Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
30D
6E
1F
Potential for minimal harm
0A
1B
2C
July 16, 2024Standard inspection, Complaint inspection · 21 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, 1) dairy walk-in refrigerator contained undated, unlabeled food items. 2) dry storage room was not maintained at appropriate temperature condition and was observed with expired items, and 3) cold food items were not held at the proper temperatures during tray line service. This was observed during the Kitchen Observation.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review conducted during the Recertification and Complaint survey (NY00335874) from 7/9/24 to 07/16/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living, and 2 (Resident #39 and #63) of 2 residents reviewed for Choices. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #143, Resident #39's, and Resident #63's wishes.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteDuring multiple observations from 7/9/24 to 7/16/24 the following were noted: 2) On Unit 6 a) Rooms 615/616/618-Name plaques were missing near bedroom doors leaving square area of mismatched, scuffed paint, b) Lock on 618A wooden closet was broken, c) a black-colored substance was noted along the floor/wall edge in shower room (lower side of unit), d) Resident #36's wheelchair armrests cracked and missing foam from right arm rest, e) Resident #102's left push handle grip missing and plastic part at end of left anti bar missing on wheelchair, f) Metal lockers and cabinet rusted and scratched (located in side hallway on unit), and g) Chipped paint, mismatched paint, scuff marks, and scratched furniture were observed throughout unit. [...]
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not assure that menus are developed/prepared/followed to meet resident choices including their nutritional, religious, cultural/ethnic needs. Specifically, 1) Resident #37 requested an ice cream during lunch service but was denied because of kosher dietary requirements, 2) Resident #143's alternative menu selection for lunch meal was not followed, and 3) Resident #58 stated the menus are developed with strict kosher dietary requirements and did not accommodating their cultural preferences.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 7/09/2024 through 7/16/2024, the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents. Specifically, there were 7 repeated deficiencies from the last survey conducted on 5/22/2023. (Refer to: F600, F609, F640, F655, F657, F758, and F880) for further information.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interviews conducted during the Recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) Registered Nurse Supervisor #8 failed to practice hand hygiene and glove changes during wound care, 2), Licensed Practical Nurse #4 failed to practice appropriate infection control during wound care treatment, and 3). [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #344) of 1 residents reviewed for Dignity out of 39 total sampled residents. Specifically, the facility did not ensure privacy and dignity were provided when a licensed nurse performed blood glucose monitoring.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 07/09/2024 to 07/16/2024, the facility did not ensure that residents are provided the option to formulate an advance directive and that advance directives are documented for each resident. This was evident for 2 (Resident #502 and Resident #233) of 6 residents reviewed for Advance Directives out of 39 sampled residents. Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for newly admitted residents.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 7/09/2024 to 7/16/2024, the facility did not immediately inform the physician when a resident's blood sugar was below the parameter that needed to be reported. This was evident for 1 (Resident #344) of 1 resident reviewed for Dignity out of 39 total sampled residents. Specifically, Resident #344 had a physician's order to notify the physician when resident's finger stick blood sugar (method of drawing drops of blood from the finger for testing the blood glucose level) result was less than 70 milligrams per deciliter or more than 400 milligrams per deciliter. The licensed nurse failed to notify the physician when Resident #344's finger stick blood sugar was below 70 milligrams per deciliter on 07/09/2024.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews conducted during the Recertification and survey from 7/09/2024 to 7/16/2024, the facility did not ensure services provided met professional standards. This was evident for 1 (Resident #193) of out of 39 total sampled residents. Specifically, Licensed Practical Nurse #5 was observed administering medications via gastrostomy tube by using the pistol syringe and forcing the medications through the gastrostomy tube.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. This was evident for 1 (Resident #143) 5 residents reviewed for Activities of Daily out of 39 sampled residents. Specifically, Resident #143 was not provided with floor ambulation program as per physical therapy and in accordance with physician's order.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, record review and interview conducted during the Recertification/ Complaint Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that a resident with indwelling catheter receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bowel function to the extent possible. This was evident for 2 (Residents #20 and #160) of 3 residents reviewed for Catheter care out of a sample of 39 residents. Specifically, the Foley urinary collection bag was improperly positioned compromising the devices' ability to maintain gravity drainage and prevent reflux of urine.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey conducted from 7/09/24 to 7/16/24, the facility did not ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 (Resident #222) of 5 residents reviewed for Unnecessary Medications out of 39 sampled residents. Specifically, the attending physician did not address the consultant pharmacist's recommendations for Resident #222 as documented that they agreed and will do.
- C
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and staff interviews, during the recertification survey from 07/09/2024 to 07/16/2024 the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System Assessment Submission and Processing system in a timely manner. Specifically, admission, annual, and quarterly assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 53 of 53 residents reviewed for the Resident Assessment facility task.
- C
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure garbage and refuse was disposed of properly. Specifically, the garbage compactor door was observed ajar, and multiple flies were observed flying on top of garbage inside the compactor.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, on 6/09/24 at 6:51 PM, the Dayroom Attendant sprayed Resident #36 with hand sanitizer when Resident #36 was trying to exit the dayroom.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 2 (Resident #36 and #102) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, a resident-to-resident altercation between Resident #36 and #102 was not reported to the New York State Department of Health within 2 hours of occurrence.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 38 total sampled residents. Specifically, the alleged staff-to-resident abuse involving the Dayroom Attendant and Resident #36 was not thoroughly investigated.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Activities of Daily Living was not revised quarterly. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 38 total sampled residents.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review, and staff interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 07/09/2024 to 07/16/2024, the facility did not ensure psychotropic drugs were not given to residents unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #102) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically, Resident #102 displayed worsening of behavioral symptoms and psychotropic medication was increased without Resident #102 being assessed for possible underlying medical cause.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Resident #143 was not provided with floor ambulation program, but documentation reflected that resident was provided with a floor ambulation program. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 39 sampled residents.
November 9, 2023Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00321932), the facility failed to protect a resident's right to be free from physical abuse by nursing home staff. This was evident for 1 of 7 residents reviewed for abuse (Resident #1). Specifically, a review of the facility surveillance camera revealed that on 08/10/2023 at 12:16 AM, Resident #1 exhibited agitation and physical aggression. Resident #1 struggled with CNA #1 and stumbled on the floor. While Resident #1 was on the floor, CNA #1 held Resident #1's arms and their left knee rested on Resident #1's left hip preventing Resident #1 from getting up and as a means to control Resident #1's behavior. A review of the camera also showed at 12:22 AM that CNA #1 held Resident #1 against the wall when Resident #1 chased CNA #1 in the hallway. Cross reference: [...]
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00321932), the facility failed to protect a resident's right to be free from physical restraint. This was evident for 1 of 7 residents reviewed for abuse (Resident #1). Specifically, a review of the facility surveillance camera revealed that on 08/10/2023 at 12:16 AM, Resident #1 exhibited agitation and physical aggression. Resident #1 struggled with CNA #1 and stumbled on the floor. While Resident #1 was on the floor, CNA #1 held Resident #1's arm and their left knee rested on Resident #1's left hip preventing Resident #1 from getting up. A review of the camera also showed at 12:22 AM that CNA #1 held Resident #1 against the wall when Resident #1 chased CNA #1 in the hallway. Cross Reference:
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00321932), the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This was evident in 1 of 7 residents reviewed for abuse (Resident #1). Specifically, Resident #1 exhibited several incidents of aggressive behavior towards staff and other residents. The facility did not evaluate the effectiveness of the interventions to address Resident #1's aggression.
May 26, 2023Standard inspection · 16 citations
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure resident Comprehensive Care Plan (CCP) was reviewed and revised upon each assessment. This was evident for 3 (Resident #60, #546, and #97) of 39 total sampled residents. Specifically, 1) Resident #60 did not have their CCP related to fluid restriction revised upon change in fluid restriction, 2) Resident #546 was not invited to their CCP meeting, and 3) Resident #97 did not have their CCP related to smoking revised upon noncompliance with facility smoking policy.
- D
Assure the security of all personal funds of residents deposited with the facility.
Inspectors wroteBased on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure a surety bond was purchased to secure all personal funds of residents deposited with the facility. This was evident for 160 residents with personal funds accounts (PFA) out of 249 residents. Specifically, the facility's PFA for 160 residents exceeded the facility's surety bond amount.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and staff interviews conducted during the recertification and complaint survey (NY00309251) from 5/22/23 to 5/26/23, the facility did not ensure that each resident was free from abuse. This was evident for 1 (Resident #143) of 4 residents reviewed for abuse out of 39 total sampled residents. Specifically, on 01/24/23 Resident #143 was slapped on the buttocks by Certified Nursing Assistant (CNA) #3 while being assisted with ADL care.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure each resident remained free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was evident for 1 (Resident #126) out of 1 resident reviewed for Physical Restraint out of a sample of 39 residents. Specifically, Resident #126, a resident with severely impaired cognition, was observed with bilateral full side rails in place, and there was no assessment, physician's order for the bilateral full side rails (SR), or medical justification. In addition, there was no assessment for the half-side rails that were ordered.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews conducted during a recertification /complaint survey (NY 00309251) from 5/22/23 to 5/26/23, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but no later than 2 hours after the allegation was made. This was evident for 2 (Resident #143 and #18) of 39 sampled residents. Specifically, 1) Resident #143 reported an allegation of abuse and the facility did not report the allegation to the NYSDOH timely, and 2) the facility did not report a resident-to-resident altercation that resulted in pain to NYSDOH involving Resident #18.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interview conducted during a Recertification survey from 05/22/23 to 05/26/23 the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, The MDS assessments did not accurately document that four side rails were used with a resident. This was evident for 1 of 1 resident reviewed for Physical Restraints out of a of 39 sample residents. (Resident #126).
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not develop and implement a Baseline Care Plan (BCP) within 48 hours of admission. This was evident for 1(Resident #546) out of 1 resident reviewed for Care Planning out of a sample of 35 residents. Specifically, Baseline Care Plan was initiated but not completed within 48 hours of admission, and residents and their representatives were not provided with a written summary of the baseline care plan.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record reviews and interviews conducted during the recertification survey from 05/22/23 to 05/26/23, the facility did not ensure that comprehensive care plans (CCP) were developed. This was evident for 2 (Resident #60 and #547) of 39 sampled residents. Specifically, a dialysis care plan was not developed for Resident #60, and an anticogulant care plan was not developed for Resident #547.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident for 1 (Resident #35) of 1 resident reviewed for Infection Control, out of a sample of 38 residents. Specifically, there was no documented evidence that a Pulmonary consult that was ordered for a resident (Resident #35), with Respiratory Syncytial Virus (RSV), was done.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents received adequate supervision to prevent accidents and hazards. This was evident for 1 (Resident #107) of 5 residents reviewed for Accidents/Hazards out of 39 total sampled residents. Specifically, Resident #107, a resident with a history of holding their own smoking materials against facility policy, did not receive adequate supervision to prevent the resident from smoking in their room.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 resident (Resident #18) reviewed for Pain Management out of 38 total sampled residents. Specifically, Resident #18 received opiod pain medications and treatment without ongoing monitoring of the efficacy of the pain management.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that if bed rails are used, correct installation, use, and maintenance was maintained. This was evident for 1 (Resident #126) resident reviewed for Physical restraint out of a sample of 39 residents. Specifically, Resident #126 had full side rails in use without (1) An assessment for risk for entrapment from bed rails prior to installation; (2) review of the risks and benefits of bed rails with Resident #126's representative to obtain informed consent prior to installation, and (3) An evaluation to ensure the bed's dimensions are appropriate for Resident #126's size and weight.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet their needs. This was evident for 1 (Resident #446) of 39 total sampled residents. Specifically, a resident was prescribed Allopurinol once a day and nurses were administering twice a day.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility failed to establish and maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases. Specifically, the facility did not follow their policy and procedures to maintain Contact precautions on a resident (Resident#35). with Respiratory Syncytial Virus (RSV). This was evident for 1 of 1 resident reviewed for Infection Control, out of a sample of 38 residents.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents, staff, and the public were provided with a safe, sanitary, and comfortable environment. This was evident for 2 (Elevator 1 and 3) of the 3 elevators. Specifically, Elevator 1 and Elevator 3 were observed with detached ceiling panels and dust buildup.
- B
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in timely. Specifically, Annual assessments were not transmitted within 14 days of the care plan completion date and Quarterly assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date. This is evident for 3 of 3 residents reviewed for the Resident Assessment facility task (Resident #s 68, 99 and 147).
October 20, 2020Standard inspection · 0 citations
Fire safety inspections
21 fire safety citations on file: 4 on July 16, 2024, 12 on May 26, 2023, 5 on October 20, 2020.
Every fire safety citation21 citations
- E
Use approved construction type or materials.
K 161 · July 16, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 16, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 16, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 16, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 26, 2023 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 26, 2023 · Corrected (the home has a date of correction)
- D
Have exits that are accessible at all times.
K 271 · May 26, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 26, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 26, 2023 · Corrected (the home has a date of correction)
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 26, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 26, 2023 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 20, 2020 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 20, 2020 · Corrected (the home has a date of correction)
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · October 20, 2020 · Corrected (the home has a date of correction)
- D
Meet other general requirements that are deficient.
K 300 · October 20, 2020 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · October 20, 2020 · Corrected (the home has a date of correction)