Preview
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
Exhibit 4
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
sTATEMENT OF DEFlclENCIES (X1) PROVIDER/sUPPLIER/CLIA (X2) MULTIPLEcONsTRUcTION (X3) DATE SURVEY
AND PLANOF CORREcTION IDENTIFICATIONNUMBER: cOMPLETED
A. BUILDING
B. WING
12/29/2021
NAMEOF PROVIDEROR SUPPLIER STREETADDRESS, CITY, STATE, ZIP cODE
3260 N 7TH STREET
FIELD OF DREAMS SENIOR LIVING
ALLEGANY, NY 14706
(X4) ID SUMMARYSTATEMENTOF DEFlcIENCIES ID PROVIDER'SPLANOF cORREcTION (XS)
PREFlX (EACH DEFlclENcY MUsT BE PRECEDEDBY FULL PREFlX (EAcH coRREcTIVE AcTloN SHOULDBE COMPLETE
TAG REGULATORYOR Lsc IDENTIFYlNG INFORMATION) TAG CROSs-REFERENCEDTO THE APPROPRIATE DATE
DEFICIENCY)
A4720 486.5 (a)(4) (v)CivilPenalties A4720 1. Of the 22 employees identifiedinthe 03/04/2022
SS=J survey, 9 have been fullyvaccinated; 9
(a) Civilpenalties for adult
certified care have received a medical exemption, and 4
facilities. staffhave been terminated frornthe
organization.
(4)Even where correction ofa violation
has occurred In accordance with paragraph (3)
of thissubdivision, the department may assess a 2. The COVID-19 policy,Resident Health
penalty if it establishesata hearing that the Checks was reviewed and revised on
particularviolation endangered or resulted in 11/29/2021 by Administration and again
harm to a resident as the result of: reviewed on 01/19/2022 by the QA/Ql
Committee. The lesson plan and
(v) the failureof systemic competency checklistwere revised to
practices and procedures as evidenced by a include the process for sanitizingthe
pattem of violations or an Inabilityto bring a resident specific locations as well as
specific area of operation
facility intocompliance monitoring for signs and symptoms.
with sections 487.4, 487.5, 487.6, 487.7, 487.8,
487.9(a)(1),(3),(7),(8),(10-15),487.9(b-d),(f),(g) On 01/19/2022, during a Quality
(1),487.10(a-b), 487.11, 487.12(b), (g)-(j), Assurance/Quality Improvement meeting,
488.4, 488.5, 488.6, 488.7, 488.8, 488.9(a)(1), the following COVID specific policies were
(2),(4),(5), (7-11),488.9(b-e), 488.10(a-b), reviewed:
488.11, 488.12(b-c), (g-i),(1), 490.4,490.5,
490.6, 490.7, 490.8, 490.9(a)(1), (3),(5), (6),(8- Resident Health Checks
13), 490.9 (b-d),(f),
490.10(a-b), 490.11, 490.12 Medical Exemption/Exception Policy
(b),or (g-j)of thisTitle;or
On 11/1/2021, a letterwas distributed to all
This LICENSURE isnot met as evidenced by: staffregarding State guidance related to
the COVID-19 pandemic and
Based on observations, review of facility education/training on Prevention of
records, and Interviews with facilitystaffduring COVID-19 Transmission.
an infection control focused partialinspection
and complaint inspection initiatedon 12/16/2021 On 11/19/2021, a Risk Management
and completed on 12/29/2021, the operator inservice included an educational segment
failedto protect residents from harm to person on employee responsibilitiesas it relatesto
and property as required by 18 NYCRR 487.7(d) Prevention of COVID-19 Transmission
(1)(v).Further the operator failedto operate the
in
facility compliance with law and regulation,as On 12/14/2021, a letterwas distributed to
required by 18 NYCRR 487.3(b) and the allstaffregarding compliance with all
operator failedto hirean administrator capable applicable State Emergency Regulations.
of and responsible for operating the In
facility
compliance with law and regulation as required On 1/24/2022, an educational blastcall(a
LABORATO Y DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically signed 03/04/2022
sTATE FORM Event ID:
XNGL11 FacIlltyID: AF0906A If continuationsheet Page 1 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
sTATEMENT OF DEFIclENcIES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULUPLE CONSTRUcTION (X3) DATE sURVEY
AND PLANOF cORREcTION IDENTIFIcATION NUMBER:
A. BUILDING
cOME
AF0906A 12/29/2021
NAMEOF PROVIDEROR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
3260 N 7TH STREET
FIELD OF DREAMS SENIOR LIVING
ALLEGANY, NY 14706
(X4) ID sUMMARY sTATEMENT OF DEFICIENcIES ID PROVIDER'SPLAN OF cORRECEON (X5)
PREFIX (EACH DEFicIENcY MUST BE PRECEDEDBY FULL PREFlX (EAcH CORREcTIVE AcTION SHoULD BE OOMPLETE
TAG REGULATORYOR LSc IDENBFYING INFORMATION) TAG CROSS-REFERENcEDTO THE APPROPRIATE DATE
DEFlclENCY}
A4720 Continued From page 1 A4720
by 18 NYCRR 487.9(c)(8)(ii),including failureto mechanism toregularly communicate
comply with 18 NYCRR §487.9(a)(18) and 10 COVID-19 related updates) was sent to
NYCRR §2.61(c), which provides: resident representatives relating tosafe
protocols and Prevention of COVID-19
"Covered entitiesshall continuously require Transmission while visitingFieldof
personnel to be vaccinated against COVID- Dreams.
fully
19. Documentation ofsuch vaccination shall be
made inpersonnel records or other appropriate On 01/24/2022, an educational reminder
records."
was sent out to staffto monitor residents
forsigns and symptoms of illness,best
Letter"
In a "Dear Administrator (DAL) 21-32, practices related to masks and shields, the
dated 11/15/2021, The Department ofHealth importance of hand hygiene and sanitation,
notifiedAdult Care Facilitiesof the need to socialdistancing and taking caution when
ensure that covered "personnel", under the activeoutside of work.
Departments August 26, 2021 -Prevention of
COVID-19 Transmission by Covered Entitles On 01/31/2022, Director of Personal Care
Emergency Regulation, who were previously did an Inservice with allresidents regarding
granted religiouseXemptions have signs and symptoms of COVID-19 and how
documentation of eithera first
dose COVID-19 to themselves safe the
keep during
vaccination or a valid medical eXemption. pandemic. Handouts were provided to all
followed by a question and answer
On 12/16/2021, a review of records
facility session.
revealed:
Allincidents of positivecases are posted in
The employee
facility's roster, which defined the entrance of Fieldof Dnsams and on all
employees by job If they
title, provided hands on three bulletinboards for residentand visitor
care, and theirvaccination status, indicated: knowledge.
- atthe time of survey, 33 unvaccinated staff
members were identified,14 ofwhom provided A CDC handout educating on Symptoms of
directcare to residents including employees #3, COVID-19 was provided toall employees
#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, in bothJanuary and February, 2022.
and #15.
- employees #2 and #21, both of whom provided Allsuch documentation of will
training be
personal care, had their 1st COVID-19 on fileforreview by surveillance staff.
vaccination greater than 6 weeks prior,and had
yet toreceive their2nd dose.
- employee #1, the Administrator, 3. Effective per the COVID
facility April,2021,
employee #21, the Director of Patient Care, and Vaccinations verificationofCOVID-
Policy,
employee #22, the Business Office Manager, 19 vaccination status willbe documented
were allidentifiedas unvaccinated employees. within both the employee health record and
resident reconi
STATE FORM Event ID: XNGL11 Facility ID: AF0906A If continuationsheet Page 2 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
sTATEMENT 0F DEFIclENCIES (X1) PROVIDER/sUPPUER/CuA (X2) MULTIPLECONsTRUcTION (X3) DATE SURVEY
AND PLANOF CORREcTION IDENTIFIcATION NUMBER: COMPLETED
A. BUILDING
B. WING
AF0906A 12/20/2021
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS,cITY, STATE, ZIP CoDE
3260 N 7TH STREET
FIELD OF DREAMS SEN1OR L1VING
ALLEGANY, NY 14706
(X4) ID SUMMARY STATEMENTOF DEFICIENclEs ID PROVIDER'SPLAN OF CORRECTION (X5)
PREFlX (EAcH DEFICIENCYMUST BE PREcEDED BY FULL PREFIX (EAcH cORREcTIVE AcTION sHOULD BE COMPLETE
TAG REGULATORYOR LSC IDENTIFYINGINFORMATION) TAG cROSS-REFERENcEDTO THE APPROPRIATE DATE
DEFICIENCY)
A4720 Continued From page 2 A4720
The Schedules
facility and Time Card Reports
dated 11/22/2021 through 12/16/2021, indicated " audits willcontinue to be
Ongoing
and verifiedunvaccinated employees worked conducted to ensure allcurrent and newly
directlywith facilityresidents including: hired staffremain in compliance.
- 9 employees on 11/29/2021, 11/30/2021,
12/1/2021 and 12/2/2021. Effective 11/16/2021, a system was set up
- 8 employees on 11/22/2021, 11/26/2021, to monitor residents forsigns and
12/6/2021, 12/8/2021, 12/10/2021, and symptoms of COVID-19 dailyto include a
12/15/2021. twice daily temperature check. New
- 7employees on 11/23/2021, 11/24/2021, admissions thereafterwere immediately
12/3/2021, 12R/2021, 12/9/2021, 12/12/2021, set up to be monitored daily.
12/13/2021, and 12/14/2021.
-6 employees on 11/25/2021 and 12/4/2021. In November, a system was put into place
- 5employees on 12/5/2021 and 12/16/2021. for a twice temperature check
daily
- 4 employees on 11/28/2021 and 12/11/2021. tostaffthat must report to
indicating they
- 3employees on 11/27/2021. RN and/or Director ofPersonal a
Care,
temperature over 100. Additionally, specific
The COVID
facility's Vaccination policy,dated signs and symptoms were detailed to
4/2021 Included: include cough, shortness of breath, body
- it wasthe obligation and of the loss ofsmell or
responsibility aches, taste, headache,
to
facility arrange forongoing vaccination of congestion, nausea and/or vomiting. Staff
residents and staffunder new regulations are prompted and forced to address this
announced by the New York State Department system twice daily.Outcomes are
of Health, effective 4/15/2021. documented. New admissions are
- the would make diligentefforts to set to be monitored twice
facility immediately up
arrange forall new personnel, including daily.The Resident Health Checks Policy
employees and contract staff,to receive the first was updated on 11/29/2021 to Include a
or any required next dose of the COVID-19 twice daily temperature check and
vaccine within 7 days of hiring,as applicable. symptom screen.
- the corporate group supported and accepted
exemptions."
"written medical and religious 4. The has
faclilty developed audittools to
- the corporate "willnot make a monitor compliance with staffadherence
group hiring
determination based upon an individuars with poilcles and procedures.
COVID-19 vaCoination historyor interest in
vaccination."
receiving COVID-19 Human Resources willprovide allaudit
- forallpersonnel who decline to be vaccinated findings to the QA Committee vla an
for COVID-19, the would
facility obtain written updated spreadsheet monthly, for six
affirmation that the personnel was offered and months indicating full
compliance with New
declined the opportunity forthe COVID-19 York State regulations and Department of
vaccination. Health guidance and directives.
STATE FORM XNGL11
Event ID: Facility ID:AF0006A If continuatIonsheet Page 3 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
STATEMENTOF DEFlcIENcIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE cONsTRUcTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFlcATlON NUMBER: COMPLETED
A. BUILDING
B. WING
12/29/2021
NAMEOF PROVIDEROR SUPPLER STREET ADDRESS,CITY, STATE, ZIP CODE
3260 N TIN STREET
FIELD OF DREAMS SENIOR LIVING
ALLEGANY, NY 14706
(X4) ID SUMMARYSTATEMENTOF DEFICIENCIES ID PROVIDER'SPLANOF CORREcTloN (X5)
PREFIX (EAcH DEFIcIENcY MUST BE PRECEDEDBY FULL PREFlX (EACH CORRECTIVEACTION SHOULDBE COMPLETE
TAG REGUI.ATORYOR LSc IDENTIFYlNGINFORMATION) TAG CROSS-REFERENCEDTO B-IE APPROPRIATE DATE
DEFICENcY)
A4720 Continued From page 3 A4720
Letters sent to allFullTime and Part Time The Administrator Isresponsible for
Employees from the Owner:
facility ensuring the Completion of the corrective
- dated "continue torespect action plan and forContinued
11/30//2021, they monitoring
your sincere religiousbeliefs against the Covid- compliance,
19 vaccinations however, my to
ability fight on
your behalf presents some level oflegal
difficulty"
and thatunvaccinated staffwould be
tested twice a week through the end ofthe year
due tothe vaccine mandate.
- dated 12/14//2021, the Department of Health
has refused making the Religious Exemption a
reason not to be vaccinated and after discussion
with allof you at a recent gatherings you have
asked forhelp to "expedite the process for
medical exemption due to the mental anguish
and stressyou have experienCed, due to the
mandate"
and you (the staff)willbe contacted to
set up an appointment via Tele-Med.
Correspondence between the and
facility the
Departments Western Regional Office (WRO)
on 12/15/2021, included:
- a telephone Outreach call,the
during facility
reported a COVID-19 positive employee.
- documentation sent to the Departments WRO,
via fax,included an unsigned note which read
the unvaccinated staffhad "religiousexemptions
that were acceptable in thecourts until
yesterday."
The owner "pursued medical advice
from a doctor about the stress associated with a
vaccine mandate as a condition of employment
and continued livelihood.The owner has since
entered into an agreement with the doctor in
order to have his unvaccinated employees seen
forthe stress condition. Such employees willbe
schedule to be evaluated by the doctor and a
medical exemption willbe issued when
"
appropriate
When interviewed on 12/16/2021 between 10
AM and 2 PM:
STATE FORM Event ID: XNGL11 Facility ID: AFO906A If continuationsheet Page 4 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
STATEMENTOF DEFlclENclES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULTIPLEcONSTRUcTloN (X3) DATE SURVEY
AND PLANOF cORRECTION IDENTIFlcATION NUMBER: cOMPLETED
A. BUILDING
B. WING
12/20/2021
NAMEOF PROVIDEROR SUPPLIER sTREET ADDRESS,clTY, STATE, ZIP cODE
3260 N 7TH STREET
FIELD OF DREAMS SENIORLIVING
ALLEGANY, NY14706
(X4) fD SUMMARYSTATEMENTOF DEFICIENclES ID PROVIDER'SPLAN OF cORREcTION (XS)
PREFlX (EACH DEFICIENCYMUST BE PREcEDED BY FU== PREPIX (EACHCORRECTIVEAcTION SHOULD BE COMPLETE
TAG REGULATORYOR LSC IDENTIFYINGINFORMATION) TAG cROSS-REFERENCEDTO THE APPROPRIATE DATE
DEFlclENcY)
A4720 Continued From page 4 A4720
- employee #17 stated that employee who
#18,
was unvaccinated, had tested COVID-19
positive on 12/13/2021.
- employees #1 and #2 stated employee #16
was the hairdresser,
facility was not vaccinated
and worked with residents
facility in thefacility
every Thursday and Friday.
- employee #2 stated had one dose of
they only
the vaccine, had contracted
COVID -19 twice and were afraid totake the
second dose, because they didn'twant to be
sick again. The employee stated they were not
against vaccines.
- employee #5 stated had their own health
they
issues, the vaccine made them uncomfortable,
and It was not a religiouschoice in nature, but a
little
bitof everything.
- employee #8 stated they had no health Issues
but were concerned about the vaccine, such as
the possible reactions. They had received the
letterfrom the owner
facility regarding the
vaccine mandate and planned on taking
advantage of theTele-Med appointment being
offerred to obtain a medical exemption
- employee #13 stated the had not
facility
pushed the vaccine on them. They had done
1heirown research on the vaccine, were
concerned about itsingredients, and wanted to
goes."
sitback and "see how it
Review of a complaint received by the
Department, on 12/17/2021, revealed the
complainant became concerned when notified
lockdown"
by the that
facility they were "on
because staffhad tested positivefor COVID-19;
and thatfacilityemployees were not required to
be vaccinated because the facilitywas a private
facility.
A review of Department records on 12/29/2021,
identifiedthe following correspondence from the
STATE FORM Event ID:
XNGL11 PacilityID: AF0906A f continuationsheet Page 5 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
STATEMENTOF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLECONsTRUCTION (X3) DATE SURVEY
AND PLANOF CORRECTION IDENTIFICATIONNUMBER: COMPLETED
A. BUILDING
B. WING
AF0906A 12/29/2021
NAMEOF PROVlDEROR SUPPLIER sTREET ADDRESS,GITY, STATE, ZIP CODE
3260 N 7TH STREET
FIELD OF DREAMS SENIOR LMNG NY 14706
ALLEGANY,
(X4) ID sUMMARY STATEMENTOF DEFICIENCIEs ID PROVIDER*SPLAN OF CORRECTION (X5)
PREFlX (EACH DEFIclENCY MUST BE PREcEDED BY FULL PREFIX (EACH CORREcTIVE ACTION SHOULDBE COMPLETE
TAG REGULATORYOR LSC IDENTIFYlNG INFORMATION) TAG CROSS-REFERENCEDTO THE APPROPRIATE DATE
DEFICIENCY)
A4720 Continued From page 5
Operator
facility to the Departments Western
Regional Office via e-mail, regarding two other
facilitiesowned and operated by the same
Operator:
- 11/22/2021 at 5:36PM, the Operator wrote "all
my ernployees have been encouraged to get the
vaccine but I believe I must also support their
constitutional rights relatedto their religious
freedoms."
- 11/26/2021 at 4:15PM, the Operator wrote "I
believe ifI dismissmy workers who refuse the
vaccine, I will
put my residents in a precarious
position."
- 11/29/2021 at 12:52 PM, the Operator wrote "It
isalso important that you review my thoughts on
individualtegal rightsof my employees. I am
liablefor injuries
as well as any discriminatory
practices thatare caused from mandated
medical procedures and vaccinations and
religiousexemptions. I believeyou are doing
what you are mandated to do as well as your
beliefsand I respect your opinion, however, I
have never been so far apart with my partners at
Health."
the Department of "If
we can't agree
and the Department does not allow me tofind a
solutionwith my staffin the next 30 days, I
believe it may be time for me toleave the
industry."
"As a practical matter, I must avoid
our residents in jeopardy due to under-
placing
staffing.We have struggled for months to fill
existingstaff vacancies and terminating or
sidelining currentstaffwould render our facilities
non-functional."
"Ialso remain concerned about
employees'
legal for
liability violating civil
rights
or forpotential physical reactions that may occur
if wewere to refuse an accommodation or force
vaccination."
"Consequently, I am giving their
requests forreasonable accommodation fortheir
sincerely held religiousbeliefs due review and
consideration."
- 12/3/2021 at 12:51 PM, staffis
"My suffering
STATE FORM Event ID: XNGL11 Facility ID: AF0906A If continuationsheet Page 6 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
STATEMENTOF DEFlclENCIES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULTIPLEcONSTRUcTION (X3) DATE SURVEY
AND PLANOF CORREcTION IDENTIFICATIONNUMBER: coMPLETED
A. BUILDING
B. WING
AF0906A 12/29/2021
NAMEOF PROVIDEROR SUPPLIER STREET CDRESS, clTY, STATE, ZIP CODE
3260 N 7TH STREET
FIELD OF DREAMS SENIORLIVING
ALLEGANY, NY 14706
I
(X4) ID SUMMARYSTATEMENTOF DEFlcIENelES ID PROVIDER'SPLAN OF CORREcTION (X5)
PREFIX (EAcH DEPICIENcY MUST BE PRECEDEDBY FULL PREFlX (EACH CORRECTIVEAcTION SHoULD BE COMPLETE
TAG REGULATORYOR LSc IDENTIPYINGINFORMATloN) TAG CROSS-REFERENCEDTO THE APPROPRIATE DATE
DEFiclENCY)
A4720 Continued From page 6 A4720
from Approach-Avoidance conflictand have
attached a report thatdefines the medical
definitionof thisserious affect the mandate Is
having on some ofmy staff.I will
be looking to
set up appointments for allofthe non-vaccinated
employees in my facilitieswith licensed qualified
findings."
Psychologists and report their
Attached to the email was a Report on Human
Hippocampus Arbitrates Approach-Avoidance
Conflict published in2014.
- 12/6/2021 at 1:06 PM, 50% of
"Approximately
the non-vaccinated had COVID and have the
antibodies and we have some staff ready to get
the vaccine. They are also going to doctons to
get exemptions. I believeby month end we
should be in a higher vaccinated population or
exemptions."
with medical
- 12/7/2021 at 9:42 AM, "Those employees
affected by the mandate who have religious
exemptions willbe seeing the doctor for
treatments that willbegin this week. This
process, to satisfy the mandates ofthe State,
willtake some time but I will
stay On it until
ithas
been completed. I thankyou foryour patIents
and I believeI will
keep our staffand residents in
the Christmas spiritas well as complete your
requests."
Attached to the email was a letter,
from an out of statepsychiatrist discussing
"working with many patients who have
experienced significantdistress related to the
mandates associated with the COVID-19
vaccination."
and which ended with, "I am
hopeful that a resolution willbe found so that the
American people can be free to make their own
care,"
choices regarding theirhealth and
In summary, the operator did not ensure
adequate supervision was provided to maintain
resident safety and compliance with the State
Emergency Orders, regulations, and guidance
related to the COVID-19 pandemic including
STATE FORM Event ID:
XNGL11 FacIllly ID: AF0906A If continuatlansheet Page 7 of
9
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560
NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022
PRINTED: 06/03/2022
FORM APPROVED
New York State Department of Health
STATEMENTOF DEFIcIENciES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLEcONSTRUCTION (X3) DATESURVEY
AND PLANOF cORREcTION IDENTIFlcATION NUMBER: cOMPLETED
A. BUILDING
B. WING
1221/2021
NAMEOF PROVIDEROR SUPPLIER STREET ADDRESS, clTY, STATE, ZIP cODE
8260 N 7TH STREET
Preview
FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 Exhibit 4 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health sTATEMENT OF DEFlclENCIES (X1) PROVIDER/sUPPLIER/CLIA (X2) MULTIPLEcONsTRUcTION (X3) DATE SURVEY AND PLANOF CORREcTION IDENTIFICATIONNUMBER: cOMPLETED A. BUILDING B. WING 12/29/2021 NAMEOF PROVIDEROR SUPPLIER STREETADDRESS, CITY, STATE, ZIP cODE 3260 N 7TH STREET FIELD OF DREAMS SENIOR LIVING ALLEGANY, NY 14706 (X4) ID SUMMARYSTATEMENTOF DEFlcIENCIES ID PROVIDER'SPLANOF cORREcTION (XS) PREFlX (EACH DEFlclENcY MUsT BE PRECEDEDBY FULL PREFlX (EAcH coRREcTIVE AcTloN SHOULDBE COMPLETE TAG REGULATORYOR Lsc IDENTIFYlNG INFORMATION) TAG CROSs-REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A4720 486.5 (a)(4) (v)CivilPenalties A4720 1. Of the 22 employees identifiedinthe 03/04/2022 SS=J survey, 9 have been fullyvaccinated; 9 (a) Civilpenalties for adult certified care have received a medical exemption, and 4 facilities. staffhave been terminated frornthe organization. (4)Even where correction ofa violation has occurred In accordance with paragraph (3) of thissubdivision, the department may assess a 2. The COVID-19 policy,Resident Health penalty if it establishesata hearing that the Checks was reviewed and revised on particularviolation endangered or resulted in 11/29/2021 by Administration and again harm to a resident as the result of: reviewed on 01/19/2022 by the QA/Ql Committee. The lesson plan and (v) the failureof systemic competency checklistwere revised to practices and procedures as evidenced by a include the process for sanitizingthe pattem of violations or an Inabilityto bring a resident specific locations as well as specific area of operation facility intocompliance monitoring for signs and symptoms. with sections 487.4, 487.5, 487.6, 487.7, 487.8, 487.9(a)(1),(3),(7),(8),(10-15),487.9(b-d),(f),(g) On 01/19/2022, during a Quality (1),487.10(a-b), 487.11, 487.12(b), (g)-(j), Assurance/Quality Improvement meeting, 488.4, 488.5, 488.6, 488.7, 488.8, 488.9(a)(1), the following COVID specific policies were (2),(4),(5), (7-11),488.9(b-e), 488.10(a-b), reviewed: 488.11, 488.12(b-c), (g-i),(1), 490.4,490.5, 490.6, 490.7, 490.8, 490.9(a)(1), (3),(5), (6),(8- Resident Health Checks 13), 490.9 (b-d),(f), 490.10(a-b), 490.11, 490.12 Medical Exemption/Exception Policy (b),or (g-j)of thisTitle;or On 11/1/2021, a letterwas distributed to all This LICENSURE isnot met as evidenced by: staffregarding State guidance related to the COVID-19 pandemic and Based on observations, review of facility education/training on Prevention of records, and Interviews with facilitystaffduring COVID-19 Transmission. an infection control focused partialinspection and complaint inspection initiatedon 12/16/2021 On 11/19/2021, a Risk Management and completed on 12/29/2021, the operator inservice included an educational segment failedto protect residents from harm to person on employee responsibilitiesas it relatesto and property as required by 18 NYCRR 487.7(d) Prevention of COVID-19 Transmission (1)(v).Further the operator failedto operate the in facility compliance with law and regulation,as On 12/14/2021, a letterwas distributed to required by 18 NYCRR 487.3(b) and the allstaffregarding compliance with all operator failedto hirean administrator capable applicable State Emergency Regulations. of and responsible for operating the In facility compliance with law and regulation as required On 1/24/2022, an educational blastcall(a LABORATO Y DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically signed 03/04/2022 sTATE FORM Event ID: XNGL11 FacIlltyID: AF0906A If continuationsheet Page 1 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health sTATEMENT OF DEFIclENcIES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULUPLE CONSTRUcTION (X3) DATE sURVEY AND PLANOF cORREcTION IDENTIFIcATION NUMBER: A. BUILDING cOME AF0906A 12/29/2021 NAMEOF PROVIDEROR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 3260 N 7TH STREET FIELD OF DREAMS SENIOR LIVING ALLEGANY, NY 14706 (X4) ID sUMMARY sTATEMENT OF DEFICIENcIES ID PROVIDER'SPLAN OF cORRECEON (X5) PREFIX (EACH DEFicIENcY MUST BE PRECEDEDBY FULL PREFlX (EAcH CORREcTIVE AcTION SHoULD BE OOMPLETE TAG REGULATORYOR LSc IDENBFYING INFORMATION) TAG CROSS-REFERENcEDTO THE APPROPRIATE DATE DEFlclENCY} A4720 Continued From page 1 A4720 by 18 NYCRR 487.9(c)(8)(ii),including failureto mechanism toregularly communicate comply with 18 NYCRR §487.9(a)(18) and 10 COVID-19 related updates) was sent to NYCRR §2.61(c), which provides: resident representatives relating tosafe protocols and Prevention of COVID-19 "Covered entitiesshall continuously require Transmission while visitingFieldof personnel to be vaccinated against COVID- Dreams. fully 19. Documentation ofsuch vaccination shall be made inpersonnel records or other appropriate On 01/24/2022, an educational reminder records." was sent out to staffto monitor residents forsigns and symptoms of illness,best Letter" In a "Dear Administrator (DAL) 21-32, practices related to masks and shields, the dated 11/15/2021, The Department ofHealth importance of hand hygiene and sanitation, notifiedAdult Care Facilitiesof the need to socialdistancing and taking caution when ensure that covered "personnel", under the activeoutside of work. Departments August 26, 2021 -Prevention of COVID-19 Transmission by Covered Entitles On 01/31/2022, Director of Personal Care Emergency Regulation, who were previously did an Inservice with allresidents regarding granted religiouseXemptions have signs and symptoms of COVID-19 and how documentation of eithera first dose COVID-19 to themselves safe the keep during vaccination or a valid medical eXemption. pandemic. Handouts were provided to all followed by a question and answer On 12/16/2021, a review of records facility session. revealed: Allincidents of positivecases are posted in The employee facility's roster, which defined the entrance of Fieldof Dnsams and on all employees by job If they title, provided hands on three bulletinboards for residentand visitor care, and theirvaccination status, indicated: knowledge. - atthe time of survey, 33 unvaccinated staff members were identified,14 ofwhom provided A CDC handout educating on Symptoms of directcare to residents including employees #3, COVID-19 was provided toall employees #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, in bothJanuary and February, 2022. and #15. - employees #2 and #21, both of whom provided Allsuch documentation of will training be personal care, had their 1st COVID-19 on fileforreview by surveillance staff. vaccination greater than 6 weeks prior,and had yet toreceive their2nd dose. - employee #1, the Administrator, 3. Effective per the COVID facility April,2021, employee #21, the Director of Patient Care, and Vaccinations verificationofCOVID- Policy, employee #22, the Business Office Manager, 19 vaccination status willbe documented were allidentifiedas unvaccinated employees. within both the employee health record and resident reconi STATE FORM Event ID: XNGL11 Facility ID: AF0906A If continuationsheet Page 2 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health sTATEMENT 0F DEFIclENCIES (X1) PROVIDER/sUPPUER/CuA (X2) MULTIPLECONsTRUcTION (X3) DATE SURVEY AND PLANOF CORREcTION IDENTIFIcATION NUMBER: COMPLETED A. BUILDING B. WING AF0906A 12/20/2021 NAME OF PROVIDEROR SUPPLIER STREET ADDRESS,cITY, STATE, ZIP CoDE 3260 N 7TH STREET FIELD OF DREAMS SEN1OR L1VING ALLEGANY, NY 14706 (X4) ID SUMMARY STATEMENTOF DEFICIENclEs ID PROVIDER'SPLAN OF CORRECTION (X5) PREFlX (EAcH DEFICIENCYMUST BE PREcEDED BY FULL PREFIX (EAcH cORREcTIVE AcTION sHOULD BE COMPLETE TAG REGULATORYOR LSC IDENTIFYINGINFORMATION) TAG cROSS-REFERENcEDTO THE APPROPRIATE DATE DEFICIENCY) A4720 Continued From page 2 A4720 The Schedules facility and Time Card Reports dated 11/22/2021 through 12/16/2021, indicated " audits willcontinue to be Ongoing and verifiedunvaccinated employees worked conducted to ensure allcurrent and newly directlywith facilityresidents including: hired staffremain in compliance. - 9 employees on 11/29/2021, 11/30/2021, 12/1/2021 and 12/2/2021. Effective 11/16/2021, a system was set up - 8 employees on 11/22/2021, 11/26/2021, to monitor residents forsigns and 12/6/2021, 12/8/2021, 12/10/2021, and symptoms of COVID-19 dailyto include a 12/15/2021. twice daily temperature check. New - 7employees on 11/23/2021, 11/24/2021, admissions thereafterwere immediately 12/3/2021, 12R/2021, 12/9/2021, 12/12/2021, set up to be monitored daily. 12/13/2021, and 12/14/2021. -6 employees on 11/25/2021 and 12/4/2021. In November, a system was put into place - 5employees on 12/5/2021 and 12/16/2021. for a twice temperature check daily - 4 employees on 11/28/2021 and 12/11/2021. tostaffthat must report to indicating they - 3employees on 11/27/2021. RN and/or Director ofPersonal a Care, temperature over 100. Additionally, specific The COVID facility's Vaccination policy,dated signs and symptoms were detailed to 4/2021 Included: include cough, shortness of breath, body - it wasthe obligation and of the loss ofsmell or responsibility aches, taste, headache, to facility arrange forongoing vaccination of congestion, nausea and/or vomiting. Staff residents and staffunder new regulations are prompted and forced to address this announced by the New York State Department system twice daily.Outcomes are of Health, effective 4/15/2021. documented. New admissions are - the would make diligentefforts to set to be monitored twice facility immediately up arrange forall new personnel, including daily.The Resident Health Checks Policy employees and contract staff,to receive the first was updated on 11/29/2021 to Include a or any required next dose of the COVID-19 twice daily temperature check and vaccine within 7 days of hiring,as applicable. symptom screen. - the corporate group supported and accepted exemptions." "written medical and religious 4. The has faclilty developed audittools to - the corporate "willnot make a monitor compliance with staffadherence group hiring determination based upon an individuars with poilcles and procedures. COVID-19 vaCoination historyor interest in vaccination." receiving COVID-19 Human Resources willprovide allaudit - forallpersonnel who decline to be vaccinated findings to the QA Committee vla an for COVID-19, the would facility obtain written updated spreadsheet monthly, for six affirmation that the personnel was offered and months indicating full compliance with New declined the opportunity forthe COVID-19 York State regulations and Department of vaccination. Health guidance and directives. STATE FORM XNGL11 Event ID: Facility ID:AF0006A If continuatIonsheet Page 3 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health STATEMENTOF DEFlcIENcIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE cONsTRUcTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFlcATlON NUMBER: COMPLETED A. BUILDING B. WING 12/29/2021 NAMEOF PROVIDEROR SUPPLER STREET ADDRESS,CITY, STATE, ZIP CODE 3260 N TIN STREET FIELD OF DREAMS SENIOR LIVING ALLEGANY, NY 14706 (X4) ID SUMMARYSTATEMENTOF DEFICIENCIES ID PROVIDER'SPLANOF CORREcTloN (X5) PREFIX (EAcH DEFIcIENcY MUST BE PRECEDEDBY FULL PREFlX (EACH CORRECTIVEACTION SHOULDBE COMPLETE TAG REGUI.ATORYOR LSc IDENTIFYlNGINFORMATION) TAG CROSS-REFERENCEDTO B-IE APPROPRIATE DATE DEFICENcY) A4720 Continued From page 3 A4720 Letters sent to allFullTime and Part Time The Administrator Isresponsible for Employees from the Owner: facility ensuring the Completion of the corrective - dated "continue torespect action plan and forContinued 11/30//2021, they monitoring your sincere religiousbeliefs against the Covid- compliance, 19 vaccinations however, my to ability fight on your behalf presents some level oflegal difficulty" and thatunvaccinated staffwould be tested twice a week through the end ofthe year due tothe vaccine mandate. - dated 12/14//2021, the Department of Health has refused making the Religious Exemption a reason not to be vaccinated and after discussion with allof you at a recent gatherings you have asked forhelp to "expedite the process for medical exemption due to the mental anguish and stressyou have experienCed, due to the mandate" and you (the staff)willbe contacted to set up an appointment via Tele-Med. Correspondence between the and facility the Departments Western Regional Office (WRO) on 12/15/2021, included: - a telephone Outreach call,the during facility reported a COVID-19 positive employee. - documentation sent to the Departments WRO, via fax,included an unsigned note which read the unvaccinated staffhad "religiousexemptions that were acceptable in thecourts until yesterday." The owner "pursued medical advice from a doctor about the stress associated with a vaccine mandate as a condition of employment and continued livelihood.The owner has since entered into an agreement with the doctor in order to have his unvaccinated employees seen forthe stress condition. Such employees willbe schedule to be evaluated by the doctor and a medical exemption willbe issued when " appropriate When interviewed on 12/16/2021 between 10 AM and 2 PM: STATE FORM Event ID: XNGL11 Facility ID: AFO906A If continuationsheet Page 4 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health STATEMENTOF DEFlclENclES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULTIPLEcONSTRUcTloN (X3) DATE SURVEY AND PLANOF cORRECTION IDENTIFlcATION NUMBER: cOMPLETED A. BUILDING B. WING 12/20/2021 NAMEOF PROVIDEROR SUPPLIER sTREET ADDRESS,clTY, STATE, ZIP cODE 3260 N 7TH STREET FIELD OF DREAMS SENIORLIVING ALLEGANY, NY14706 (X4) fD SUMMARYSTATEMENTOF DEFICIENclES ID PROVIDER'SPLAN OF cORREcTION (XS) PREFlX (EACH DEFICIENCYMUST BE PREcEDED BY FU== PREPIX (EACHCORRECTIVEAcTION SHOULD BE COMPLETE TAG REGULATORYOR LSC IDENTIFYINGINFORMATION) TAG cROSS-REFERENCEDTO THE APPROPRIATE DATE DEFlclENcY) A4720 Continued From page 4 A4720 - employee #17 stated that employee who #18, was unvaccinated, had tested COVID-19 positive on 12/13/2021. - employees #1 and #2 stated employee #16 was the hairdresser, facility was not vaccinated and worked with residents facility in thefacility every Thursday and Friday. - employee #2 stated had one dose of they only the vaccine, had contracted COVID -19 twice and were afraid totake the second dose, because they didn'twant to be sick again. The employee stated they were not against vaccines. - employee #5 stated had their own health they issues, the vaccine made them uncomfortable, and It was not a religiouschoice in nature, but a little bitof everything. - employee #8 stated they had no health Issues but were concerned about the vaccine, such as the possible reactions. They had received the letterfrom the owner facility regarding the vaccine mandate and planned on taking advantage of theTele-Med appointment being offerred to obtain a medical exemption - employee #13 stated the had not facility pushed the vaccine on them. They had done 1heirown research on the vaccine, were concerned about itsingredients, and wanted to goes." sitback and "see how it Review of a complaint received by the Department, on 12/17/2021, revealed the complainant became concerned when notified lockdown" by the that facility they were "on because staffhad tested positivefor COVID-19; and thatfacilityemployees were not required to be vaccinated because the facilitywas a private facility. A review of Department records on 12/29/2021, identifiedthe following correspondence from the STATE FORM Event ID: XNGL11 PacilityID: AF0906A f continuationsheet Page 5 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health STATEMENTOF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLECONsTRUCTION (X3) DATE SURVEY AND PLANOF CORRECTION IDENTIFICATIONNUMBER: COMPLETED A. BUILDING B. WING AF0906A 12/29/2021 NAMEOF PROVlDEROR SUPPLIER sTREET ADDRESS,GITY, STATE, ZIP CODE 3260 N 7TH STREET FIELD OF DREAMS SENIOR LMNG NY 14706 ALLEGANY, (X4) ID sUMMARY STATEMENTOF DEFICIENCIEs ID PROVIDER*SPLAN OF CORRECTION (X5) PREFlX (EACH DEFIclENCY MUST BE PREcEDED BY FULL PREFIX (EACH CORREcTIVE ACTION SHOULDBE COMPLETE TAG REGULATORYOR LSC IDENTIFYlNG INFORMATION) TAG CROSS-REFERENCEDTO THE APPROPRIATE DATE DEFICIENCY) A4720 Continued From page 5 Operator facility to the Departments Western Regional Office via e-mail, regarding two other facilitiesowned and operated by the same Operator: - 11/22/2021 at 5:36PM, the Operator wrote "all my ernployees have been encouraged to get the vaccine but I believe I must also support their constitutional rights relatedto their religious freedoms." - 11/26/2021 at 4:15PM, the Operator wrote "I believe ifI dismissmy workers who refuse the vaccine, I will put my residents in a precarious position." - 11/29/2021 at 12:52 PM, the Operator wrote "It isalso important that you review my thoughts on individualtegal rightsof my employees. I am liablefor injuries as well as any discriminatory practices thatare caused from mandated medical procedures and vaccinations and religiousexemptions. I believeyou are doing what you are mandated to do as well as your beliefsand I respect your opinion, however, I have never been so far apart with my partners at Health." the Department of "If we can't agree and the Department does not allow me tofind a solutionwith my staffin the next 30 days, I believe it may be time for me toleave the industry." "As a practical matter, I must avoid our residents in jeopardy due to under- placing staffing.We have struggled for months to fill existingstaff vacancies and terminating or sidelining currentstaffwould render our facilities non-functional." "Ialso remain concerned about employees' legal for liability violating civil rights or forpotential physical reactions that may occur if wewere to refuse an accommodation or force vaccination." "Consequently, I am giving their requests forreasonable accommodation fortheir sincerely held religiousbeliefs due review and consideration." - 12/3/2021 at 12:51 PM, staffis "My suffering STATE FORM Event ID: XNGL11 Facility ID: AF0906A If continuationsheet Page 6 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health STATEMENTOF DEFlclENCIES (X1) PROVIDER/SUPPLIER/cLIA (X2) MULTIPLEcONSTRUcTION (X3) DATE SURVEY AND PLANOF CORREcTION IDENTIFICATIONNUMBER: coMPLETED A. BUILDING B. WING AF0906A 12/29/2021 NAMEOF PROVIDEROR SUPPLIER STREET CDRESS, clTY, STATE, ZIP CODE 3260 N 7TH STREET FIELD OF DREAMS SENIORLIVING ALLEGANY, NY 14706 I (X4) ID SUMMARYSTATEMENTOF DEFlcIENelES ID PROVIDER'SPLAN OF CORREcTION (X5) PREFIX (EAcH DEPICIENcY MUST BE PRECEDEDBY FULL PREFlX (EACH CORRECTIVEAcTION SHoULD BE COMPLETE TAG REGULATORYOR LSc IDENTIPYINGINFORMATloN) TAG CROSS-REFERENCEDTO THE APPROPRIATE DATE DEFiclENCY) A4720 Continued From page 6 A4720 from Approach-Avoidance conflictand have attached a report thatdefines the medical definitionof thisserious affect the mandate Is having on some ofmy staff.I will be looking to set up appointments for allofthe non-vaccinated employees in my facilitieswith licensed qualified findings." Psychologists and report their Attached to the email was a Report on Human Hippocampus Arbitrates Approach-Avoidance Conflict published in2014. - 12/6/2021 at 1:06 PM, 50% of "Approximately the non-vaccinated had COVID and have the antibodies and we have some staff ready to get the vaccine. They are also going to doctons to get exemptions. I believeby month end we should be in a higher vaccinated population or exemptions." with medical - 12/7/2021 at 9:42 AM, "Those employees affected by the mandate who have religious exemptions willbe seeing the doctor for treatments that willbegin this week. This process, to satisfy the mandates ofthe State, willtake some time but I will stay On it until ithas been completed. I thankyou foryour patIents and I believeI will keep our staffand residents in the Christmas spiritas well as complete your requests." Attached to the email was a letter, from an out of statepsychiatrist discussing "working with many patients who have experienced significantdistress related to the mandates associated with the COVID-19 vaccination." and which ended with, "I am hopeful that a resolution willbe found so that the American people can be free to make their own care," choices regarding theirhealth and In summary, the operator did not ensure adequate supervision was provided to maintain resident safety and compliance with the State Emergency Orders, regulations, and guidance related to the COVID-19 pandemic including STATE FORM Event ID: XNGL11 FacIllly ID: AF0906A If continuatlansheet Page 7 of 9 FILED: CATTARAUGUS COUNTY CLERK 08/19/2022 03:18 PM INDEX NO. 91560 NYSCEF DOC. NO. 5 RECEIVED NYSCEF: 08/19/2022 PRINTED: 06/03/2022 FORM APPROVED New York State Department of Health STATEMENTOF DEFIcIENciES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLEcONSTRUCTION (X3) DATESURVEY AND PLANOF cORREcTION IDENTIFlcATION NUMBER: cOMPLETED A. BUILDING B. WING 1221/2021 NAMEOF PROVIDEROR SUPPLIER STREET ADDRESS, clTY, STATE, ZIP cODE 8260 N 7TH STREET