Pine Haven Home
April 1, 2025 Certification/complaint Survey

Standard Health Citations

FF15 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: 483. 60(i) Food safety requirements. The facility must - 483. 60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. 483. 60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, (a) a container of tomato juice was found unlabeled in the refrigerator; and (b) a container of opened, unlabeled cranberry juice was found in the dry storage area. This is evidenced by: During the initial tour of the kitchen between 11:00 AM and 12:00 PM on 3/24/2025, the following was observed: (a) A pitcher with red liquid, unlabeled in the dessert refrigerator. At the time of observation, Kitchen Director #1 identified the red liquid to be tomato juice, stated there should have been a label on it stating it was opened today. Kitchen Director #1 then removed the pitcher and stated that they would refresh the supplies correctly. (b) An opened, unlabeled bottle of Ocean Spray Cranberry Juice in the dry storage area. At the time of observation, Regional Food Director #1 stated that a new employee that started a week prior had walked out an hour before the survey team arrived at the facility, and they believed the item was left by the employee. The facility's policy titled, Food from Home, dated 12/01/2022, documented that it was the policy of this facility to provide safe and sanitary storage, handling and consumption of all foods including those brought to residents by family and other visitors. Additionally, the policy documented that the food service workers, cooks, dietary aides, dishwashers, food prep aides, or any person (s) who were in the kitchen working with any type of food, were responsible for to adhere to the food safety requirements. During an interview on 3/24/2025 at 11:25 AM, Kitchen Director #1 stated that all food items must be dated and labeled when they were opened and prior to bring refrigerated. During an interview on 3/24/2025 at 12:15 PM, Regional Food Director #1 stated that they believed the two unlabeled bottles of liquid found in the refrigerator and the dry storage area belonged to the employee. 10 New York Codes of Rules and Regulations 415. 14(h)

Plan of Correction: ApprovedApril 25, 2025

No residents were affected by this deficient practice. The pitcher containing red liquid was immediately removed at the time of survey by the Food Service Director and discarded. The opened, unlabeled bottle of Ocean Spray Cranberry juice was removed at the time of survey by the Regional Food Service Director and discarded. All residents have the potential to be affected by this deficient practice. A facility wide inspection of all food storage areas, including unit nourishment kitchens and food storage areas was conducted to identify any other unlabeled or incorrectly stored food items. The policy for personal food in the work area was reviewed with no modifications needed. The Dietary staff were re-educated on the appropriate labeling and storage of food items as well as the policy on personal food in the work area. An audit tool was created for the Director of Food Service or designee to monitor the storage of food through a weekly inspection of food storage areas observing for proper food storage and to verify that there are no personal food items in the work area. Results of these weekly audits will be shared monthly with the Quality Assurance Performance Improvement committee who will determine the need for monitoring and reporting until compliance is achieved. Any deficient practice identified will be addressed with staff re-education and/or formal disciplinary action. The Food Service Director is responsible for this plan of correction.

FF15 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: 483. 25(d) Accidents. The facility must ensure that - 483. 25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483. 25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification and abbreviated survey (Case #NY 721), the facility did not ensure the environment remained as free of accident hazards as possible for one (1) (Resident #41) of seven (7) residents reviewed for accident hazards. Specifically, for Resident #41 the temperature of the resident's microwave reheated beverage was not checked prior to serving, resulting in a first degree burn to the resident's chest. This is evidenced by: The facility Policy and Procedure titled Food - Microwave Reheating, last revised 7/26/2024, documented the staff were to use the thermometer to ensure a maximum temperature of the reheated food or beverage was not greater than 140 degrees Fahrenheit prior to serving. Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident could understand, be understood, and moderate cognitive impairment. The Care Plan initiated 5/2/2020, titled Functional Abilities/Eating, documented the resident required set-up and clean-up assistance. An Incident/Accident Report dated 10/8/2024 at 11:45 AM documented the resident spilled hot tea on upper chest resulting in a surface burn In a written statement dated 10/8/2024 Registered Nurse #1 documented they heated the Resident's tea in the microwave and placed it on the bedside table. Approximately ten minutes later an aide reported the resident had spilled the tea resulting in a burn. A Nurse Practitioner Note dated 10/8/2024 documented the resident was seen for a thermal burn resulting from hot liquid spilled on the chest. The [DIAGNOSES REDACTED]. During an interview on 3/25/25 at 12:10 PM, Resident #41 stated they remembered the incident because everyone made a big fuss out of nothing. I missed my mouth, spilled tea down the front of myself and got a little burn. Registered Nurse #1 is no longer employed by the facility and could not be reached for interview. During an interview on 3/27/2025 at 9:15 AM, Director of Nursing #1 stated the nurse responsible for the accident immediately reported they forgot to check the temperature prior to serving the reheated tea and felt terrible about it. The nurse was an excellent employee with no other issues. All nursing staff were re-educated regarding the microwave policy. 10 New York Codes, Rules, and Regulations 415. 12(h)(1)

Plan of Correction: ApprovedMay 8, 2025

For Resident #41 a hot liquid safety assessment was updated on 10/8/24 and all hot liquids will be provided in a covered mug. All associated care plans and Certified Nursing Assistant care cards were updated on 10/8/ 24. Resident #41s skin remained intact and the reddened area healed without complications. Nurse #1 was re-educated on 10/9/24 and was able to re-demonstrate competency on reheating and serving microwaved hot liquids. All residents have the potential to be affected by this deficient practice. All licensed staff had received an in-service titled ?ôRe-Heating Foods or Liquids?Ø between July-August 2024. Additional training on this topic was completed with all nursing direct care staff on 10/9/24 and 10/11/ 24. This training has been added to the orientation and annual training programs. The Food-Microwave Reheating Policy was reviewed with no changes or modifications determined to be necessary at this time. The Director of Nursing and/or designee conducted random weekly audits for four weeks on all shifts monitoring the microwave re-heating of liquids by means of staff task observation and demonstration of competency. Any deficient practice noted during the auditing process was corrected immediately with staff re-education and/or formal disciplinary action. Results of the weekly audits were reported monthly to the Quality Assurance Performance Improvement committee in (MONTH) 2024, (MONTH) 2024 and (MONTH) 2025, with no compliance issues noted. As compliance was demonstrated, these audits have been reduced in frequency to semi-annual. The Director of Nursing or Designee was responsible for this plan of correction.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: N/A
Severity: N/A
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

ZT1N 415.26, 415.26:ORGANIZATION AND ADMINISTRATION

REGULATION: N/A

Scope: N/A
Severity: N/A
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

FF15 483.12(b)(5)(i)(A)(B)(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: 483. 12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483. 12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 483. 12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #NY 923), the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for one (1) (Resident #115) of eight (8) residents reviewed for abuse. Specifically, an allegation of verbal abuse reported by a resident to a Certified Nurse Aide on 2/05/2023 was not reported to Administration until 2/06/2023, and not reported to The New York State Department of Health until 2/08/ 2023. This is evidenced by: Facility policy titled, Abuse Policy-Prevention and Management, reviewed (MONTH) 2024, documented the Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. Under the heading Identification the policy documents instruct staff, resident/patient, family, visitor, to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse. Under the heading Reporting the policy documents staff would notify the Shift Supervisor/Charge Nurse/Manager immediately of an allegation or suspected abuse. This responsible Manager would then notify the Administer and Director of nursing immediately. The designated State agency(s) would be notified within 2 hours after identification of the alleged/suspected abuse. Resident #115 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 1/28/2023, documented the resident could be understood, could understand others, and had no cognitive impairment. The facility Investigation Summary dated 2/14/2023 documented the resident reported that on 2/05/2023 Certified Nurse Aide #3 yelled at them, and they felt intimidated. The resident reported the incident was witnessed by Certified Nurse Aide # 4. It was determined that the accused did not act with the intention to upset the resident, however, did not use an appropriate approach as outlined in the resident's care plan. The Summary also documented there was no awareness of this event until 2/06/2023 when the resident asked to speak with the social worker During an interview on 4/01/25 at 10:27 AM, Administrator #1 stated they were unable to substantiate the abuse allegation but terminated the agency staff because they were not receptive to being educated on how to speak to the residents. Administrator #1 stated they did question Certified Nurse Aide #4 about why they did not report the incident, and the Aide said they did not think of it as abuse because the accused was usually loud and gruff with everyone. Administrator #1 stated they were new to the position when this incident occurred and may have been unclear as to their responsibilities to report. They further stated they were now aware this should have been reported sooner and made sure all relevant incidents are reported within 2 hours as they should. 10 New York Codes, Rules, and Regulations 415. 4(b)(2) 1

Plan of Correction: ApprovedApril 25, 2025

Resident #115 was discharged from the facility on (MONTH) 24, 2023. Certified Nursing Aides #3 and #4 are no longer employed at the facility. All residents have the potential to be affected by this deficient practice. All staff will be re-educated on their obligation to report all instances of actual or perceived abuse immediately to the supervisor and/or administrator in order to initiate investigation and allow for reporting within two hours to the appropriate state agencies. The Abuse ÔÇ£ Prevention and Management Policy was reviewed with no changes or modifications determined to be necessary at this time. An Incident/Event Report Checklist is currently being completed for each incident by the Administrator to ensure that any incident involving an allegation of abuse is reported within the two hour timeframe to the appropriate individual and state agencies. A weekly audit of Incident/Event Report Checklists completed for the applicable week will be done by the Administrator or designee in order to verify that all incidents involving an allegation of abuse were reported timely and to the appropriate individual and state agencies. Results of the weekly audit will be reported to the Quality Assurance Performance Improvement committee monthly and will continue in frequency based on the determination of the committee. At a minimum, monthly audits will continue until compliance is maintained for a period of 3 consecutive months. Any identified non-compliance will be addressed through staff re-education and/or formal disciplinary action. The Administrator or Designee is responsible for this plan of correction.

FF15 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: 483. 35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483. 71. 483. 35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. 483. 35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated survey (Case #s NY 923 and NY 733), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, between 3/23/2025 and 3/31/2025, the minimum hours of nursing care per resident day was less than the established minimum set by the Centers for Medicaid/Medicare Services. This is evidenced by: The Facility assessment dated [DATE], documented under Staffing plan, that the facility worked diligently to maintain staffing levels for all departments that met Center for Medicare and Medicaid Services Guidelines for providing optimal resident centered care. Facility Nursing Levels based on an Average Daily Census of 110 (in past 30 days) equaled 3. 07 Hours Per Patient Day. Licensed Nursing equaled 1. 43 Hours Per Patient Day. Certified Nurse Aides equaled 1. 64 Hours Per Patient Day. Below were the facility's documented staffing levels per unit (including house staff and contracted agency staff). Day Shift (7 AM to 3 PM) Certified Nurse Aides: 4 standard (2 minimum) Licensed Nurse (Registered and Licensed Practical): 4 standard (2 minimum) Supervisor Registered Nurse: 1 House Supervisor every day, and 3 Unit Managers Monday through Friday Evening Shift (3 PM to 11 PM) Certified Nurse Aides: 4 standard (2 minimum) Licensed Nurse (Registered and Licensed Practical): 2 standard (1 minimum) Supervisor Registered Nurse: 1 House Supervisor Night Shift (11 PM to 7 AM) Certified Nurse Aides: 2 standard (1 minimum) Licensed Nurse (Registered and Licensed Practical): 1 standard Supervisor Registered Nurse: 1 House Supervisor It was noted that when there was a minimal number of Certified Nurse Aides on any unit, a licensed nurse would be assigned to assist with direct care. Continued efforts were being made to increase staffing levels to meet the minimum requirements. These efforts included, but were not limited to working with recruiters, negotiating agency contracts for temporary staff, enforcing attendance policies and offering incentives (bonuses and flexible schedules) to encourage staff to cover needed shifts. Recruitment and retention efforts were a constant operational focus to maintain adequate staffing levels while experiencing a state of emergency in the state regarding the health care worker shortage. Review of the untitled staff assignment sheets dated 3/23/2025 through 3/31/2025, documented less than Centers for Medicaid/Medicare Services' minimum hours of care per resident day nursing staffing levels for 8 out of 9 days, as follows: ?é?À 3/23/2025 facility census 115. ?é?À Requiring a total staffing hours of 402. 5 hours. ?é?À Per facility staffing sheets provided, 336 hours of resident care staff hours scheduled, facility short 66. 5 hours of staffing care. ?é?À Should have been 16 Licensed Nurses, 36 Certified Nurse Aides working to cover a census of 115. ?é?À Schedule reflected that there were 16 Licensed Nurses and 26 Certified Nurse Aides working. ?é?À 3/24/2025 facility census 116. ?é?À Requiring a total staffing hours of 406 hours. ?é?À 392 hours of resident care staff hours were scheduled. ?é?À Facility short 14 hours of staffing care. ?é?À Schedule reflected that there were 19 Licensed Nurses and 30 Certified Nurse Aides working. ?é?À 3/25/2025 facility census 117. ?é?À Requiring a total staffing hours of 409. 5 hours. ?é?À 408 hours of resident care staff hours were scheduled. ?é?À facility short 1. 5 hours of staffing care. ?é?À There should have been 17 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. ?é?À Schedule reflected that there were 19 Licensed Nurses and 32 Certified Nurse Aides working. ?é?À 3/26/2025 facility census 117. ?é?À Requiring a total staffing hours of 409. 5 hours. ?é?À 400 hours of resident care staff hours were scheduled. ?é?À Facility short 9. 5 hours of staffing care. ?é?À There should have been 17 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. ?é?À Schedule reflected that there were 22 Licensed Nurses and 28 Certified Nurse Aides working. ?é?À 3/28/2025 facility census 117. ?é?À Requiring a total staffing hours of 409. 5 hours. ?é?À 360 hours of resident care staff hours were scheduled. ?é?À Facility short 49. 5 hours of staffing care. ?é?À There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. ?é?À Schedule reflected that there were 19 Licensed Nurses and 26 Certified Nurse Aides working. ?é?À 3/29/2025 facility census 115 ?é?À Requiring a total staffing hours of 402. 5 hours. ?é?À 320 hours of resident care staff hours were scheduled ?é?À Facility short 82. 5 hours of staffing care. ?é?À There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 115. ?é?À Schedule reflected that there were 17 Licensed Nurses and 23 Certified Nurse Aides working. ?é?À 3/30/2025 facility census 115 ?é?À Requiring a total staffing hours of 402. 5 hours. ?é?À 328 hours of resident care staff hours were scheduled ?é?À Facility short 74. 5 hours of staffing care. ?é?À There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 115. ?é?À Schedule reflected that there were 13 Licensed Nurses and 23 Certified Nurse Aides working. ?é?À 3/31/2025 facility census 116 ?é?À Requiring a total staffing hours of 406 hours. ?é?À 328 hours of resident care staff hours were scheduled. ?é?À Facility short 78 hours of staffing care. ?é?À There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 116. ?é?À Schedule reflected that there were 18 Licensed Nurses and 29 Certified Nurse Aides working. During an interview on 4/01/2025 at 12:57 PM, Director of Nursing #1 stated that they knew the minimum hours of resident care required was 3. 5 hours per day per resident. Director of Nursing #1 stated that the facility struggled to hire Certified Nurse Aides and attributed much of the difficulty to the remote location of the facility. Additionally, when there were large gaps in the staffing schedule, Licensed Practical Nurses would work as Certified Nurse Aides and that there was a team approach to resident care at the facility. During an interview on 4/01/2025 at 12:57 PM, Administrator #1 stated that Director of Nursing #1 had a solid orientation, low turnover, and that they were both looking to feel exclusive with their staffing so that the people that worked there felt important. The schedule was flexed for employees in school and cluster schedule people that carpooled to help with transportation as there was no public transportation due to the rural nature of the area. Additionally, Administrator #1 listed the ways they had been working to encourage people to come work at the facility including hiring 2 outside recruiters, offering a Certified Nurse Aide online course, working with the local Board of Cooperative Educational Services, ads, local boards in the community, by recruiting people that come and hand out applications in site. They also relied on word of mouth from other employees, incentives for picking up shifts and recruiting other people, and encouraging staff advancement. 10 New York Code Rules and Regulations 415. 13(a)(1)(i-iii)

Plan of Correction: ApprovedMay 1, 2025

There was no identified negative effect specified for any individual resident resulting from this deficient practice. The facility assessment has been updated to read ?ôThe facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis.?Ø The in-house census along with resident acuity and care needs were reviewed by the Director of Nursing and compared to the staffing levels currently being scheduled. The scheduled staffing levels for the week ending (MONTH) 19, 2025 were determined to be in accordance with the staffing levels outlined in the facility assessment. All residents have the potential to be affected by this deficient practice. All resident and/or family concerns regarding staffing are addressed directly by the Administrator or Director of Nursing. The nurse unit managers and/or shift supervisors conduct unit rounds at a minimum of 3x/shift observing each patient to ensure that resident needs are met and care is being delivered according to their care plans. On a daily basis, the Director of Nursing or designee will monitor compliance with medication administration records, treatment administration records, 24-hour report and Certified Nursing Assistant's care documentation to verify that all care was delivered as scheduled. In addition, all quality measures are monitored on a weekly basis and used to identify any care deficit that may relate to inadequate staffing. Any identified care deficit is addressed with re-education of the caregiver and/or formal disciplinary action. The facility assessment was reviewed and updated to read ?ôThe facility works diligently to maintain staffing levels for all departments that will allow for the delivery of optimal resident centered care. Staffing levels for the nursing department specifically will be based on the in-house resident acuity and clinical care needs. The Director of Nursing or Designee uses the quality measures and other clinical indicators; including but not limited to the number of medications, treatments, and/or behaviors of residents, to evaluate the resident acuity on a weekly basis.?Ø Unit Mangers/Registered Nurse Supervisors were educated on the need to report insufficient staffing on their units to the Director of Nursing or Staffing Coordinator. The Staffing Coordinator was educated to report insufficient staffing to the Director of Nursing/Designee and Administrator. Additional recruitment efforts such as holding an open house for hiring, increased online job postings, in-house referral incentives were initiated to ensure sufficient staffing for all shifts. Orientation for new hires is scheduled every week (or more as needed) to increase the staffing level. A contingency staffing plan was developed to ensure coverage for any call outs and emergency staffing shortages; including incentive bonuses for staff to work additional shifts, and the use of additional nursing staffing agencies. The facility developed a weekly staffing audit tool to ensure that each shift meets the minimal required staffing levels, tracking the number of actual hours per day of nursing staff compared to the staffing levels outlined in the facility assessment. The Director of Nursing/Designee and Staffing Coordinator will review the audit weekly to ensure compliance with staffing levels. The Director of Nursing/Designee will conduct weekly staffing audits for compliance weekly for four weeks. The results of these audits will be reported to the Quality Assurance Performance Improvement committee monthly, who will determine the need for monitoring and reporting until compliance is achieved. Any trends or patterns of non-compliance will be identified, and additional training or corrective measures will be implemented as necessary. The Director of Nursing or Designee is responsible for this plan of correction.

Standard Life Safety Code Citations

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18. 3. 2. 5. 2, 19. 3. 2. 5. 2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18. 3. 2. 5. 3, 19. 3. 2. 5. 3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18. 3. 2. 5. 4, 19. 3. 2. 5. 4. Cooking facilities protected according to NFPA 96 per 9. 2. 3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18. 3. 2. 5. 1 through 18. 3. 2. 5. 4, 19. 3. 2. 5. 1 through 19. 3. 2. 5. 5, 9. 2. 3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on record review and interviews during the recertification, the facility did not protect all cooking facilities in accordance with adopted regulations relative to Building # 1. Specifically, the kitchen fire extinguishing system was not maintained as required by the National Fire Protection Association (NFPA) 17A Standard for Wet Chemical Extinguishing Systems 2009 edition section 7. 2. This is evidenced by: During observations on 03/31/2025 at 10:46 AM, 4 of 6 caps for covering the discharge nozzles servicing the kitchen fire suppression system were not in place. During an interview on 03/31/2025 at 1:37 PM, Facilities Manager #1 that they would discuss with their staff, the criteria of the monthly quick check owners inspection of the kitchen fire suppression system including ensuring that the nozzle caps are in place. 42 Code of Federal Regulations 483. 70 (a) (1) 2012 NFPA 101 9. 2. 3 2009 NFPA 17A 7. 2 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)

Plan of Correction: ApprovedMay 12, 2025

The four missing caps for covering the discharge nozzles servicing the kitchen fire suppression system were put back into place by the Maintenance Director. All residents have the potential to be affected by this deficient practice. All other caps for the discharge nozzles servicing the kitchen fire suppression system were verified to be in place. Education will be conducted with the dietary staff on the importance of monitoring the caps covering the discharge nozzle and other components of the kitchen fire suppression system. The Maintenance Department will be educated on the means of inspecting all caps covering the discharge nozzle and other components of the kitchen fire suppression system. This training topic will be added to the department's annual education packet. A check of the caps covering the discharge nozzle was added to the existing monthly inspection of the kitchen fire suppression system, which is completed by the maintenance department. A monthly audit will be conducted by the Maintenance Director or designee to verify that the caps covering the discharge nozzle are being inspected and remain in place. Results from the monthly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director is responsible for the completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7. 7, provides a level walking surface meeting the provisions of 7. 1. 7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18. 2. 7, 19. 2. 7

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interview during the recertification survey, the facility did not maintain exits in accordance with adopted regulations relative to Building # 2. Specifically, exit discharges were not marked to make clear the direction of egress travel from the exit discharge to a public way in accordance with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19. 2. 7 and 7. 7. This is evidenced by: During observations on 03/31/2025 at 11:00 AM, the exit discharges from the south nursing unit did not make clear the direction of egress travel from the exit discharge to a public way. During an interview on 03/31/2025 at 2:21 PM, Facilities Manager #1 stated that they would mark the exit discharges to make clear the direction to the public way. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101 19. 2. 7, 7. 7 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)(1)

Plan of Correction: ApprovedMay 12, 2025

Signage will be placed at each exit stating that ?ôIn the event of an emergency, follow arrows to a public way?Ø. Arrows will be painted on the walkway to direct individuals towards the direction of egress travel from the exit discharge to a public way. All residents have the potential to be affected by this deficient practice. All exit areas will have the appropriate signage indicating the direction to a public way. A monthly audit will be conducted by the Maintenance Director or designee to verify that the signage and arrows indicating direction of egress travel from the exit discharge to a public way remain intact. Any deficient practice identified will be corrected immediately. Results from the monthly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director is responsible for completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7. 2. 1. 8. 2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18. 2. 2. 2. 7, 18. 2. 2. 2. 8, 19. 2. 2. 2. 7, 19. 2. 2. 2. 8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interview during the recertification survey, vertical openings were not protected as required by adopted regulations relative to Building # 1. Specifically, the stairwell door was kept open with a tool inserted into the space between the door and frame and did not self-close and seat to the door frame as required by the National Fire Protection Association (NFPA) 101, Life Safety Code 2012 edition sections 19. 2. 2. 2. 7 and 7. 2. 1. 8. 2. This is evidenced by: During observations on 03/31/2025 at 10:36 AM, the stairwell door was kept open with a tool inserted into the space between the door and frame. During an interview on 03/31/2025 at 1:15 PM, Facilities Manager #1 stated that they would discuss with their staff regarding not propping stairwell doors open. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101 19. 2. 2. 2. 7, 7. 2. 1. 8. 2 10 New York Codes, Rules, and Regulations 415. 29

Plan of Correction: ApprovedMay 13, 2025

The tool was immediately removed from between the stairwell door and the frame, allowing the door to self-close. All residents have the potential to be affected by this deficient practice. All of self-closing doors were inspected to verify that they were not being held open with any tool or device. The Maintenance department was educated on the appropriate way to indicate, using signage, that a repair is being made. The department was educated not to use any tool or device to hold open a self-closing door. A weekly audit will be conducted for four weeks by the Maintenance Director or designee to verify that there are no self-closing doors being held open or in need of repair. Any deficient practice identified will be corrected immediately. Results from the weekly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director will be responsible for the completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9. 4. Elevators are inspected and tested as specified in ASME A 17. 1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A 17. 3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A 17. 3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19. 5. 3, 9. 4. 2, 9. 4. 3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interviews during the recertification survey, the facility did not inspect and test the elevator in accordance with the adopted regulations relative to Building # 1. Specifically, the elevator was not tested at 12-month, inspected at 6-month intervals, and defects were not corrected as required by American Society of Mechanical Engineers booklet A17-1 Safety Code for Elevators and Escalators 2004 Edition Section 8. 11. 1. 3 and Table N- 1. This is evidenced by: There was no documented evidence that the elevator was tested during 2024, that the elevator was inspected during 02/2025 (six months after 08/2024 inspection), and that per the 11/2023 report, the hoist way door guide was repaired, back-up power was provided for the emergency bell, and a fire extinguisher with a passing annual test was installed in the machine room. During an interview on 04/01/2025 at 2:42 PM, Facilities Manager #1 stated that they would contact their vendor to schedule an elevator test and inspection and to obtain any documentation as to when or if the hoist way door guide was repaired, back-up power was provided for the emergency bell, and a fire extinguisher with a passing annual test was installed in the machine room. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101: 9. 4 2008 American Society of Mechanical Engineers booklet A 17. 3 1. 5 2004 American Society of Mechanical Engineers booklet A 17. 1 8. 6, Table N-1 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)

Plan of Correction: ApprovedMay 12, 2025

An elevator inspection is currently being scheduled with the elevator vendor. An annual elevator test is currently being scheduled with the elevator vendor. All repairs indicated on the 11/2023 report including repairs to the hoist door guide, and back-up power provided to the emergency bell and installation of a fire extinguisher with a passing annual test, were made on 8/12/24 as evidenced by the Routine Inspection Report for Elevators, Escalators from that same date. All residents have the potential to be affected by this deficient practice. There were no further repairs to the elevator identified as needed at this time. Copies of the inspection and testing reports will be reviewed by the Administrator and Maintenance Director to verify that corrections are made immediately as indicated. In addition, the reports will be uploaded electronically to the tracking system to verify that the scheduled inspections and tests are completed timely. A quarterly audit of the inspection and testing schedule will be conducted by the Maintenance Director of designee in order to verify that all are current. Results from the quarterly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director is responsible for completion of this plan of correction.

EP01 484.102(c)(2), 441.184(c)(2), 485.727(c)(2), 494.6:EMERGENCY OFFICIALS CONTACT INFORMATION

REGULATION: 403. 748(c)(2), 416. 54(c)(2), 418. 113(c)(2), 441. 184(c)(2), 460. 84(c)(2), 482. 15(c)(2), 483. 73(c)(2), 483. 475(c)(2), 484. 102(c)(2), 485. 68(c)(2), 485. 542(c)(2), 485. 625(c)(2), 485. 727(c)(2), 485. 920(c)(2), 486. 360(c)(2), 491. 12(c)(2), 494. 62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at 483. 73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at 483. 475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on record review and interview during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include contact information for physicians, federal emergency preparedness officials, and the Office of the Long-Term Care Ombudsman. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Preparedness Program, Communications Program included contact information for physicians, federal emergency preparedness officials, and the Office of the Long-Term Care Ombudsman. During an interview on 04/01/2025 at 2:26 PM, Administrator #1 stated that they would add contact information for physicians, federal emergency preparedness officials, and the Office of the Long-Term Care Ombudsman to their emergency plan. 42 Code of Federal Regulations 483. 73(c)

Plan of Correction: ApprovedMay 13, 2025

The Emergency Plan was updated to include current phone and contact information for all attending physicians, Federal Emergency Management Agency regional office and the Office of the Long-Term Care Ombudsman. All residents have the potential to be affected by this deficient practice. An audit will be completed ensuring that all necessary contact information is included in the Emergency Plan. A monthly audit will be conducted by the Administrator or designee to verify that the Emergency Plan and Pandemic Plan are all inclusive and current. Results from the monthly audit will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Administrator is responsible for completion of this plan of correction.

EP01 484.102(a)(3), 441.184(a)(3), 485.727(a)(3), 494.6:EP PROGRAM PATIENT POPULATION

REGULATION: 403. 748(a)(3), 416. 54(a)(3), 418. 113(a)(3), 441. 184(a)(3), 460. 84(a)(3), 482. 15(a)(3), 483. 73(a)(3), 483. 475(a)(3), 484. 102(a)(3), 485. 68(a)(3), 485. 542(a)(3), 485. 625(a)(3), 485. 727(a)(3), 485. 920(a)(3), 491. 12(a)(3), 494. 62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at 483. 73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the emergency plan did not provide documentation about the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. This could affect all residents at the facility. This is evidenced as by: There was no documented evidence that the emergency plan documented a description of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. During an interview on 04/01/2025 at 2:18 PM, Administrator #1 stated that they would start with the facility assessment and add a description of the of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. 42 Code of Federal Regulations: 483. 73(a)(3)

Plan of Correction: ApprovedMay 12, 2025

The Emergency Plan was updated to outline a description of resident populations that would be at risk during an emergency event and the type of services that have been put in place to address their unique vulnerabilities. All residents have the potential to be affected by this deficient practice. After any update to the Facility Assessment that indicates a change in the resident population that would be at risk during an emergency event and/or the services that have been put in place to address their unique vulnerabilities, the Emergency Plan will be updated as well. A monthly audit will be conducted by the Administrator or designee to verify that the Emergency Plan is all inclusive and complete. Results from the monthly audit will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Administrator is responsible for completion of this plan of correction.

EP01 484.102(d)(1), 441.184(d)(1), 485.727(d)(1), 483.4:EP TRAINING PROGRAM

REGULATION: 403. 748(d)(1), 416. 54(d)(1), 418. 113(d)(1), 441. 184(d)(1), 460. 84(d)(1), 482. 15(d)(1), 483. 73(d)(1), 483. 475(d)(1), 484. 102(d)(1), 485. 68(d)(1), 485. 542(d)(1), 485. 625(d)(1), 485. 727(d)(1), 485. 920(d)(1), 486. 360(d)(1), 491. 12(d)(1). *[For RNCHIs at 403. 748, ASCs at 416. 54, Hospitals at 482. 15, ICF/IIDs at 483. 475, HHAs at 484. 102, REHs at 485. 542, "Organizations" under 485. 727, OPOs at 486. 360, RHC/FQHCs at 491. 12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at 418. 113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at 441. 184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at 460. 84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at 483. 73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at 485. 68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at 485. 625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at 485. 920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on record review and interview during the Standard Life Safety Code Survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Preparedness Program, Training Program included training for and a demonstration of knowledge of the emergency responses for snowfall, epidemic/pandemic, and workplace violence. During an interview on 04/01/2025 at 2:32 PM, Administrator #1 stated that the most likely hazards to face their facility included snowfall, epidemic/pandemic, and workplace violence and that they would update the training program to include training for and a demonstration of knowledge (e.g., quiz) on the most likely hazards. 42 Code of Federal Regulations 483. 73(d)(1)(ii)

Plan of Correction: ApprovedMay 12, 2025

The employee Emergency Plan training program has been updated to include a post-test to determine the employees understanding of each specific likely hazard that has been identified on the Hazardous Risk Assessment; including, snowfall, epidemic/pandemic and workplace violence. All residents have the potential to be affected by this deficient practice. All employees will be provided education and be required to complete a post-test (demonstration of knowledge) regarding the hazards that were identified on the Hazardous Risk Assessment; including snowfall, epidemic/pandemic and workplace violence. Training on these hazards will be added to the new employee orientation program and the annual employee training. Upon the completion of the Hazardous Risk Assessment annually, the employee Emergency Plan training program will be reviewed to verify that all appropriate risks are identified and include educational information on such and a demonstration to knowledge. A monthly audit will be conducted by the Staff Development Coordinator to verify that the employee Emergency Training program is inclusive of each specific likely hazard that has been identified on the Hazardous Risk Assessment. Results from the monthly audit will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Staff Development Coordinator is responsible for completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:EXIT SIGNAGE

REGULATION: Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7. 10 with continuous illumination also served by the emergency lighting system. 19. 2. 10. 1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interview during the recertification survey, the facility did not identify all means of egress in accordance with adopted regulations relative to Building # 2. Specifically, doors that could be confused as exits were not marked as required by the National Fire Protection Association (NFPA) 101, 2012 Edition, Section 19. 2. 10. 1. This is evidenced by: During observations on 03/31/2025 at 11:31 AM: The core area door to the courtyard was not marked with the verbiage No Exit. The Resident Lounge to the courtyard was not marked with the verbiage No Exit. During an interview on 03/31/2025 at 2:37 PM, Facilities Director #1 stated that they would correct the signs on the doors that are not exits and would remove the sign from the main courtyard door. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101 19. 2. 10. 1 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)(1)

Plan of Correction: ApprovedMay 13, 2025

The doors to the courtyard from the core area and the Resident Lounge will be marked with a sign with the verbiage NO EXIT using the required specifications. All residents have the potential to be affected by this deficient practice. All doors that open to outside, but are not emergency exits, will be audited and NO EXIT signs will be installed as necessary. A monthly audit will be conducted by the Maintenance Director or designee in order to verify that the No Exit signs remain intact. Results from the monthly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director will be responsible for the completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9. 6. 1. 3, 9. 6. 1. 5, NFPA 70, NFPA 72

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building # 2. Specifically, the malfunction indicated by a trouble signal on the fire alarm panel was not corrected, smoke detector sensitivity was not tested , and smoke detectors were not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm Code 2010 edition sections 14. 2. 1. 2. 2 and 14. 4. 5. 3, 14. 6. 2. 4, and 17. 7. 4. 1. This is evidenced by: During observations on 03/31/2025 at 10:01 AM, a trouble signal was activated on the fire panel. During an interview on 03/31/2025 at 10:49 AM,(NAME)Wright, Director of Building Services #1 stated that they did not know the fire alarm system had a trouble signal and would have to contact their fire alarm system vendor to discover the cause. The document titled Fire Alarm Inspection Report and dated 05/06/2024 documented that 27 of 139 smoke detectors had failed sensitivity inspection. There was no documented evidence that the smoke detector sensitivity was re-tested . During an interview on 03/31/2025 at 1:15 PM, Facilities Manager #1 stated that they were not sure if smoke detector sensitivity was re-checked but would check with their vendor. During observations on 03/31/2025 at 11:17 AM, smoke detectors were located within 3-feet of ventilation ducts in the following areas: ?é?À room [ROOM NUMBER], 6, 7. ?é?À Resident Lounge. ?é?À Core area by Minimum Data Set Office. During an interview on 03/31/2025 at 2:03 PM, Facilities Manager #1 stated that they would contact their vendor and have the smoke detectors too close to the vents moved. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101 9. 6. 1. 3 2010 NFPA 72 14. 2. 1. 2. 2, 14. 4. 5. 3, 14. 6. 2. 4, 17. 7. 4. 1 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)

Plan of Correction: ApprovedMay 12, 2025

The fire alarm system vendor was on-site 3/31/25 to determine the cause of the trouble light and the issue indicated by the trouble light was resolved. The 27 smoke detectors that had failed sensitivity inspection have been replaced and the system is in normal operating conditions. The next sensitivity inspection is scheduled for May 2026. All identified smoke detectors have been relocated to be 3 feet from any ventilation duct. All residents have the potential to be affected by the deficient practice. All smoke detectors were evaluated to verify that they were not within 3 feet of a ventilation duct. Education will be provided to the nursing and reception staff members regarding how to monitor and immediately report any issues with the fire annunciator panels that are located at each nurses station and in the lobby. Education on this topic will be added to the annual training packets for both departments. The Maintenance Department will perform random visual audits to verify that the fire panels do not have any illuminated trouble indicators. Results from the weekly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director is responsible for completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7. 8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18. 2. 8, 19. 2. 8

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building # 2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19. 2. 8 and 7. 8. This is evidenced by: During observations on 03/31/2025 at 11:00 AM, from the physical therapy room, emergency lighting along the path of exit discharge was missing and emergency lighting with two fixtures was missing above the exit discharge door. From the North Unit and West Unit, emergency lighting along the path of exit discharge was missing. During observations on 03/31/2025 at 11:25 AM, emergency lighting or emergency lighting that would operate automatically without manual intervention was not provided along the means of egress in the following areas: ?é?À Resident Lounge ?é?À Personal Care Area (shower) During an interview on 03/31/2025 at 2:25 PM, Facilities Manager #1 stated that they would add the emergency lighting. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101: 19. 2. 8, 7. 8 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)(1)

Plan of Correction: ApprovedMay 13, 2025

Emergency lighting will be installed along the path of exit discharge from the physical therapy room and North Unit and West Unit; emergency lighting with two fixtures will be installed above the exit discharge door from the physical therapy room; and emergency lighting or emergency lighting that would operate automatically without manual intervention will be provided along the means of egress in the Resident Lounge, and Personal Care Area (shower). All residents have the potential to be affected by this deficient practice. An audit will be conducted throughout the facility to identify the need to install any additional lighting that would operate automatically without manual intervention along the means of egress. Any additional lighting needed will be installed A monthly audit will be conducted by the Maintenance Director or designee in order to verify that the emergency lighting in all means of egress areas is operable. Results from the monthly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director will be responsible for completion of this plan of correction.

K307 NFPA 101, NFPA 101, NFPA 101, NFPA 101, NFPA 101,:MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19. 7. 6, 8. 3. 3. 1 (LSC) 5. 2, 5. 2. 3 (2010 NFPA 80)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on record review and staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations relative to Building # 1. Specifically, defects in fire door assemblies were not corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition section 5. 1. 5. This is evidenced by: During observations on 03/31/2025 at 10:38 AM, the core area/West Unit smoke barrier door would not close and latch. The document titled Fire/Smoke Barrier Door Assembly Report documented that door S4 had failed inspection during 2022, 2023, and 2024. There was no documented evidence that door S4 was repaired. During an interview on 03/31/2025 at 1:25 PM, Facilities Manager #1 stated that they would have the Core Area/West Unit smoke barrier door repaired and would search for replacement hardware for door S 4. 42 Code of Federal Regulations 483. 70 (a)(1) 2012 NFPA 101 8. 3. 3. 1 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)(1)

Plan of Correction: ApprovedMay 12, 2025

The West Unit smoke barrier door was repaired on 4/1/ 25. The replacement part to repair the S4 Fire/Smoke Barrier door are in the process of being located. In the event that they are unavailable, the entire Exit Device will be replaced on the door. All residents have the potential to be affected by this deficient practice. All other Fire/Smoke Barrier doors were inspected and no further repair needs were identified. The Maintenance Department will be re-educated on how to inspect all components of the Fire/Smoke Barrier doors during the annual inspection. A quarterly inspection of all Fire/Smoke Barrier doors will be conducted by the Maintenance Director or designee to verify that they are all operable. Results from the quarterly audits will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Maintenance Director will be responsible for this plan of correction.

EP01 484.102(a)(1)-(2), 441.184(a)(1)-(2), 485.727(a)(1:PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: 403. 748(a)(1)-(2), 416. 54(a)(1)-(2), 418. 113(a)(1)-(2), 441. 184(a)(1)-(2), 460. 84(a)(1)-(2), 482. 15(a)(1)-(2), 483. 73(a)(1)-(2), 483. 475(a)(1)-(2), 484. 102(a)(1)-(2), 485. 68(a)(1)-(2), 485. 542(a)(1)-(2), 485. 625(a)(1)-(2), 485. 727(a)(1)-(2), 485. 920(a)(1)-(2), 486. 360(a)(1)-(2), 491. 12(a)(1)-(2), 494. 62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at 418. 113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at 483. 73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at 483. 475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include strategies for addressing each emergency event identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the emergency preparedness plan included provisions for Cyber-attack, care-related emergencies, and the use of portable generators and that the plan for Pandemic/Emerging Infectious Disease was updated within the past year. During an interview on 04/01/2025 at 2:04 PM, Administrator #1 stated that they would update the emergency preparedness plan for Pandemic/Emerging Infectious Disease and add plans for Cyber-attack, care-related emergencies, and the use of portable generators. 42 Code of Federal Regulations 483. 73(a)(1)

Plan of Correction: ApprovedMay 12, 2025

The emergency preparedness plan has been updated to include provisions for cyber-attack, care-related emergencies and the use of portable generators. The Pandemic Plan was updated to include current policies. All residents have the potential to be affected by this deficient practice. A log was placed in the Pandemic Plan to document formal reviews and updates to the plan. The Hazardous Risk Assessment will be used during the annual Emergency Plan review to verify all identified risks are addressed. A monthly audit will be conducted by the Administrator or designee to verify that the Emergency Plan and Pandemic Plan are all inclusive and current. Results from the monthly audit will be presented to the Quality Assurance Performance Improvement Committee who will determine the frequency for continued audits thereafter. The Administrator is responsible for completion of this plan of correction.