Lemay Avenue Health and Rehab LLC

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Based on observations and staff interviews during the survey, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.7.3.1 and Chapter 7, 1.10.1. This was evidenced by the following: The west courtyard exit path is not maintained free of snow and ice.This deficient practice could affect all residents, staff, and visitors in two of eight smoke compartments if this exit discharge to the public way is compromised. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of a.. Based on observations and staff interviews during the survey, the facility failed to maintain a gas fireplace in accordance with Life Safety Code 101, 19.5.2.3 (2) d, e, & f, and 19.5.2.3 and NFPA 55. This was evidenced by the following: The gas fireplace in the 2nd-floor common space has an open flame in the vicinity of residents on oxygen therapy.This deficiency could affect all occupants in this smoke compartment if they encounter an open flame or expose their oxygen source to it. NFPA 101, 19.5.2.3 (2) Direct-vent gas fireplaces, as defined in NFPA 54, Nation.. Based on observations and staff interviews during the survey, the facility failed to maintain exit signs in accordance with Life Safety Code 101, 19.2, and Section 7.10.1.5.1. This was evidenced by the following: The exit signs are missing in the 2nd-floor elevator lobby: one directional exit sign and one above the doors leading to the common area. The west courtyard exit gate is missing an exit sign.This deficient practice could affect all residents, staff, and visitors throughout the smoke compartment if the exit cannot be identified during an emergency. NFPA 101, 7.10.5.2.1 Ever.. Based on observations and staff interviews during the survey, the facility failed to maintain hazardous areas in accordance with NFPA 101, 19.3.2.1.3; NFPA 99, 9.3.7; and NFPA 96A, 5.3.1.2. This was evidenced by the following: The soiled utility room on the 2nd floor, near room 211, has a door that does not latch. The soiled utility room on the 1st floor, near room 1104, has a door missing a closer and that will not latch. The oxygen transfer rooms on the 1st and 2nd floors have ventilation ducting with no evidence of fire or fire/smoke dampers for these rated rooms.. Based on observations and staff interviews during the survey, the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code, 400.8. This evidenced the following deficiencies: 1. Improper use of a household extension cord to provide power to the microwave and refrigerator in the doctor’s office. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code.NFPA 70, Section 400.8, Flexible cords and cables shall not be .. Based on observations and staff interviews, it was determined that the facility failed to provide documentation that combustible decorations and fabrics were fire-retardant and/or treated with a fire-retardant spray in accordance with the Life Safety Code, NFPA 101, 19.7.5.1, and 10.3.1. This was evidenced by the following: Prohibited hanging of combustible decorations on the corridor side of resident room doors throughout the facility.This deficient practice could affect all residents, staff, and visitors in all eight smoke compartments in the event of a fire, potentially comp.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on December 4, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 “Existing Health Care Occupancies.”This structure is a two (2) story, Type II (111) construction. The facility was built in 2004 and has eight smoke compartments. There is no basement. The facility is licensed for 130 beds, and..

A recertification survey with CO#2589155, Incident #1936158 and Incident #2590234 was completed on 9/8/25 to 9/11/25.One deficiency was cited. An Emergency Preparedness survey was conducted from 9/8/25 to 9/11/25. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of eight units.Specifically, the facility failed to:-Ensure the vital signs machine was disinfected after being used in a COVID-19 positive room;-Ensure the vital signs machine was disinfected between each resident’s use on the secure unit; and,-Ensure housekeeping staff doffed (took off) their personal protective equipment (PPE) and closed the trash bags before exiting a COVID-19 positive room.Findings include:I. Failed to ensure the vital signs machine was disinfected after being utilized in a COVID-19 positive roomA. Professional referenceAccording to the Centers for Disease Control And Prevention’s (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, updated June 2024, retrieved from https://www.cdc.gov/infection-control/hcp/disinfection-and-sterilization/index.html on 9/15/25, “Medical equipment surfaces blood pressure cuffs, stethoscopes, hemodialysis machines, and Xray machines) can become contaminated with infectious agents and contribute to the spread of healthcare–associated infections. For this reason, non-critical medical equipment surfaces should be disinfected with an EPA-registered low-level or inter..

A survey prompted by complaint #CO39271 was completed on 2/18/25 to 2/19/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure three (#13, #11 and #12) of three residents out of 11 sample residents had their grievances resolved promptly by the facility.Specifically, the facility did not promptly respond to Resident #13, Resident #11 and Resident #12' s grievances of long call light times.Findings include:I. Facility policy and procedureThe Grievance Procedure policy, revised on 10/31/24, was provided by the nursing home administrator (NHA) on 2/19/25 at 6:10 p.m. The policy revealed the purpose of the policy was to protect resident rights and ensure prompt resolution of grievances. If at any time, a resident or representative had a grievance, it was their responsibility to express it orally or in writing to the nursing home administrator (NHA) or designee. Each resident had the right to voice grievances without discrimination, reprisal, or retribution. The facility had a Grievance Committee, which consisted of the NHA or their designee, a resident selected by the facility' s residents and a third person agreed upon by the NHA and the facility' s resident representative. The NHA or designee was responsible for overseeing the process to the conclusion, maintaining confidentiality, issuing written decisions and coordinating with regulatory agencies as necessary.A review of the grievance would be completed within three (3) calendar days of receiving the grievance and a written explanation of the findings with proposed remedies would be provided. If dissatisfied with the findings and remedies, the aggrieved party might appeal to the Grievance Committee within ten (10) calendar days of receiving the written explanation. The committee would confer with the person involved, within ten (10) calendar days of the date of the appeal and would provide a written explanation of the findings and the proposed remedies.II. Resident #13A. Resident statusResident #13, age greater than 65, was admitted on 10/2/23. According to the February 2025 computerized physician orders (CPO), diagnoses included unsteadiness on feet, histor..

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. No records or documentation of generator battery monthly conductance testing.NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting.Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1This deficiency has the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency.This was discussed during the record review and again during the exit co.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 19.2.9 and 7.9.3.1.1. This was evidenced by the following:1. No records or inadequate documentation for emergency lighting 90-minute annual testing.NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.2.3. The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting.This d.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2.This was evidence by the following:1. Kitchen stove and cooking equipment missing wheel docking blocks.NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations.NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location.NFPA 54, 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer' s installation instructions.This deficient practice could affect all residents, and staff should a fire occur and the suppression syste.. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on December 7, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a two (2) story, Type II (111) construction. The facility was built in 2004. There is no basement. The facility is licensed for 130 beds and the census on the date of the survey was 123. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The wet-pipe system protects all levels. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Maintenance Director and the Executive Director during the exit conference.