Brothers of Mercy Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to ensure that all alleged violations involving abuse or mistreatment are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (Resident #2) of three residents reviewed. Specifically, an allegation of staff to resident physical abuse or mistreatment was not reported to the New York State Department of Health within the required two-hour timeframe.

Inspectors wroteBased on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations of abuse or mistreatment were thoroughly investigated for two (Residents #1 and #2) of three residents reviewed. Specifically, there was lack of evidence that thorough investigations were completed into allegations of a missing personal item (Resident #1) and physical abuse/mistreatment by a staff member (Resident #2).

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 01/16/2026, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected four (4) (first, second, third, and fourth floors) of four (4) resident use floors. The finding is:The undated Directive and Procedure titled Testing of Carbon Monoxide Detectors documented the detectors will be manually tested weekly as per manufacturers specifications and must be kept free of dust and debris. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that each resident was treated with respect and dignity, cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for three (3) (Resident #1, #32 and #59) of five (5) residents reviewed for dignity. Specifically, residents were treated disrespectfully and without dignity when a staff member spoke in an unprofessional manner (#32 and #59) while their room. Additionally, Resident #1 did not receive timely assistance with toileting resulting in them having an incontinence episode that was upsetting to them.

Inspectors wroteBased on interview and record review the facility did not ensure that all alleged violations involving abuse were reported immediately but not later than two (2) hours after the allegation was made to the State Survey Agency for two (2) (Residents #32 & Resident #59) of five (5) residents reviewed for abuse. Specifically, an allegation of verbal abuse was not reported to the New York State Department of Health within the required (2) two-hour timeframe.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 01/16/2026, the facility did not ensure that residents who are unable to carry out activities of daily living receives the necessary services to maintain personal hygiene to meet the resident's needs for two (Resident #1 and #168 of two residents reviewed for toileting. Specifically, residents were not provided with toileting assist as planned.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident who entered the facility with an indwelling (foley) catheter (tube inserted into the bladder to drain urine) was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for one (1) (Resident #168) of one (1) resident reviewed. Specifically, there was lack of a voiding trial (removal of a urinary catheter to see if someone can pass urine normally) when the resident was admitted to the facility from the hospital with a foley catheter. Additionally, there was lack of documented medical justification for the use of the foley catheter; and the catheter bag and tubing were observed on the floor on several occasions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for two (2) (Residents #15 and #152) of six (6) residents reviewed. Specifically, Resident #15 had a pressure ulcer with drainage that required a dressing and was not placed on Enhanced Barrier Precautions (interventions designed to reduce the transmission of multi-drug resistant organisms, including gowns and glove use during high contact resident care activities); staff did not wear personal protective equipment (gowns) while providing incontinent care for Resident #152 who was on Enhanced Barrier Precautions for a chronic wound.

Inspectors wroteBased on observation, interview and record the facility did not provide a safe, clean, comfortable and homelike environment for two (2) (3 East and 4 West) of six (6) shower rooms. Specifically, the 3 East and 4 [NAME] shower rooms had issues that involved dirty floors and drains, and standing water on multiple days. Additionally, there were unlabeled personal care items were stored on the shelf in the 4 [NAME] shower room. Resident #223 was involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good nutrition for one (Resident #118) of four residents reviewed. Specifically, Resident #118 was not provided with continuous supervision or touching assistance (limited assist) with eating in the alcove as planned. The finding is: The policy and procedure titled Feeding Assistance/Tray Labeling revised 7/2020, documented staff members designated the duties of feeding residents are aware of the assistance level needed by referencing the tray ticket placed on each resident's meal tray and the care guide for each resident. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for one (Resident #142) of three residents reviewed. Specifically, the resident developed an unstageable (full thickness skin or tissue loss-depth unknown) pressure ulcer; wound assessments were incomplete. The wound consultants recommendations dated 12/28/23 were not implemented, and the comprehensive care plan was not fully developed to promote wound healing. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #8) of 5 residents reviewed. Specifically, the facility did not implement effective interventions to prevent falls for Resident #8, who had over 60 falls since their admission to the facility in August of 2023. The finding is: The policy and procedure titled Fall Prevention Plan revised 5/19 documented the facility will implement a fall prevention plan on every resident to maximize resident safety and identify those at risk for falls. The Certified Nurse Aide will ensure all equipment, including alarms is present and functioning. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/9/2024, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for one (Unit 4 East) of three resident units observed for medication storage. Specifically, there were three bottles of liquid Lorazepam (Ativan, Schedule IV controlled substance - sedative/antianxiety medication) in a locked box that was not permanently affixed in small refrigerator located in the medication room. Residents #14 and #478 were involved. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, residents have the right to a safe, clean, comfortable, and homelike environment and the facility did not provide housekeeping and maintenance services necessary to maintain a clean and comfortable interior. Specifically, five units (2 East, 2 West, 3 East, 3 [NAME] and 4 West) of six units had issues with dirty wall heaters.