Seneca Rehabilitation Hospital

“MEDICAL STAFF RESPONSIBILITIES - UPDATE CFR(s): 482.22(c)(5) [The bylaws must:] [Include a requirement that --] (ii) An updated examination of the patient, including any changes in the patient’s condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration, and except as provided under paragraph (c)(5)(iii) of this section. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 50550 Based on document reviews and staff interviews, it was determined the facility failed to follow their H&P (History and Physical) policy for the Rehabilitation Hospital in 3 (three) out of 10 (ten) patient (patient #3, #5 and #7) charts reviewed. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Physician Services”, revision date 02/21. The policy states, “...The medical care of each patient is supervised by a licensed physician...3. Supervising the medical care of patients includes (but is not limited to): ...b. Completing a history and physical upon admission.” A policy was reviewed titled “Late Entry Documentation”, no date. The policy states, “Definition and Purpose, A late entry is an addition to a medical record that provides information omitted from the original documentation at the time of the service ...” A review of medical records was conducted for patient #5 admitted on 04/17/26 with a diagnosis of Cerebral Infarction, patient #7 admitted on 04/17/26 with a diagnosis of Cerebral Infarction, and patient #8 admitted on 04/10/26 with a diagnosis of Right Above the knee amputation. Updated History and Physicals (H&P) were not documented at the time of the record review of the charts. Hours later the updated H&Ps are recorded as late entries with dates and times as follows: patient #5 dated 04/20/26 at 3:25 p.m.; patient #7 dated 04/20/26 at 3:30 p.m.; and patient #8 dated 04/20/26 at 2:50 p.m. An interview was conducted with staff #2 on 04/20/26 at 5:13 p.m. Staff #2 stated, “The H&P’s were not in the patient’s charts at the time of the record review, the patients’ charts have late entries, and the patients’ charts were done after the surveyor requested the charts”. When asked what the expectations are when a provider documents the H&P, staff #2 states “I do not know”. When asked what the Medical Staff Bylaws/Rules and Regulations said about H&P, staff #2 states, “I do not know”. An interview was conducted with staff #1 on 04/20/26 at 5:30 p.m. Staff #1 stated, “[He/She] was unsure of the location of the Medical Staff Bylaws/Rules and Regulations, the facility is still operating under the previous administration, and they just hired a nurse to modify and/or create new policies and guidelines according to Acute Care.” It should be noted that staff #1 gave the surveyors the Medical Staff bylaws after the exit meeting and stated, “Look what I found”.”

“CONTENT OF RECORD: ASSESSMENT CFR(s): [All records must document the following, as appropriate: (i) Evidence of --] (C) An assessment of the patient (in lieu of the requirements of paragraphs (c)(4)(i)(A) and (B) of this section) completed and documented after registration, but prior to surgery or a procedure requiring anesthesia services, when the patient is receiving specific outpatient surgical or procedural services and when the medical staff has chosen to develop and maintain a policy that identifies, in accordance with the requirements at § 482.22(c)(5)(v), specific patients as not requiring a comprehensive medical history and physical examination, or any update to it, prior to specific outpatient surgical or procedural services. This Standard is not met as evidenced by:”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50550 Based on staff interviews, observations, and document reviews it was determined the facility failed to follow their staffing matrix (see tag A 0392), and that the RN was not on the unit at all times to supervise care (see tag A 0393) in 8 (eight) out of 8 (eight) days. This failure had the potential to negatively impact all patients receiving care at the facility. Cross Reference: §482.23(b) Standard: Staffing and Delivery of Care. Cross Reference: 482.23 Nursing Services: The hospital must have an organized nursing service that provides 24-hour nursing services.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50550 Based on document reviews, observation, and staff interviews, it was determined the facility failed to follow their staffing matrix on the unit at all times in 8 (eight) out of 8 (eight) days. This failure had the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Staffing Policy IRF” no date. The policy states, “When there are 5 or less patients the IRF will be staffed by 1 RN and a PCT. The RN is either designated to the IRF or covers the IRF and the SNF. When there are 6 or more patients there is a designated RN for the IRF with a PCT. When you get 12 patients the IRF will be staffed with 1 RN and 1 RN/LPN with 2 PCT’s.” A review of medical records was conducted of patient #1 admitted on 02/21/26 with diagnosis of Aphasia following Cerebral Infarction, and patient #2 admitted on 2/17/26 with a diagnosis of Displaced Intertrochanteric fracture of left femur. On 03/03/26 from 8:30 a.m. through 3:00 p.m. the unit was unsupervised by an RN (Registered Nurse). A review of the facility staffing “Acute Unit” also known as “Unit 4 and/or IRF” is described as follow: 03/03/26 at 8:30 a.m. through 3:00 p.m. the unit was not supervised by an RN, and from 3:00 p.m. through 11:00 p.m. the RN was in charge of 2 (two) units that are two (2) separate entities. It should be noted the other entity is a Skilled Nursing Facility. An interview was conducted with staff #8 on 03/10/26 at 10:07 a.m. Staff #8 stated that he/she typically works on Wing 1 (one) and occasionally will help cover on Wing 4 (four)”. Staff #8 states that there typically is always an RN (Registered nurse) in the building. He/she states if he/she needs an RN to assist him/her, or perform jobs out of his/her scope, that he/she frequently has to call office personnel such as unit managers, supervisors, or even the DON (director of nursing) at times. Staff #8 states that he/she was unaware that an RN was to be immediately available for the bedside care on Wing 4 (four). Staff #8 states he/she has been left alone on the floor in charge of Wing 4 (four) with the need to contact a chain of RN’s when one was needed. An interview was conducted with staff #4 on 03/10/26 at 10:49 a.m. Staff #4 stated, “there is always an RN in this building.” Staff #4 stated that the RN in the building is supposed to do hourly rounds throughout the entire building to each wing, checking patients, checking to see if staff need any help or have any questions, all while having their own assignments or duties elsewhere. Staff #4 states that when there are under 5 (five) patients on Wing 4 (four), that a nurse or a PCT will be the only staff on Wing 4 (four). There are times there are only a PCT (Patient Care Technician) in charge of Wing 4 (four), requiring the PCT to call for an RN from another part of the facility when in need of assistance or an emergency. He/she was unable to give a specific example Staff #4 states “He/she understands the difference between having an RN available in the building and an RN immediately available for bedside care.” He/ she also stated that staff are frequently pulled out of offices to assist temporarily when needed but are not staffed on the floor. An interview was conducted with staff #5 on 03/10/26 at 11:33 a.m. Staff #5 states that on 03/03/26 he/she was assigned 2 (two) units to cover as the only nurse for Wing 1 (one) and Wing 4 (four). He/she believes there was a PCT to cover Wing 4 (four) in his/her absence. He/she states that if an RN was needed then he/she would need to call another floor to see if one could assist. He/she states in a true emergency that he/she would page overhead. Staff #5 states he/she does not always feel that there are enough staff and agrees that there can be delays and care due to staffing issues, particularly because “call-offs are big.” He/she stated that Wing 4 (four) is oftentimes scheduled with an RN, but otherwise there’s one somewhere in the building. A telephone interview was conducted with staff #10 on 03/10/26 at 12:14 p.m. Staff #10 stated that he/she worked on Wing 4 (four) on Tuesday night, where there was 1 (one) RN upstairs, 1 (one) RN that covered Wings 2 (two) and 3 (three), and an RN on Wing 1 (one). He/she stated that there was an RN nursing supervisor in the building, however, that was 1 (one) of the RN scheduled on a wing. Staff #10 states that he/she was scheduled alone on Wing 4 with 3 (three) patients. He/she stated that they tried to have an RN to cover that unit but not always. Staff #10 stated that additional staff are needed throughout the facility, especially as staffing is not based on acuity. He/she stated that nursing supervisors cannot and do not round the building when they have an assignment on a wing. A telephone interview was conducted with staff #6 on 03/10/26 at 3:53 p.m. Staff #6 stated the supervisors cover Wings 1 (one) and 4 (four), and if passing meds on Wing 1 (one) then wing 4 (four) is left without nursing coverage, and a PCT is left on the unit alone. He/she feels that staffing is someone adequate and sometimes not. He/she stated that they are unsure if staffing is increased with acuity but usually do not have the staff to do it even so. Staff #6 also stated that the competency between PCT’s varies and he/she is not always comfortable working with his/her assignment. “I would prefer to have a nurse [RN] on that unit [Wing 4] at all times.” A telephone interview was conducted with staff #7 on 03/10/26 at 4:43 p.m. Staff #7 states there usually is always an RN in the building, and that “No medical facility has enough staff.” He/she stated that staff respond relatively quickly when you call them from another unit to help. An interview attempt was made on 03/10/26 at 12:09 p.m. with a phone call to staff #9. A message was left to call back. On 3/10/26 at 12:37 p.m. a text message was sent to staff #9 with no response or call back. An interview was conducted with staff #2 [DON] on 03/11/26 at 12:28 p.m. Staff #2 concurred, “We split the RN between 2 [two] units. There is either an RN in their office down the hall or else somewhere else in the building. There is not always a nurse staffed in this unit [IRF].” He/she explained staffing from the sheets on 03/02/26. An LPN was scheduled for 2 (two) units, the IRF and Wing 1 (one). There was an RN in the office down the hall if needed but not staffed on the floor. At 3:00 p.m., there was a PCT on the IRF from 3:00 p.m. to 7:00 p.m., with an RN scheduled on another floor on Wing 8 (eight) for coverage if needed. There was an RN scheduled from 7:00 p.m. to 7:00 a. m. on the IRF but scheduled to cover 2 (two) units. When asked about the different levels of care for the IRF patients, he/she stated, “The only difference between the patients here is that they can tolerate PT [Physical Therapy] for 3 (three) hours a day and the others cannot. States that he/she is “unaware that they needed to have different policies and rules for this unit. These are the same things that we followed from the last administration”. When asked to see a floor plan to locate the manager’s office as the RN supervising the floor, the document shows the office off the wing, past a set of fire doors, 2 (two) elevator towers, a welcome desk, and 2 (two) doors down the hallway heading to the rear of the building. It should be noted the RN “Down the hall” was not on the IRF unit but past the Fire doors of the unit. An interview was conducted with staff #1 [CEO] on 03/11/26 at 1:21 p.m. He/she entered the room stating that he/she wanted to clear something up to the surveyors. “All staff in this Hospital are under the same license, and an LPN or RN anywhere in this building counts [for RN coverage of IRF].” It should be noted that the IRF is one wing of the facility and all other wings are a separate entity and not all wings are on the same floor. The separate entity is a Skilled Nursing Facility.”

“RN/LPN STAFFING CFR(s): 482.23(b)(1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under o488.54(c) of this chapter. This Standard is not met as evidenced by: 50550 Based on document reviews, observation, and staff interviews, it was determined the facility failed to staff an RN on the unit at all times in 8 (eight) out of 8 (eight) days. This failure had the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Staffing Policy IRF” no date. The policy states, “When there are 5 or less patients the IRF will be staffed by 1 RN and a PCT. The RN is either designated to the IRF or covers the IRF and the SNF. When there are 6 or more patients there is a designated RN for the IRF with a PCT. When you get 12 patients the IRF will be staffed with 1 RN and 1 RN/LPN with 2 PCT’s.” A review of medical records was conducted of patient #1 admitted on 02/21/26 with diagnosis of Aphasia following Cerebral Infarction, and patient #2 admitted on 2/17/26 with a diagnosis of Displaced Intertrochanteric fracture of left femur. On 03/03/26 from 8:30 a.m. through 3:00 p.m. the unit was unsupervised by an RN (Registered Nurse). A review of the facility staffing “Acute Unit” also known as “Unit 4 and/or IRF” is described as follow: 03/03/26 at 8:30 a.m. through 3:00 p.m. the unit was not supervised by an RN, and from 3:00 p.m. through 11:00 p.m. the RN was in charge of 2 (two) units that are two (2) separate entities. It should be noted the other entity is a Skilled Nursing Facility. An interview was conducted with staff #8 on 03/10/26 at 10:07 a.m. Staff #8 stated that he/she typically works on Wing 1 (one) and occasionally will help cover on Wing 4 (four)”. Staff #8 states that there typically is always an RN (Registered nurse) in the building. He/she states if he/she needs an RN to assist him/her, or perform jobs out of his/her scope, that he/she frequently has to call office personnel such as unit managers, supervisors, or even the DON (director of nursing) at times. Staff #8 states that he/she was unaware that an RN was to be immediately available for the bedside care on Wing 4 (four). Staff #8 states he/she has been left alone on the floor in charge of Wing 4 (four) with the need to contact a chain of RN’s when one was needed. An interview was conducted with staff #4 on 03/10/26 at 10:49 a.m. Staff #4 stated, “there is always an RN in this building.” Staff #4 stated that the RN in the building is supposed to do hourly rounds throughout the entire building to each wing, checking patients, checking to see if staff need any help or have any questions, all while having their own assignments or duties elsewhere. Staff #4 states that when there are under 5 (five) patients on Wing 4 (four), that a nurse or a PCT will be the only staff on Wing 4 (four). There are times there are only a PCT (Patient Care Technician) in charge of Wing 4 (four), requiring the PCT to call for an RN from another part of the facility when in need of assistance or an emergency. He/she was unable to give a specific example Staff #4 states “He/she understands the difference between having an RN available in the building and an RN immediately available for bedside care.” He/ she also stated that staff are frequently pulled out of offices to assist temporarily when needed but are not staffed on the floor. An interview was conducted with staff #5 on 03/10/26 at 11:33 a.m. Staff #5 states that on 03/03/26 he/she was assigned 2 (two) units to cover as the only nurse for Wing 1 (one) and Wing 4 (four). He/she believes there was a PCT to cover Wing 4 (four) in his/her absence. He/she states that if an RN was needed then he/she would need to call another floor to see if one could assist. He/she states in a true emergency that he/she would page overhead. Staff #5 states he/she does not always feel that there are enough staff and agrees that there can be delays and care due to staffing issues, particularly because “call-offs are big.” He/she stated that Wing 4 (four) is oftentimes scheduled with an RN, but otherwise there’s one somewhere in the building. A telephone interview was conducted with staff #10 on 03/10/26 at 12:14 p.m. Staff #10 stated that he/she worked on Wing 4 (four) on Tuesday night, where there was 1 (one) RN upstairs, 1 (one) RN that covered Wings 2 (two) and 3 (three), and an RN on Wing 1 (one). He/she stated that there was an RN nursing supervisor in the building, however, that was 1 (one) of the RN scheduled on a wing. Staff #10 states that he/she was scheduled alone on Wing 4 with 3 (three) patients. He/she stated that they tried to have an RN to cover that unit but not always. Staff #10 stated that additional staff are needed throughout the facility, especially as staffing is not based on acuity. He/she stated that nursing supervisors cannot and do not round the building when they have an assignment on a wing. A telephone interview was conducted with staff #6 on 03/10/26 at 3:53 p.m. Staff #6 stated the supervisors cover Wings 1 (one) and 4 (four), and if passing meds on Wing 1 (one) then wing 4 (four) is left without nursing coverage, and a PCT is left on the unit alone. He/she feels that staffing is someone adequate and sometimes not. He/she stated that they are unsure if staffing is increased with acuity but usually do not have the staff to do it even so. Staff #6 also stated that the competency between PCT’s varies and he/she is not always comfortable working with his/her assignment. “I would prefer to have a nurse [RN] on that unit [Wing 4] at all times.” A telephone interview was conducted with staff #7 on 03/10/26 at 4:43 p.m. Staff #7 states there usually is always an RN in the building, and that “No medical facility has enough staff.” He/she stated that staff respond relatively quickly when you call them from another unit to help. An interview attempt was made on 03/10/26 at 12:09 p.m. with a phone call to staff #9. A message was left to call back. On 3/10/26 at 12:37 p.m. a text message was sent to staff #9 with no response or call back. An interview was conducted with staff #2 [DON] on 03/11/26 at 12:28 p.m. Staff #2 concurred, “We split the RN between 2 [two] units. There is either an RN in their office down the hall or else somewhere else in the building. There is not always a nurse staffed in this unit [IRF].” He/she explained staffing from the sheets on 03/02/26. An LPN was scheduled for 2 (two) units, the IRF and Wing 1 (one). There was an RN in the office down the hall if needed but not staffed on the floor. At 3:00 p.m., there was a PCT on the IRF from 3:00 p.m. to 7:00 p.m., with an RN scheduled on another floor on Wing 8 (eight) for coverage if needed. There was an RN scheduled from 7:00 p.m. to 7:00 a. m. on the IRF but scheduled to cover 2 (two) units. When asked about the different levels of care for the IRF patients, he/she stated, “The only difference between the patients here is that they can tolerate PT [Physical Therapy] for 3 (three) hours a day and the others cannot. States that he/she is “unaware that they needed to have different policies and rules for this unit. These are the same things that we followed from the last administration”. When asked to see a floor plan to locate the manager’s office as the RN supervising the floor, the document shows the office off the wing, past a set of fire doors, 2 (two) elevator towers, a welcome desk, and 2 (two) doors down the hallway heading to the rear of the building. It should be noted the RN “Down the hall” was not on the IRF unit but past the Fire doors of the unit. An interview was conducted with staff #1 [CEO] on 03/11/26 at 1:21 p.m. He/she entered the room stating that he/she wanted to clear something up to the surveyors. “All staff in this Hospital are under the same license, and an LPN or RN anywhere in this building counts [for RN coverage of IRF].” It should be noted that the IRF is one wing of the facility and all other wings are a separate entity and not all wings are on the same floor. The separate entity is a Skilled Nursing Facility.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 38626 Based on observation, record review, and staff interview it was determined the facility failed to ensure compliance with National Fire Protection Association (NFPA) 101, and 80. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Findings include: a) Observation during the facility inspection tour conducted on 07/08/25 at 10:20 a.m., revealed the B-2 Wing Fire Doors not latching and six penetrations to the doors from missing hardware screws. b) Observation during the facility inspection tour conducted on 07/08/25 at 10:21 a.m., revealed the frame of the B-3 Wing Fire Doors to have penetrations due to missing hardware screws. c) Interview on 07/08/25 at approximately 10:45 a.m., with the Facility Maintenance Supervisor verified these findings. The findings were were also acknowledged by the Director of Nursing at the exit interview on 07/08/25.”

“Maintenance, Inspection & Testing - Doors CFR(s): 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) This Standard is not met as evidenced by: 38626 Based on observation, record review, and staff interview it was determined the facility failed to ensure compliance with National Fire Protection Association (NFPA) 101, and 80. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Findings include: a) Observation during the facility inspection tour conducted on 07/08/25 at 10:20 a.m., revealed the B-2 Wing Fire Doors not latching and six penetrations to the doors from missing hardware screws. b) Observation during the facility inspection tour conducted on 07/08/25 at 10:21 a.m., revealed the frame of the B-3 Wing Fire Doors to have penetrations due to missing hardware screws. c) Interview on 07/08/25 at approximately 10:45 a.m., with the Facility Maintenance Supervisor verified these findings. The findings were were also acknowledged by the Director of Nursing at the exit interview on 07/08/25.”