supply a permanent source of power to two televisions in Resident room [ROOM NUMBER] was removed by Maintenance Director. 2. All residents are at risk for deficient practice of using extension cords and power strips being used as a supply of power to equipment. 3. An entire house audit will be conducted to check for use of extension cords. Any deficient practices will be corrected and brought to QAPI for further review. 4. All staff were educated by RN Educator regarding policy and procedure use of extension cords. All residents and families received written notice on use of extension cords by Administrator. 5. A monthly audit of extension cords will be conducted by Maintenance and any deficient practices will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

An emergency generator at the facility was not properly maintained, as evidenced by the lack of documentation for required inspections and tests. The facility failed to provide records verifying that weekly inspections of the emergency generator were conducted prior to April 23, 2024. Additionally, there was no documentation that the generator was run under load for at least 30 minutes monthly before March 12, 2024. The absence of these records indicates that the facility did not adhere to its policy and procedure titled 'Generator Maintenance - Emergency Power Use,' which mandates weekly spot checks and monthly load testing to ensure operational status. Furthermore, the facility did not have documentation of an annual inspection of the building's electrical system main and feeder circuit breakers for the years 2023 and 2024. This deficiency affected the entire first floor, including all resident units, the second-floor administration area, and the basement. The Maintenance Director confirmed the lack of documentation during an interview, highlighting the facility's failure to comply with the relevant codes and standards, including the 2012 NFPA 101 and 2010 NFPA 110, which require regular maintenance and testing of emergency power systems.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Administrator and Maintenance Director reviewed past year worth of testing and lack of documentation including weekly inspections of the generator. Maintenance Director has been running generator tests per policy since he started. An Annual inspection of the buildings electrical system main and feeder circuit breakers was completed by outside vendor. 2. All residents are at risk for deficient practice of not having generator run on full load for 30 minutes monthly and annual inspection of buildings electrical system main and feeder circuit breakers. 3. Administrator educated Maintenance Director and Maintenance Tech on Generator policy and procedure. 4. A monthly audit of generator will be conducted by Maintenance Director and brought to QAPI for review. Any deficient practices will be corrected immediately. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that electrical junction boxes were not maintained properly, as covers were missing from several boxes. This issue was identified in two of the three resident units and the basement of the facility. Specifically, missing covers were found in the basement storage room, above the Unit 6 corridor ceiling near the Beauty Shop, above the smoke barrier doors near a resident room, near the ceiling-mounted illuminated exit sign at the entrance to Unit 5, and above the tub in a bathroom in a resident room. The Maintenance Director acknowledged that maintenance staff checked electrical junction boxes for covers when working above ceiling tiles but admitted there was no documentation for these checks.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The two electrical junction boxes in the storage room were fixed by the Maintenance Director. Junction box near the beauty shop was replaced by the Maintenance Director. The electrical junction box located above the smoke barrier near resident room [ROOM NUMBER] was replaced. The electrical junction box located near the ceiling-mounted illuminated exit sign at the entrance to Unit 5 was replaced by the Maintenance Director. The junction box located above the tub in the bathroom in Resident room [ROOM NUMBER] was replaced by the Maintenance Director. 2. All residents are at risk for deficient practices of missing electrical junction boxes. 3. A full house audit of all junction boxes will be conducted by Maintenance. Any deficient practices will be fixed and brought to QAPI for further review. 4. Administrator educated Maintenance Director/Tech on junction boxes. 5. All junction boxes will be audited quarterly to ensure junction boxes are in place and in good condition. Any deficient practices will be fixed immediately and brought to QAPI for further review. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility's fire and evacuation policies and procedures were found to be inconsistent with the actual practices during a Life Safety Code survey. The documented Fire Plan Policy required the use of red circular magnets to mark evacuated rooms, but observations revealed the absence of these magnets in resident rooms. Instead, orange and yellow plastic tags were found in fire extinguisher cabinets, which were used to identify fire rooms and evacuated rooms, respectively. Interviews with the Administrator and Maintenance Director confirmed the use of these tags, but they were unaware of the red magnets mentioned in the policy. Further interviews with the Infection Preventionist, who had been assisting with new employee orientations, revealed a lack of documentation and education regarding the use of room marking tags. The Infection Preventionist was not provided with any materials about the marking system and verbally instructed staff based on the available tags. Fire Drill Reports from earlier in the year indicated that knowledge of room tags was part of the observations, yet the facility's current practice did not align with the documented procedures, leading to the deficiency.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. A review of the fire/evacuation policy and procedure was conducted by Administrator on 12/31/2024. The Policy and procedure was updated for fire and evacuation during potential fire. 2. All residents are at risk for policies and procedures for fire evacuation not matching the actual procedures. 3. RN Educator will educate all staff on the new policy and procedure for fire and evacuation practices. 4. A mock drill was conducted on fire and evacuation procedures. The drill was discussed at QAPI and any deficient practices were reeducated. 5. The facility will audit all fire drills conducted monthly. Any deficient practices will be addressed and brought to QAPI for further review. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility was found to be deficient in conducting and documenting fire drills as required by New York State law. The policy and procedure titled 'Fire Drill' mandates that drills be conducted quarterly across all shifts. However, during the Life Safety Code survey, it was discovered that the facility lacked documentation for a Second Shift fire drill in the Second Quarter of 2024. Additionally, there was no documentation for any fire drills conducted prior to May 10, 2024. The Maintenance Director confirmed that the previous Maintenance Director claimed to have conducted a fire drill but failed to submit the necessary paperwork, stating it was left in his car. The review of Fire Drill Reports showed that drills were conducted on May 10, 2024, at 1:30 PM, and on June 28, 2024, at 11:10 PM. However, there was no evidence of a Second Shift drill in the Second Quarter, as required. This lack of documentation and failure to conduct the necessary drills on all shifts led to the citation under 10 NYCRR 415.29(a)(2), 711.2(a)(1), and 2012 NFPA 101 standards.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. A review of all fire drills was completed by Maintenance Director and Administrator for the past year. All deficient practices were discussed and lack of paperwork was noted to QAPI. 2. All residents are at risk for deficient practices of not completing fire drills on all 3 shifts quarterly. 3. Administrator educated Maintenance Director/Maintenance Tech on Fire drills and holding each drill per shift quarterly. 4. Monthly audit of all fire drills will be conducted and brought to QAPI for further review. Any deficient practices will be corrected. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, deficiencies were identified in the storage and maintenance of oxygen cylinders in a long-term care facility. On Unit 1/2, two E-sized oxygen cylinders were found stored in a Clean Utility room, only four inches away from combustible materials such as cardboard boxes containing disposable gowns and face shields. The room's door was not lockable, and there was no signage indicating the presence of oxygen cylinders. The Maintenance Director acknowledged the oversight, noting that the cylinders should have been stored in the designated Oxygen Storage room. On Unit 5, an E-sized oxygen cylinder was stored in the Oxygen Storage/Clean Linen room, just three inches from a metal rack containing various linens. Additionally, a C-sized and an E-sized oxygen cylinder were found free-standing and unsecured in a resident's room, between a wooden dresser and wardrobe. The Maintenance Director was unaware of this improper storage and confirmed that staff were instructed to secure oxygen cylinders in a cart or rack. Despite daily checks of oxygen storage rooms, these deficiencies were not addressed, indicating lapses in adherence to safety protocols.

Plan Of Correction

Plan of Correction: Approved January 9, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A full facility audit of all oxygen storage areas was conducted to ensure that oxygen cylinders were properly stored, and proper signage was in place. A full facility audit was conducted of all storage and utility rooms to ensure that oxygen cylinders were not improperly stored in these rooms and where oxygen storage cabinets exist, that proper signage was in place and that doors were lockable. A full facility audit of all resident rooms was conducted to ensure that all oxygen cylinders were properly stored, and proper signage was in place. Two E Oxygen Cylinders were placed back in the proper storage areas during survey. The cardboard boxes of disposable gowns and shields were removed from the area during survey. Signage for the door was placed on door and door was repaired allowing the door to latch. The oxygen cylinders on Unit 5 were placed back in the proper storage units during survey. The oxygen cylinder located on unit 5, a c sized cylinder, was placed in the oxygen room during survey. The oxygen cylinder in resident room [ROOM NUMBER] was removed from room and placed in oxygen storage area during survey. 2. All residents are at risk for oxygen cylinders being placed 5 feet from combustible materials, room where oxygen was stored is not lockable and no signage in room where oxygen is stored and oxygen cylinders free standing and unsecured. 3. The Policy Oxygen Supplies and Concentrators Inventory revised 12/24 to include the verbiage regarding oxygen cylinders being stored less than five feet from combustible materials, doors to rooms that oxygen cylinders were being stored in being lockable, room that oxygen cylinders were being stored in having signage indicating that oxygen cylinders were being stored in that room, and oxygen cylinders not being stored free standing and unsecured was reviewed by the Consultant, no revision was necessary. 4. All facility staff will be in-serviced on proper storage of medical gases by the Consultant, (NAME) J Pietrowski, MSN RN LNHA. 5. Five audits will be conducted weekly on oxygen cylinders being placed within 5 feet from combustible materials, ensuring door to oxygen room is properly locked. Signage is available where oxygen is stored and oxygen is in secured storage. Any deficient practices will be immediately corrected and brought to QAPI for further review. Person Responsible: Maintenance Director Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that hazardous area doors in the facility were not maintained properly, affecting multiple units and areas. Specifically, doors in Unit 1/2 and Unit 5 on the First Floor, as well as several storage and utility rooms in the Basement and the Second Floor Administration area, failed to self-close and latch into their door frames. In some cases, the doors were obstructed by objects such as a five-gallon bucket or had their self-closing devices detached, preventing them from functioning correctly. These deficiencies were noted in areas storing soiled linen, trash, medical supplies, and other materials. The survey revealed that in several instances, the doors were intentionally obstructed or altered to facilitate easier access for staff, such as taping over latch plates or removing door closer arms. The Maintenance Director acknowledged these issues during interviews, indicating that staff might have removed door closer arms to ease the movement of supplies. Additionally, some doors were found to be hung up on the floor, preventing them from closing properly, and requests for necessary tools to fix these issues had not been approved by the facility's owner. The facility had documentation of inspections conducted on hazardous area doors, but the deficiencies observed during the survey suggest that these inspections were either inadequate or not acted upon. The report does not mention any immediate corrective actions taken by the facility to address these issues, nor does it indicate any potential consequences or risks directly stated in the report.

Plan Of Correction

Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A 100% audit of all doors/latches and doorframes was conducted on 1/3/2025 to ensure proper functioning. The door to Unit 1/2 Soiled Utility Room (near Resident room [ROOM NUMBER]) latch on the inside the door was repaired by Maintenance Director. Unit 5 Soiled Utility Room (near Resident room [ROOM NUMBER]) was repaired by Maintenance Director. Folded paper towels that were taped over the latch plate preventing the door from latching were removed during survey 12/6/2024. Unit 5 apartment door was repaired by Maintenance Director. Basement - LaVerna was repaired by Maintenance Director. The arm of the self-closing device on the right leaf was re-attached to the door. Basement - A Wing Housekeeping Storage Room Door (A6) was repaired by Maintenance Director. Basement - A Wing Storage Room door (A2) was repaired by Maintenance Director. The door's self-closing device was re-attached to the door. Basement - B Wing Housekeeping Supply Storage Room Doors (B5) and (B7) was repaired by Maintenance Director. The arms on both door's self-closing devices were re-attached to the doors. Basement - C Wing Housekeeping Storage Room door (C12) was repaired by Maintenance Director. Basement - C Wing Boiler Room door (C10) was repaired by Maintenance Director. The floor of the C Wing Corridor was grounded down so the door no longer got hung-up on it. Basement - Activities Storage Room door (A1) was repaired by Maintenance Director. The floor of the basement's center corridor was grounded down so the door no longer got hung-up on it. 2nd Floor Administration area - kitchenette was repaired by Maintenance Director. The floor of the kitchenette was grounded down so that the door no longer got hung-up on it. 2. All residents are at risk for deficient practice of hazardous doors not closing and latching in the frame. 3. All hazardous doors were audited by Maintenance Director for deficient practice of doors not closing and latching in frame. Any deficient finding was immediately repaired. 4. Policy and Procedure for hazardous doors was reviewed by Administrator. No change was made to policy. 5. All staff were in-serviced by the Consultant regarding the regulation for properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. Administrator inserviced Maintenance Director/Tech on policy and procedure for Hazardous Doors. 6. Monthly Audits of door/latches and door frames will be conducted by the Director of Maintenance and reviewed by the Administrator at the monthly QAPI meeting. Any deficient findings will be corrected and brought to QAPI. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility failed to maintain proper illumination of means of egress, as observed during a Life Safety Code survey. Specifically, the survey revealed that continuous egress lighting capable of automatic operation without manual intervention was not provided on the exterior of the building at exit doors. This deficiency affected Unit 6 and the Therapy room located between Unit 5 and Unit 6. Observations on the exterior of the First Floor on Unit 6 showed that there were no light fixtures installed above exit doors (13) and (10), with existing light fixtures positioned too far away and only partially illuminating the doors. Similarly, the Therapy Room's exit door (6) also lacked an exterior light fixture. Interviews with the Maintenance Director confirmed the absence of exterior light fixtures above the mentioned exit doors. The facility's Monthly Outdoor Light Check sheets indicated that the last check of outdoor lights was conducted on 11/22/24, suggesting a lapse in regular maintenance checks. The lack of proper egress lighting is a violation of the 2012 NFPA 101 standards and New York Codes, Rules, and Regulations (NYCRR), which require adequate illumination for safe evacuation routes.

Plan Of Correction

Plan of Correction: Approved January 1, 2025 1. Exterior of the First Floor on Unit 6 had light fixture installed with two light fixtures above exit door by Maintenance Director on 1/17/2025. Exterior of the First Floor on the Unit 6 had two light fixture installed above exit door located by Resident lounge by Maintenance Dir on 1/17/2025. Exterior of the First Floor between Unit 5 and Unit 6 had two light fixture installed by Maintenance Director on 1/17/2025. 2. All residents are at risk for deficient practice of not having proper illumination above means of egress. 3. Administrator reviewed policy and procedure for life safety illumination of egress doors and no change to the policy was institute. 4. Administrator educated Maintenance Director/Maintenance Tech on illumination above egress doors. 5. All egress doors were audited by Maintenance for proper illumination. Any deficient practices were corrected immediately and brought to QAPI for further review. Weekly audits will occur for 8 weeks then monthly for 6 months. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that certain facility doors were not maintained in compliance with safety regulations. Specifically, doors within a means of egress were equipped with locks that required more than one releasing operation to open. On the first floor, the door separating the Unit 1/2 Resident Lounge from the Unit 1 corridor had a thumb turn lock that required two actions to open: turning the thumb lock to the unlocked position and then turning the doorknob. The Maintenance Director confirmed that the maintenance staff had inspected the facility's corridor doors and had documentation for these inspections. Further observations in the basement revealed similar issues with doors leading to storage rooms. The door to the La(NAME) storage room and the Therapy Storage room (A5) both had thumb turn locks requiring two actions to open. These doors were also marked with illuminated exit signs. The facility's Annual Door Audit sheets indicated that the doors were checked in September 2024, but the deficiency persisted, affecting the safety of the egress routes.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. All locks requiring more than one releasing operation were audited on 12/30/2024 by Maintenance Director. The door that separates the first and second unit was audited and the locking mechanism was replaced. The door in the basement by La(NAME) Storage room was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. The door for therapy storage in the basement was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. 2. All residents are at risk for deficient practice of doors within a means of egress being equipped with locking mechanisms with more than one releasing mechanism. 3. The policy and procedure for life safety doors with a section on doors within a means of egress was created on 12/30/2024 by the Administrator. 4. An entire building-wide audit will be conducted on all doors within a means of egress having locks with more than one releasing mechanism. All doors with deficient practice will be repaired. 5. The Maintenance Director/Tech will be educated on this issue by the Administrator on 1/10/2025. 6. The Maintenance Director will report completion of lock changes to the QAPI Committee to ensure compliance with K200. An audit will be completed monthly by the Maintenance Director/Tech to ensure this issue is no longer present in the facility. The QAPI Committee will review completion and determine any further changes needed. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that portable fire extinguishers in the facility were not properly maintained. Specifically, the safety seal or tamper indicator was missing from the fire extinguishers located in the Unit 6 Resident Lounge and the B Wing Laundry room in the Basement. The last recorded monthly inspection for these extinguishers was on November 4, 2024. The Maintenance Director, when interviewed, was unaware of the missing safety seals and stated that they checked the safety seals during monthly inspections. Additionally, in the B Wing Central Supply/Medical Supply room in the Basement, a large metal rack filled with medical supplies was found obstructing access to a portable fire extinguisher. The Maintenance Director explained that a staff member had been organizing the room and must have moved the rack in front of the extinguisher. The facility's fire extinguisher check sheets confirmed that monthly inspections had been conducted throughout the year.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Portable fire extinguisher located in the Unit 6 Resident Lounge tamper seal was replaced by Maintenance Director. Portable fire extinguisher located in the B Wing Laundry room had tamper seal replaced by Maintenance Director. Basement in the B Wing Central Supply/Medical Supply room had items removed from obstruction of portable fire extinguisher by Maintenance Director. 2. All residents are at risk for deficient practice of fire extinguishers missing safety seal and obstruction of fire extinguishers. 3. A complete audit of all fire extinguishers was completed by Maintenance Director. Any deficient practices were fixed. 4. All staff were educated on keeping all fire extinguishers free of obstruction by RN Educator. Maintenance Director/Tech were educated by Administrator to ensure tamper seals are in place on portable fire extinguishers. 5. A monthly audit of all fire extinguishers to check for obstruction and tamper seals will be done for the next 6 months. Any deficient practices will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility's automatic sprinkler system was found to be inadequately maintained during a Life Safety Code survey. Observations revealed that sprinkler piping and hangers were subjected to external loads, with ceiling tiles and a light fixture improperly attached to the sprinkler piping using metal wires. Additionally, electrical wires were taped to a sprinkler pipe. These issues were observed in multiple locations on the First Floor, including above the Unit 6 corridor ceiling near the Beauty Shop and between resident rooms. The Maintenance Director confirmed that there had been no recent work in these areas and that the facility lacked documentation of inspections for the sprinkler piping above the ceiling tiles. Furthermore, the facility failed to provide documentation verifying that the automatic wet and dry sprinkler systems had been inspected, tested, and maintained on a quarterly basis. The Maintenance Director admitted that quarterly inspections and testing were not conducted for the Third and Fourth Quarters of 2023 and the First Quarter of 2024. A review of inspection reports and electronic documentation from the contractor's Property Owner Portal confirmed the absence of records for these periods, indicating a lapse in compliance with required safety standards.

Plan Of Correction

Plan of Correction: Approved January 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility is requesting temporary waiver for F353 in order to make the necessary physical corrections to come into compliance with life safety code for the load on the sprinkler head. a. The Assessment of the sprinkler head load throughout building will be conducted by maintenance by removing all ceiling tiles. This will be done by 1/31/2024. The sprinkler load will be assessed by maintenance weekly until all load items have been removed. b. Building materials needed to be reviewed including removing wires from sprinkler load. This will include removing load from sprinkler pipe and placing on ceiling. Load will be reassessed weekly by maintenance until full removal of load from all sprinkler pipes. The material phase will be completed by [DATE]th. c. Safety plan will include area where maintenance is removing the load on the sprinkler and reinstalling in the ceiling. This will include safety precautions for all residents in work area. Residents will be removed from area while work is being performed. Unit 1/2 will be completed by [DATE]th. Unit 5 will be completed by (MONTH) 14th and unit 6 will be completed by (MONTH) 31st. d. All areas will be reviewed by maintenance staff for goal of 100% removal of wiring on sprinkler pipes and removing all load from sprinkler pipe. This will be completed on (MONTH) 31st. 2. The facility will need until (MONTH) 1, 2025 as the time needed to reinstall ceiling grid and remove it from the sprinkler head is extensive. The time needed is based on in-house labor hours. The facility will institute a safety plan for the project while the ceiling is removed and reinstalled. 3. All wires attached to sprinkler pipe will be removed including first floor corridor unit 6. All ceiling tiles attached to sprinkler head were removed by Maintenance. Light fixture hung from Sprinkler head on First Floor above the Unit 6 corridor ceiling tile between Resident rooms [ROOM NUMBERS] were removed by Maintenance staff. The facility had sprinkler system testing completed by outside vendor. 4. All residents are at risk for deficient practice of obstruction of sprinkler head and testing not being completed per regulations. 5. A full audit of all sprinkler system will be completed to ensure nothing is hanging from the sprinkler system. Administrator and Maintenance reviewed all documentation not completed in past 12 months. 6. Administrator reviewed policy and procedure on sprinkler system including obstruction including external loads and testing required. Changes were made to policy. 7. Administrator trained Maintenance Director/Tech on sprinkler external loads and mandatory testing that needs to be completed. RN educator educated all staff on sprinkler head obstruction on 1/17/2025. 8. 5 weekly audits will be completed by Maintenance on sprinklers to ensure no obstruction or external loads are provided to sprinkler pipes. Any deficient practice will be done and brought to QAPI for further review. Monthly audit of all required testing will be completed monthly by Maintenance Director and brought to QAPI for further review. Any deficient practices will be corrected. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that stairway doors in the facility were not maintained properly, leading to deficiencies. On the First Floor, the Main Kitchen rear stairway exit door failed to self-close and latch into its door frame due to a missing latch. The door had a significant opening where the latch should have been, and the metal around this opening was bent outward. The Food Service Director and the Maintenance Director indicated that the door had been pried open and broken three months prior. In the Basement, two additional stairway exit doors were found to be deficient. The A Wing stairway exit door did not self-close and latch, and it was noted that this door led to the exterior of the building. An illuminated exit sign was present near the door. The Maintenance Director mentioned that the facility had documentation of checks on the stairway doors. Additionally, the Laundry room rear stairway exit door was observed to not self-close and latch due to a door sweep that caused the door to hang up on the floor of the stairway. The Maintenance Director was uncertain if the door sweep alone was the issue or if the door was also catching on the floor. The facility's Annual Facility Door Audit sheets showed that the stairway doors were checked in September.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Main Kitchen rear stairway exit door had self closing mechanism latch replaced by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. Basement A Wing stairway exit door had self closing mechanism installed by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. Basement door by Laundry room rear stairway exit door had self closing mechanism installed and door was repaired by Maintenance on 1/10/2025. Door was then tested to ensure it self closed and latched in the frame. 2. All stairway doors and stairwell areas have potential to be affected by deficient practice of obstruction from closing and latch not working. 3. All facility doors will be inspected to ensure self-closers work properly, and needed repairs to ensure doors close per regulation and latch into frames. 4. The facility’s policy and Life Safety - Means of Egress/ Exits - Hazardous Area Enclosure - Doors with Self Closing Devices, Stairway and Smoke Proof Enclosures policies and audit tool were reviewed and revised to include inspection for penetrations, fire resistance labeling and monthly QA process. 5. Facility Administrator to educate Maintenance Director/Tech on policy and procedure for Means of Egress for self closing devices. 6. A door audit tool will be developed to inspect and identify issues with facility doors including properly working self-closers affixed fire resistance labeling, latching into frame, and without penetrations. - All doors will be audited monthly for 12 months by administrator or designee. - All stairwells will be inspected weekly for 1 month and then monthly for 2 months. - Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results. Person Responsible: Administrator

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that the smoke barrier walls in Unit 5 of the facility were not properly maintained. Specifically, the walls were not complete from floor to roof deck, lacked a 30-minute fire resistance rating, and were not designed to resist the passage of smoke due to penetrations. These deficiencies were identified in several locations: a two-inch by one-inch penetration near a steel support beam above the smoke barrier doors near Resident Room 519, a four-inch by two-inch area filled with mineral wool but not sealed with fire-rated material above the smoke barrier doors near Resident Room 522, and a five-inch by three-inch penetration near plumbing pipes below the sink in the bathroom of Resident Room 522. Interviews with the Maintenance Director revealed a lack of awareness regarding the penetration below the sink in Resident Room 522, and it was noted that no recent plumbing work had been conducted in that area. Furthermore, the Maintenance Director admitted that while the maintenance staff checked the facility's smoke barrier walls, there was no documentation available for these checks. This lack of documentation and awareness contributed to the failure in maintaining the smoke barrier walls as required by the facility's Smoke Barrier Penetration Policy.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. The Unit 5 corridor ceiling penetration next to a steel support beam near Resident Room 519 was sealed by Maintenance. The Unit 5 corridor ceiling penetration located by the corrugated roof deck and the smoke barrier wall above the smoke barrier doors near Resident Room 522 was sealed with a fire rated material by Maintenance Director. The First Floor on Unit 5 penetration near plumbing pipes that were installed through the smoke barrier wall below the sink in the bathroom of Resident Room 522 was sealed with fire rated material by Maintenance Director. 2. All residents are at risk for the deficient practice of smoke barrier walls not being maintained. 3. All smoke barrier walls will be audited for penetrations. Any deficient practice will be repaired. 4. Administrator educated Maintenance Director and Maintenance Tech on Smoke barrier walls and 30 minute resistance rating. 5. The facility will conduct quarterly audits on Smoke barrier walls. Any deficient practices will be repaired and brought to QAPI for further review. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #25, who had diagnoses including unspecified dementia and stroke, was observed multiple times with visible food debris in both their upper and lower dentures. The care plan for Resident #25 did not document the presence of dentures or instructions for their care, and oral hygiene was marked as 'Not Applicable' in the Certified Nurse Aide task documentation. Interviews with staff revealed a lack of awareness and documentation regarding the resident's denture care needs. Resident #10, diagnosed with multiple sclerosis and diabetes mellitus type 2, was observed with long fingernails containing brown debris and 1/2 inch long white chin hairs. Despite the resident expressing a desire for assistance with nail care and chin hair removal, staff did not provide these services. Observations showed that during morning care, the resident's hands and nails were not cleaned, and chin hair was not removed. Interviews with Certified Nurse Aides indicated confusion about responsibilities for nail care and grooming, with some aides believing it was the responsibility of the Activities Department. The Director of Nursing and other staff interviews highlighted a lack of adherence to the facility's policies regarding personal hygiene and grooming. The care plans were not updated to reflect the residents' needs, and there was a failure to provide necessary hygiene services, impacting the residents' dignity and infection control. The facility's policies required regular monitoring and care for residents' oral hygiene and grooming, which were not followed, leading to the observed deficiencies.

Plan Of Correction

Plan of Correction: Approved January 8, 2025 1. Resident #25's care plan and closet care plan was updated by IDT. Resident received oral care on day of survey. The staff on resident #25 unit was educated on resident #25 care plan that reflects oral care CCP. Resident #10 has facial hair addressed during survey. Resident #10's care plan and closet care plan was updated by IDT. The staff on resident #10's unit was educated on facial care plan by RN Educator. A full house review of all residents was completed and all facial hair and nail care per preference was performed. Any deficient practices were corrected immediately. 2. All residents are at risk for deficient practices of ADL care not being completed per plan of care. 3. Policy and procedure titled ADL Care was reviewed by Director of Nursing and no changes were made to policy. 4. All nursing staff were educated by outside consultant on ADL care specifically dental care and facial hair. 5. All residents were audited for facial hair and dental care by RN and compared to CCP. Any deficient practices were corrected immediately. 6. Unit Managers/designee will conduct Care Plan, Closet Care Plan audits of 5 residents weekly on each unit for grooming needs/preferences. Unit LPNs will conduct 5 random observation audits of residents’ ADL/grooming/hygiene each shift during medication passes. Observation audits will be turned into the RN Supervisor/Unit Manager and then turned over to the DON for trending and analyzing. The Unit Managers will conduct 5 random interviews per week with residents regarding grooming and care preferences. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing

Penalty

No penalty information released

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

The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, the staff did not ensure that the resident's left and right palm guards were worn as recommended by occupational therapy. Observations revealed that the resident's hands were not equipped with palm guards during multiple checks, and there was inconsistent documentation of range of motion exercises being performed as per the care plan. The resident in question had a history of cerebral vascular accident, dysphasia, and muscle weakness, with severe cognitive impairment. The care plan required the resident to be on a restorative nursing program, which included assistive active range of motion exercises for the lower extremities and passive range of motion for the upper extremities. The resident was also supposed to wear palm guards except during specific activities. However, the palm guards were not consistently applied, and there were gaps in the documentation of range of motion exercises. Interviews with staff revealed a lack of communication and adherence to the care plan. Certified Nursing Assistants and Licensed Practical Nurses were responsible for ensuring the resident wore the palm guards and received range of motion exercises, but there was no process in place to monitor the documentation. The Director of Nursing and other staff acknowledged the importance of following the care plan but failed to ensure its implementation, leading to the deficiency.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Resident #30 was reviewed by PT/OT for range of motion. Resident #30 had left and right palm guards applied per plan of care. All staff on resident #30 was trained on residents plan of care for left and right palm guards. All staff on resident #30's unit was trained on documentation for range of motion and residents plan of care by RN Educator. 2. All residents with Range of motion orders are at risk for deficient practice of not providing Range of motion or adaptive equipment per plan of care. 3. Director of Nursing reviewed policy and procedure on Range of motion and splints. No changes were made to policy. 4. All Residents with Range of motion orders and/or splints were audited to ensure resident had adaptive equipment applied per plan of care by RN. All residents documentation for past 30 days was audited by RN for documentation regarding ROM and splint use. Any deficient practices were immediately corrected and brought to QAPI for further review. 5. All nursing staff were trained on policy and procedure of ROM and policy and procedure for splint care by RN Educator. 6. 5 residents on Range of Motion will be audited by MDS weekly for 2 months and monthly for 3 months for documentation on range of motion. Any deficient practices will be immediately corrected and brought to QAPI for further review. 5 residents with splint application will be audited by therapy to ensure splints are applied per plan of care, this will be done weekly for 2 months and monthly for 3 months. Any Deficient practices will be corrected immediately. Person Responsible: Therapy Director

Penalty

No penalty information released

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

The facility failed to ensure proper infection control practices for a resident with an indwelling foley catheter. Resident #45, who had a history of urinary infections and dementia, was observed with a urinary drainage bag and catheter tubing that were improperly placed on the floor, which could introduce bacteria into the bladder. The spigot of the urinary collection bag was not secured and was also touching the floor. During an observation, a Certified Nurse Aide emptied the urine from the collection bag without sanitizing the spigot, and the foley catheter was not secured to the resident's thigh as required. The staff member admitted to not having alcohol pads and forgetting to clean the spigot, although they acknowledged the importance of doing so for infection control. Interviews with various staff members, including Licensed Practical Nurses and the Infection Preventionist, confirmed that the facility's protocol required the spigot to be cleaned with an alcohol swab after each use and that the catheter bag and tubing should not be on the floor. The staff also stated that the drainage bag should be dated and changed monthly or as needed. The Director of Nursing and other staff members reiterated the expectation that catheter drainage bags and tubing should be kept off the floor to prevent infection. The deficiency was identified as a failure to adhere to these infection control practices, as outlined in the facility's policy.

Plan Of Correction

Plan of Correction: Approved January 8, 2025 1. Resident #45 was assessed by RN for foley catheter care per policy and procedure including proper care of foley catheter care by staff. Any deficient findings were immediately addressed. All staff who provided care for Resident #45 was educated on policy and procedure for foley catheter care including proper infection control practices by RN Educator. All residents with foley catheters were audited by RN to ensure proper/appropriate practices were followed. Any deficient practices were corrected immediately. 2. All residents with foley catheter care are at risk for deficient practice of not following policy and procedure for proper foley catheter care including proper infection control practice. 3. Director of Nursing reviewed policy on foley catheter care and no changes were made to policy. 4. All nursing staff were trained by RN Educator on foley catheter care including proper infection control practices related to foley catheter care. 5. All residents with foley catheters will be audited weekly by unit manager/designee for month and monthly for 5 months for proper care of foley catheter care including proper infection control techniques. This will include staff competency to ensure they are following all practices per policy on foley catheters. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing

Penalty

No penalty information released

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

The facility failed to ensure acceptable parameters of nutritional status for Resident #65, who experienced significant weight loss. Resident #65, diagnosed with dementia, protein-calorie malnutrition, and macular degeneration, required extensive assistance with eating. Observations during meal times revealed that the resident was not receiving the necessary assistance, as staff were occupied with other residents. The meal ticket indicated the need for extensive assist feeding, but no staff were present to provide this support. Additionally, there was a lack of documentation regarding meal and supplement acceptance, and the medical provider was not informed of the resident's significant weight loss. Resident #65's weight decreased from 114 pounds at admission to 98 pounds, indicating a 14% loss over several months. Despite the resident being on a therapeutic diet with supplements like Boost Plus and Magic Cup, the documentation of meal and supplement intake was inconsistent and incomplete. The dietary progress notes and nutrition assessments highlighted the resident's weight loss trend, but there was no evidence that the medical provider or the resident's representative was notified of the significant weight loss. Interviews with staff, including LPNs, the Unit Manager, and the Dietary Technician, revealed a lack of awareness and communication regarding the resident's weight loss. The facility's failure to monitor and document Resident #65's nutritional intake and weight loss adequately, as well as the lack of communication with the medical provider, contributed to the deficiency. The Dietary Technician and Dietitian acknowledged the importance of monitoring residents' weights and notifying the medical provider of significant changes. However, the documentation and communication processes were insufficient, leading to the oversight of Resident #65's nutritional needs and weight loss.

Plan Of Correction

Plan of Correction: Approved January 13, 2025 1. Resident #65 was reviewed by Dietitian for weight loss and conducted detailed nutritional assessment. Physician was updated on any change in weight. Any deficient findings were corrected immediately. The Occupational Therapy department conducted a review of the resident #65's plan of care and observed resident in unit dining including using adaptive equipment as per plan of care. Any deficient practices were corrected immediately. The MD conducted full review of the patient to review for weight loss. The Unit manager and/or designee will review meal consumption and ensure accuracy on daily basis. Any deficient practices were corrected immediately. The Director of Nursing reviewed the resident #65 meal consumption record. Any deficient findings were corrected immediately. All staff members who take care of Resident #65 were reeducated on residents plan of care related to meal intake and documentation on food consumption by RN Educator. It is the Dietitian's responsibility to alert Nursing to update Physician of any weight loss and document in medical record. 2. All residents with significant weight loss are at risk for deficient practice of resident not being reviewed by IDT and MD for weight loss and lack of nourishment and meal acceptance by nursing staff. 3. Policy and procedure for meal and nourishment was reviewed by Director of Nursing and no changes were made. 4. All nursing staff were trained by RN Educator on meal and nourishment intakes. 5. All residents meal intakes with significant weight loss were audited by Dietitian for lack of documentation. Dietitian reported any weight loss to nursing manager to update physicians of weight loss. Any deficient findings were immediately addressed. 6. All resident meal consumption records will be audited by Diet Tech / Nursing Supervisor daily for 3 months and weekly for 2 months for deficient practice of lack of documentation for meal consumption. Any deficient findings will be corrected immediately and brought to QAPI for further review. Diet tech/Dietitian and designee will audit meal pass weekly for meal acceptance. Any deficient practice will be corrected. The Unit manager/designee will audit meal consumption daily for meal observation versus documentation accuracy. Any deficient practices will be corrected immediately and brought to QAPI for further review. Person Responsible: Dietitian

Penalty

No penalty information released

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

The facility was found to have deficiencies in food storage, preparation, distribution, and serving practices during a standard survey. Specifically, the kitchen had issues with unlabeled and outdated food items in the refrigerator. Observations revealed several containers of mixed fruit, sliced pears, chopped peaches, and other food items that were not labeled or dated. Some of these items had visible mold, indicating they had been stored for longer than the facility's policy of three days. The facility's policy requires all refrigerated foods to be labeled, dated, and discarded after three days to minimize spoilage and contamination. Interviews with dietary staff confirmed that the food items should have been labeled and dated upon opening and disposed of after three days. The dietary staff acknowledged the presence of mold in some of the food items and admitted that they did not know when these items were placed in the refrigerator. The Dietary Department Director stated that dietary aides are responsible for labeling and dating food items, but ultimately, it is their responsibility to ensure compliance with the facility's policies and procedures. The presence of mold and unlabeled food items indicates a failure to adhere to food safety standards, which is crucial to prevent contamination and ensure the safety of the food served to residents.

Plan Of Correction

Plan of Correction: Approved January 3, 2025 1. Administrator reviewed policy and procedure titled Food safety requirements. No changes were made. All items listed that were outside of the 3 days were thrown away. All kitchen staff were immediately educated on the Food Safety requirements by Food Service Director. 2. All residents are at risk for deficient practice of having refrigerated foods past 3 days. 3. The refrigerator was reviewed for all food past 3 day requirements and any undated food by Food Service Director. Any deficient practices were corrected immediately. 4. All dietary staff were educated by outside consultant regarding food safety. 5. The refrigerator and freezer will be audited daily by Food Service Director and supervisor for undated food and food outside of the 3 day period. This will occur daily for 6 months and weekly for 6 months. All deficient findings will be corrected and brought to QAPI for further review. Person Responsible: Food Service Director

Penalty

No penalty information released

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

The facility failed to ensure a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for two residents under enhanced barrier precautions. Resident #10, who had chronic pressure ulcers and a history of osteomyelitis, was not provided with proper personal protective equipment (PPE) by Certified Nurse Aides during morning care. Despite the presence of precaution signage and available PPE, the aides did not wear gowns, which was a requirement for infection control. The aides admitted to not following the precautions due to nervousness and lack of attention to the signage. Resident #43, who had an ileostomy, was also not provided with proper PPE during care. Although signage indicated the need for a gown, gloves, and mask, the Licensed Practical Nurse only donned gloves and a mask while changing the ileostomy bag/flange. The nurse acknowledged forgetting to wear a gown, which was necessary for infection control. The facility's Infection Preventionist and Director of Nursing confirmed that enhanced barrier precautions were required for residents with invasive devices or open wounds to protect both the resident and staff from potential infections. The facility's policy on enhanced barrier precautions was not adequately implemented, as evidenced by the lack of PPE use during high-contact care activities for residents at risk of multi-drug resistant organism transmission. The care plans for both residents did not include specific interventions for enhanced barrier precautions, contributing to the oversight in infection control practices. Interviews with staff revealed a lack of adherence to the facility's infection prevention protocols, highlighting a deficiency in maintaining a safe environment for residents.

Plan Of Correction

Plan of Correction: Approved January 8, 2025 1. Resident #10, #43 and Resident #42 was reviewed by the Infection Preventionist. The careplan was reviewed and closet careplan was updated by Director of Nursing to reflect the Enhanced Barrier precautions needed to provide care. All staff assigned to Resident #10, Resident #43 and Resident #42 will be educated by the Infection Preventionist on proper Enhanced Barrier PPE needed to provide care. IDT team makes decisions based on current criteria for EBP for enhanced barrier precautions. It is the Unit manager/designee who ensures compliance of all residents on EBP. Any deficient practices will be corrected and brought to DON for review. 2. All residents with Enhanced Precaution Barriers are at risk for the deficient practice of staff not wearing proper PPE when providing care. 3. Director of Nursing reviewed the policy and procedure on Enhanced Barrier Precautions and no changes were made to the policy. 4. All staff were educated by the consultant on Enhanced Barrier Precautions. 5. An Audit of all residents on Enhanced Barrier Precaution was conducted by the Infection Preventionist to audit staff wearing of PPE. Any deficient practice will be corrected immediately and brought to QAPI for further review. 6. 5 residents on Enhanced Barrier Precautions will be audited weekly to ensure staff are wearing proper PPE when providing care. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Infection Preventionist

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that alcohol-based hand rub (ABHR) was improperly stored in the Administration area on the Second Floor of the facility. Specifically, nine one-gallon containers of liquid hand sanitizer, each containing 80% Ethyl Alcohol, were stored in a storage closet across from Storage room 216. This storage exceeded the allowable quantity of five gallons in a single smoke compartment and did not meet the requirements of the 2012 edition of the National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code. Further observations revealed that the door to the storage closet did not self-close and latch into its door frame, nor was it equipped with a self-closing device, which is necessary for areas storing flammable materials. During an interview, the Maintenance Director admitted to being unaware of the storage of these containers in the closet and acknowledged the regulations regarding the storage of alcohol-based hand sanitizer. This oversight affected the safety protocols required for hazardous areas, as outlined in the facility's policy and procedure for alcohol-based hand sanitizers.

Plan Of Correction

Plan of Correction: Approved January 2, 2025 1. 2nd Floor Administration Area - The door to the storage closet was repaired by Maintenance Director with a self-closing device. All liquid hand sanitizer was removed to a more appropriate storage area by Maintenance Director with proper signage. 2. All residents are at risk for deficient practice of liquids in quantities greater than 5 gallons in a single smoke compartment not being stored in proper hazardous areas. 3. A full facility audit of all storage areas will be conducted by the Director of Maintenance to ensure that liquid alcohol-based hand rub or other flammable items were properly stored and proper signage was in place. 4. The policy "Alcohol-Based Hand Sanitizer and Solutions" with a date of revision of 12/24, was reviewed by the Consultant; no revision was necessary. 5. All facility staff will be in-serviced on proper storage of liquid alcohol-based hand rub and other flammable liquids by the Consultant, (NAME) J Pietrowski, MSN RN LNHA. 6. A weekly audit will be completed by Maintenance Director/Tech to ensure alcohol-based hand rub and other flammable liquids are stored properly. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

A deficiency was identified during a Life Safety Code survey concerning the maintenance of the kitchen hood extinguishment system in the Main Kitchen located on the First Floor. The system was not inspected and tested at least every six months as required. Documentation revealed that the system was inspected on 3/29/23, 8/7/23, 4/16/24, and 10/31/24. However, there was a gap between inspections from 8/7/23 to 4/16/24, which exceeded the six-month requirement. The Maintenance Director confirmed the lack of documentation for inspections between 3/29/23 and 4/16/24 and acknowledged that the system had not been continually inspected every six months. This finding is in violation of the New York State Department of Health regulations and the National Fire Protection Association standards.

Plan Of Correction

Plan of Correction: Approved January 2, 2025 1. Administrator and Maintenance Director review all inspections for Kitchen for previous 12 months. Most recent hood inspection completed on 10/31/2024. 2. All residents are at risk for deficient practice of timely hood inspections. 3. Administrator reviewed policy and procedure on kitchen hood inspection. No changes were made to the Kitchen(NAME) Inspection policy. 4. Administrator educated Maintenance Dir/Maintenance Tech on Kitchen(NAME) inspection policy. 5. Maintenance inspection log will be brought to QAPI monthly to ensure all inspections are completed per schedule. Any deficient practices will be corrected. Person Responsible: Maintenance Director

Penalty

No penalty information released

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 a Life Safety Code survey, it was observed that a door on the first floor of Unit 1/2, equipped with a delayed egress locking mechanism, lacked the required signage indicating how the door could be opened during a fire or other emergency. The door, located near resident rooms, was supposed to have a sign stating, 'Push Unit Alarm Sounds Door Can be Opened in 15 Seconds.' Although an illuminated exit sign was installed near the door, the absence of the specific signage was noted. The Maintenance Director confirmed that the delayed egress mechanism had been installed three months prior, and documentation showed that checks of the doors with such mechanisms were conducted regularly, including on 11/28/24 and 12/2/24. However, the lack of appropriate signage was a deficiency affecting one of the three resident units.

Plan Of Correction

Plan of Correction: Approved December 29, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Stairway exit door near resident rooms [ROOM NUMBERS] was equipped with proper signage. Push Unit Alarm Sounds. Door can be opened in 15 seconds. 2. All residents are at risk for deficient practice of not having proper signage for exit door with delayed egress signage explaining functionality of door. 3. All exit doors with delayed egress features will be audited to ensure proper signage by the Maintenance Director/Designee. 4. The Maintenance Tech/Maintenance Director was inserviced by the Administrator that monthly audits have to be completed per the audit tool called Monthly Emergency Exit Doors and Signs. The Maintenance Director/Tech will submit this audit monthly to the QAPI Committee. The QAPI Committee will determine additional process change needed based on findings. Person Responsible: Administrator

Penalty

No penalty information released

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

A deficiency was identified during a Life Safety Code survey when a portable electric space heater was found improperly maintained in the Basement Laundry room of the facility. The heater was plugged in and running on its low setting, with no documentation available to confirm that its heating element did not exceed 212 degrees Fahrenheit. The heater was positioned on a laundry linen folding table, surrounded by combustible materials such as folded blankets, pillowcases, and sheets, all within three feet of the heater, contrary to the manufacturer's safety warning. The Maintenance Director was unaware of the heater's presence in the Laundry room and stated that portable electric heaters were not allowed in the building. The facility did not provide the heater, and there was no documentation to verify its compliance with safety standards. The facility's policy on space heaters, which applies to non-resident areas, requires approval and supervision of such devices, but this policy was not adhered to in this instance.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Space Heater located in Basement was removed by Maintenance Director. Facility conducted audit of all rooms to check for space heaters. Any deficient findings were corrected immediately. 2. All residents are at risk for deficient practices of not having proper documentation showing portable electric heater did not exceed 212 degrees. 3. All staff were educated on policy and procedure regarding space heaters by RN Educator. 4. An audit will be conducted monthly by QA staff to ensure no space heaters are present. Any deficient practice will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility failed to honor a resident's right to self-determination by not providing a tub bath as per the resident's preference. Resident #64, who has a history of malignant neoplasm of the prostate, diabetes mellitus type 2, and osteoarthritis, expressed a preference for tub baths, which was documented in their Activity Interview for Daily and Activity Preferences form. However, the facility did not have a functioning tub available, which prevented the resident from receiving their preferred method of bathing. Observations and interviews revealed that the facility's bathtubs were either non-functional or used for storage, with no available tubs in the units' shower rooms. The Environmental Department Director and other staff members confirmed that the tubs had been non-functional for an extended period, with some stating they had been broken for over a year or even two years. Despite the resident's preference being documented, the facility did not take action to repair or provide access to a functioning tub, and staff were unaware of any available alternatives. The facility's failure to provide a functioning tub bath option was acknowledged by various staff members, including the Director of Nursing and the Administrator, who were unaware of the issue until it was brought to their attention. The lack of communication and maintenance regarding the tubs led to the inability to accommodate Resident #64's bathing preference, which is a violation of the resident's rights as outlined in the facility's policies and state regulations.

Plan Of Correction

Plan of Correction: Approved January 14, 2025 1. Facility made repairs to the tub. Facility obtaining quotes to fix all tubs. Resident #64 received tub per preference. 2. All residents who prefer to have a tub are at risk for deficient practice of not receiving a tub bath. 3. All residents' assessments for preference will be audited by MDS to see who prefers a bath. Any deficient practices will be corrected immediately. 4. Policy and procedure for maintenance of the facility tubs were reviewed and updated. 5. Administrator educated Maintenance Director and Maintenance Tech on tub policy. 6. Facility will audit all tubs monthly to ensure tubs are functioning and available for preferences of the resident. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Maintenance Director

Penalty

No penalty information released

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

The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan. The plan, which was last reviewed on 10/16/24, lacked documentation on the method for sharing information with residents and their families or representatives. This deficiency affected the entire first floor, including three resident units, the second-floor administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan was the current emergency preparedness plan in use since the facility's inception in 2024. However, the Administrator also acknowledged that an updated Emergency Preparedness Plan was being developed but had not yet been implemented.

Plan Of Correction

Plan of Correction: Approved December 29, 2024 1. Administrator reviewed current EPP and updated EPP on items not included. The EPP and Pandemic Plan were updated to facility's website on 1/17/2025. 2. All Residents are at risk for deficient practice for not having updated EPP posted on the website. 3. All staff and residents were notified that the EPP is posted on the website on 1/17/2025 by written correspondence by Administrator. 4. The EPP plan will be reviewed quarterly in the QAPI meeting to ensure updated EPP is available via website for staff, residents, and family. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan and associated assessments. The review, conducted in conjunction with a Life Safety Code survey, revealed that the facility's Disaster Manual Disaster Plan, Facility Assessment, and both facility-based and community-based risk assessments lacked documentation regarding procedures for missing residents. This deficiency affected all resident use floors, including three resident units, the administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan, last reviewed in October 2024, was the current Emergency Preparedness Plan in use, and that an updated plan was being developed but had not yet been implemented. The absence of documentation for missing residents was noted as a deficiency under 42 CFR 483.73-Emergency Preparedness.

Plan Of Correction

Plan of Correction: Approved December 29, 2024 1. Administrator completed updated HVA and included elopement into assessment on 12/29/2024. 2. All Residents are at risk for deficient practice for not having HVA assessment including elopement risk as a risk in the EPP. 3. All staff were trained on the emergency preparedness plan which included elopement risk and steps to follow in case of risk by RN Educator. Education was completed for all staff on 1/24/2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated HVA is reviewed and updated on any new risks. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility was found to be non-compliant with emergency preparedness requirements during a review of their Disaster Manual Disaster Plan, conducted in conjunction with a Life Safety Code survey. The plan, which was last reviewed on 10/16/24, lacked policies and procedures for providing a means to shelter in place for residents, staff, and volunteers who remained in the facility. This deficiency affected the entire first floor, including three resident units, the second-floor administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan was the current emergency preparedness plan in use since the facility's inception in 2024, and acknowledged that an updated plan was being developed but had not yet been implemented.

Plan Of Correction

Plan of Correction: Approved December 29, 2024 1. Administrator reviewed the current Emergency Preparedness plan and updated EPP on 12/29/2024 to include policy and procedure for Sheltering in place. 2. All Residents are at risk for deficient practice for not having sheltering in place policy procedure addressed in the EPP. 3. All staff were trained on the emergency preparedness plan which policy and procedure on sheltering in place and steps to follow in case of emergency by RN Educator. Education was completed for all staff on 1/24/2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on any new changes. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility was found to be non-compliant with emergency preparedness requirements during a review of its Disaster Manual Disaster Plan. The plan, which was last reviewed on 10/16/24, did not include policies and procedures for the use of volunteers and other staffing strategies. This deficiency affected all resident use floors, including three resident units, the administration area, and the basement. During an interview, the Administrator confirmed that the Disaster Manual Disaster Plan was the current emergency preparedness plan in use since the facility's inception in 2024. The Administrator also acknowledged that an updated Emergency Preparedness Plan was being developed but had not yet been implemented.

Plan Of Correction

Plan of Correction: Approved December 29, 2024 1. Administrator completed review of the current EPP on 12/29/2024 and updated EPP to include policy and procedure for Volunteer and procedure for staffing procedures on 12/29/2024. 2. All Residents are at risk for deficient practice for not having policy procedure on volunteer and staffing procedures addressed in EPP. 3. All staff were trained on the emergency preparedness plan which included policy and procedure on volunteers and staffing procedure by RN Educator. Education was completed for all staff on 1/24/2024. 4. The EPP will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on all policies required to be included in EPP including Volunteers and staffing strategies. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions and maintenance issues. On Units 1 and 5, surveyors observed brown stained ceiling tiles in both hallways and resident rooms, indicating potential water leaks. The Environmental Department Director acknowledged awareness of the leaks and the need for roof replacement but was not informed about specific stained tiles in resident rooms. This lack of communication and action contributed to the ongoing issue of stained and potentially moldy ceiling tiles, which were not addressed promptly. In Unit 5's Resident Spa, surveyors noted a strong fecal odor, soiled wet linens on the floor, and a soiled shower curtain over several days. Certified Nurse Aide #5 and the Director of Housekeeping confirmed that aides were responsible for removing soiled linens and bodily fluids, while housekeepers were to sanitize the area. However, the persistent unsanitary conditions indicated a failure in executing these responsibilities, leading to an infection control issue as highlighted by the Infection Preventionist. Additionally, the baseboards in Unit 5's hallways were observed to be dirty with dark debris, contributing to an unclean and unhomelike environment. Staff interviews revealed dissatisfaction with the cleanliness and maintenance of the facility, with reports of sticky floors and concerns from family members about the facility's state. The Administrator acknowledged the need for clearer job duties and recognized the leaking roof as a problem, but the ongoing issues with cleanliness and maintenance were not adequately addressed, resulting in a deficiency in providing a homelike environment.

Plan Of Correction

Plan of Correction: Approved January 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident room [ROOM NUMBER] had four ceiling tiles replaced by maintenance. Unit 1 hall ceiling tiles were replaced. Wallpaper was removed where damaged by maintenance. Resident room [ROOM NUMBER] ceiling tiles were replaced by maintenance. Resident spa on Unit 5 was sanitized by housekeeping. Unit 5 hallways were sanitized by housekeeping. Baseboards were cleaned by housekeeping. Hallway floors were stripped and waxed by Floor tech. The Roof will be reviewed in Spring 2025 for roof repairs. 2. All residents are at risk for deficient practice of facility not being homelike as evidenced by sticky unclean floors, soiled ceiling tiles, dirty showers. 3. An Audit of all shower rooms was conducted by EVS Director and all shower rooms were sanitized. An Audit was completed of all ceiling tiles in the facility and any deficient practice was corrected. An Audit of all baseboards was completed and baseboards were cleaned by floor tech. 4. Administrator reviewed the policy and procedure on floor care, daily housekeeping care, and ceiling tiles. New policies were created for the facility. Administrator reviewed the policy and procedure for ceiling tiles; no changes were made. The Outside consultant will educate all staff on reporting environmental concerns including soiled ceiling tiles, cleaning issues in showers, and floors. 5. Administrator educated EVS Director on floor care and daily housekeeping. All Housekeepers were educated on floor care and daily housekeeping. Administrator reviewed P and P on ceiling tile replacement with Maintenance Director. 6. QA Members will conduct weekly rounds for 6 months on floor care, ceiling tiles, and shower room cleaning. Any deficient practices will be corrected immediately and brought to QAPI for further review. Resident grievances will be reviewed monthly for environmental concerns. Any deficient practices will be corrected immediately. Person Responsible: EVS Director

Penalty

No penalty information released

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

The facility failed to implement its written policies and procedures for screening employees to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not conduct a required verification check against the New York State Nurse Aide Registry for one of its employees, a Housekeeping Aide, prior to their employment. The policy in place required that all individuals hired undergo a review of qualifications and be checked against the registry upon hire. However, this procedure was not followed for Employee #3, who was hired and began working before the registry check was completed. Employee #3 was hired on August 14, 2024, and worked several shifts from August 15 to August 18, 2024, before the registry verification was conducted on August 19, 2024. The Human Resources Director, who was responsible for conducting these verifications, was out of the building when the employee attended orientation and did not complete the verification until returning on August 19. This oversight resulted in a failure to adhere to the facility's policy, as the employee worked without the necessary registry check being completed, which is a requirement under 10 NYCRR 415.4(b).

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. Employee #3 had nurse aide registry check completed by HR Director. The HR Director reviewed all employees for Nurse Aide Registry that had deficient practice of not having Nurse Aide Registry check completed prior to employment. Any deficient practices were corrected immediately by HR Director. 2. All residents are at risk for the deficient practices of new employees not having nurse aide registry check completed prior to employment. 3. Administrator reviewed policy and procedure for Abuse, Neglect and exploitation including process for New York State Nurse Aide registry verification. No changes were made. 4. The HR director was educated by Administrator on policy and procedure for Abuse, Neglect and exploitation including process for New York State Nurse Aide registry verification. 5. The Administrator will conduct weekly audits of new hires for 6 months and monthly for 6 months of all new hires including all new employees to ensure New York State Nurse Aide registry check is completed prior to hire. Any deficient practices will be corrected immediately and brought to QAPI for further review. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility failed to ensure that criminal history information was requested, received, reviewed, and acted upon in a timely manner for Employee #3, a Housekeeping Aide. According to New York State Part 402: Criminal History Record Check, each provider must ensure timely processing of criminal history information. However, Employee #3's personnel file lacked documentation of fingerprinting and submission of fingerprint information to the Criminal History Record Check Legal Review Unit. The employee worked for 83 days without this compliance, from August 14, 2024, to December 4, 2024. The deficiency arose due to issues with the facility's credit card on file with the contractor responsible for digital fingerprinting. The Human Resources Director and Staffing acknowledged the problem, stating that the credit card sometimes worked and sometimes did not, affecting the fingerprinting process. The Administrator was aware of the issue and had been in contact with the contractor since August 5, 2024, to resolve the credit card and contact information issues. Despite multiple emails and attempts to update the information, the process was lengthy, and Employee #3 was not fingerprinted as required.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. All employees hired in the past 6 months were audited by HR Directed to ensure all CHRC fingerprinting was completed per policy and procedure for CHRC. Any deficient practices were corrected immediately. Administrator was added for CHRC processing. 2. All residents are at risk for CHRC not being completed per policy. 3. Administrator reviewed policy on CHRC and no changes were made. 4. Administrator educated HR Director of CHRC. 5. Administrator to conduct weekly audits of all new hires and CHRC checks to ensure policy and procedure for CHRC is being followed. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Administrator

Penalty

No penalty information released

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

The facility failed to comply with New York State Public Health Law 2803-12 by not making its Pandemic Emergency Plan (PEP) available to the public on its website. According to the New York State Department of Health Dear Administrator Letter Nursing Home 20-09, each residential health care facility was required to prepare and make the PEP available to the public on the facility's website by a specified date in 2020. During an interview on December 5, 2024, the Administrator confirmed that while the facility had a PEP, it was not accessible to the public on the website. A review of the facility's website with the Administrator corroborated that the PEP was indeed missing from the site.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. Facility posted Pandemic Emergency Plan on website. 2. All residents are at risk for not having accessibility of the PEP plan available to them per policy and procedure for PEP. 3. PEP was reviewed by Administrator and changes were made to PEP prior to posting to website. 4. Admissions staff will be educated on process of posting up to date PEP by Administrator. 5. The QAPI reviewed PEP prior to posting to website. The PEP will be brought to QAPI quarterly and website will be checked quarterly by Administrator to ensure compliance. Person Responsible: Administrator

Penalty

Fine: $37,138

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

The facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for seven residents identified as being at risk for elopement. On the morning of June 18, 2024, Resident #1 was found outside the facility and returned by staff. Despite this incident, the facility did not implement safety interventions to prevent recurrence, and Resident #1 eloped again later that morning. The resident was eventually returned to the facility by their Health Care Proxy after being found by a concerned citizen. The facility's policy required residents identified as at risk for elopement to be reassessed monthly and placed on 15-minute visual checks upon return from an elopement. However, there was no documented evidence that these checks were completed for Resident #1 after their initial elopement. Interviews with staff revealed a lack of communication and failure to implement the required checks, despite the resident's known history of exit-seeking behavior. Additionally, the facility's windows in rooms of residents at risk for elopement did not have adequate safety devices to prevent them from being fully opened. Observations showed that window stops could be easily removed, allowing windows to open wide enough for a resident to exit. The Maintenance Director was not informed of the residents' elopement risk status, and the facility did not have a specific policy for window safety, contributing to the deficiency.