Humboldt House Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure the resident's right to be free from physical abuse by staff for one (Resident #1) of three residents reviewed. Specifically, based on facility surveillance footage, facility investigation, and an eyewitness account, a certified nurse aide was physically abusive to Resident #1. This is identified as past noncompliance

Inspectors wroteBased on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations involving abuse are reported immediately but not later than two 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 #1) of three residents reviewed. Specifically, an allegation of staff to resident verbal and physical abuse was not reported to the facility Administrator and to the New York State Department of Health within the required two-hour timeframe. This is identified as past noncompliance.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, observations of one (1) of one (1) kitchen revealed an active ceiling leak in front of the walk-in refrigeration and freezer units, several missing and broken wall tiles, the commercial oven range was soiled with grease and food debris, the wall behind the stove, oven, and two (2) bay sink was heavily soiled with grease, the drain pipe underneath the hand wash sink leaked, the paper towel dispenser by the hand wash sink was non-working, and ceiling pipes were covered with dust. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the survey the facility failed to ensure that each resident had the right to be treated with respect and dignity for one (1) (Resident # 20) of three (3) residents reviewed. Specifically, Resident #20 was served their lunch meal when they were visibly incontinent. In addition, there were soiled linens, a large amount of fecal matter, and soiled briefs and linens on the floor between their bed and wall.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey the facility failed to ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (1) (Residents #20) of three (3) residents reviewed. Specifically, Resident #20 was not provided with incontinent care every two (2) to three (3) hours and was not provided with timely incontinent care prior to lunch being served. Additionally, a care plan was not developed for bowel and bladder incontinence.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #19) of three (3) residents reviewed for Foley catheters. Specifically, Resident #19 had a history of urinary tract infections, and the urine collection bag was observed lying directly on the floor on multiple occasions. Additionally, infection control practices were not maintained while emptying the urine collection bag and staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) when providing direct hands-on care.

Inspectors wroteBased on interviews and record review conducted during an Extended Recertification Survey and complaint investigations (#NY00385595 - 574018, #NY00381410 - 574678) completed on 10/10/2025, the facility failed to protect residents' right to be free from physical abuse, mistreatment, and neglect for five (5) (Residents #15, #29, #34, #91, #135) of eight (8) residents reviewed for abuse. Specifically, the facility failed to implement sufficient interventions to protect and prevent resident-to-resident abuse resulting in Resident #155 hitting four (4) residents between 02/15/2025 to 07/02/2025. Administration and medical staff failed to recognize abuse and neglect. [...]

Inspectors wroteBased on interviews and record review conducted during Complaint investigations (#NY00365084-574660, #NY00385595-574018, NY00381410- 574678) completed during an Extended recertification survey completed on 10/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for five (5) (Resident #8, #15, #131, #135 and #155) of five (5) residents reviewed. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (NY00372414 - 574672) during the Standard survey completed on 09/19/2025, the facility did not ensure that there was sufficient nursing staff with the appropriate competencies on a 24-hour basis to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility (floors two (2), three (3), four (4)). Specifically, there was insufficient staff to meet all the residents needs including long wait times to get mediations and call bells answered, toileting/hygiene, and showers. Additionally, the facility did not meet their assessed minimum staffing levels for Licensed Nurses based on the facilities assessment to meet the needs of each resident.

Inspectors wroteBased on interview and record review conducted during the Extended Recertification Survey completed on 10/10/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the administration did not ensure that psychiatric services were available, make outside arrangements or assist residents with accessing such services.

Inspectors wroteBased on interviews and record review conducted during the Extended Survey completed on 10/10/2025, the facility did not ensure that the Medical Director was responsible for implementing resident care policies and coordination of medical care in the facility. Specifically, the Medical Director normalized physical altercations between dementia residents. The finding is:Refer to F 600 Free from Abuse and Neglect - Scope and Severity = L The undated facility document titled Medical Director Job Description documented the Medical Director must ensure the implementation of resident care policies and coordination of medical care in the facility to promote quality, safety, and compliance with federal and state regulations. Responsibilities included but were not limited to promoting a culture of accountability, safety, and continuous improvement; [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 09/16/2025, the facility did not maintain an effective pest control program for four (4) (first, second, third, and fourth floors) of four (4) resident use floors. Issues included observations of evidence of rodents (dead rodents and rodent droppings) and flies.

Inspectors wroteBased on observation, interview, and record review during a Complaint investigation (NY00370611-574668, NY00372414-574672, and 2563935) completed during the Standard survey on 09/16/2025, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, there were areas of damaged walls and ceilings, dust laden fans inside resident rooms, soiled and sticky floors, and unpleasant odors. This affected three (3) (second, third, and fourth floors) of four (4) resident use floors.

Inspectors wroteBased on interview, observation, and record review conducted during a Standard survey completed on 9/16/2025, it was determined that the facility did not ensure that the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. Specifically, one of three residents (Resident #5) reviewed for choices had issues with not receiving a shower for three weeks per their preference. The finding is:The policy and procedure titled Resident Rights dated 12/2016 documented that the resident has a right to self-determination. The policy and procedure titled Resident Rights Guideline for All Nursing Procedures dated 10/2010 documented that the resident has a freedom of choice. Resident #5 was admitted to the facility with diagnoses of paralysis of the right side of the body and depression. [...]

Inspectors wroteBased on interview and record review during the Standard survey completed on 09/16/2025, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified three (3) (Registered Nurse Supervisor #1, Unit Clerk #1, and Dietary Supervisor #1) of eight (8) employees reviewed that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 9/16/2025, the facility did not ensure that comprehensive care plans included to the extent practicable, the participation of the resident and the resident's representative(s); an explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan; and were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) (Residents #29 and #74) of two (2) residents reviewed for care plan participation and care plan revision related to accidents. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 9/16/25, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) (Resident #88) of one (1) resident reviewed for positioning. Specifically, while sitting in their wheelchair, Resident #88's feet were hanging down and were approximately four (4) to six (6) inches from touching the floor for extended periods of time. Based on observation, interview, and record review conducted during the Standard survey completed on 9/16/25, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (1) (Resident #88) of one (1) resident reviewed for positioning. [...]

Inspectors wroteBased on interview, and record review conducted during the Standard survey, completed on 09/16/2025, it was determined that the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities; and if necessary, must assist the resident in making appointments for one (1) (Resident #57) of one (1) resident reviewed for treatment/services to maintain vision. Specifically, the facility did not act on the optometry recommendations for cataract surgery for Resident #57 from 10/29/2024 and again on 06/10/2025. The finding is:The policy titled Resident Rights, last revised December 2016, documented federal and state laws guaranteed certain basic rights to all residents of the facility. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Complaint investigation (Complaint #NY00381662-574015) during the Standard survey on 09/16/2025, the facility did not ensure the resident's environment remained free from accident hazards over which the facility had control and provide adequate supervision to prevent accidents for one (1) (Resident #29) of one (1) resident reviewed for elopement. Specifically, on 05/26/2025 Resident #29 had exited the facility through a service door, out of a fenced gate and was found at the local corner store. Additionally, Resident #29 was observed not wearing their wander guard as care planned, wander guard checks were not implemented for placement every shift, and the 11:00 PM-7:00 AM wander guard checks for functionality were not implemented. [...]

Inspectors wroteBased on observation, interviews and record review conducted during an Extended survey completed on 10/10/2025, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for two (2) (Residents #6 and #155) of five (5) residents reviewed. Specifically, Resident #6 was not receiving psychotherapy services and/or group therapy services as recommended by their psychiatry provider and there was a delay in obtaining a follow up psychiatry consult as recommended for Resident #155.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (Complaint #NY00379533) the facility did not maintain an effective pest control program so that the facility was free of rodents for three (first, third, and fourth floors) of four resident use floors. Specifically, there were multiple observations of dead rodents in traps, evidence of rodent droppings, and complaints of rodent sightings in resident rooms.

Inspectors wroteBased on observation, record review and interviews during a complaint investigation (#NY00356620) the facility did not ensure that all residents receive treatment and care in accordance with professional standards of practice for the comprehensive care plans for one (1) (Resident #2) of three (3) residents reviewed. Specifically, treatments to the resident's bilateral lower extremity venous (relating to the vein) ulcers were not being completed as ordered by the physician. The finding is: The policy and procedure titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol with a revision date of March 2014 documented the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey completed on 12/31/24 (Complaint # NY00357248) the facility did not protect residents from sexual abuse for two (Resident #1 and #2) of three residents reviewed for abuse. Specifically, Resident #1 wandered into Resident #2's room without staff knowledge and they were found engaged in sexual activity. Resident #1 and Resident #2 both lacked the ability to consent due to their cognitive impairment. The finding is: The policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised September 2021, documented residents have the right to be free from abuse by anyone which includes but is not limited to verbal, mental, sexual, and physical abuse. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint (#NY00363866) investigation, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #1) of three residents reviewed for quality of care. Specifically, there was no skin assessment completed for a resident readmitted to the facility with multiple pressure and vascular ulcers (develop due to poor circulation) that included measurements, description of the ulcers, and staging (pressure); this resulted in a delay in obtaining physician orders and treatment initiation. The finding is: The undated policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol documented the staff will examine the skin of a new admission for ulcerations or alterations in skin. The nurse shall describe and document/report the following: [...]

Inspectors wroteBased on interview and record review conducted during an Extended Recertification and Complaint (reference #NY00339732 and #NY00325989) survey from 5/13/2024 to 5/23/2024 the facility failed to protect resident's rights to be free from abuse and failed to protect residents from further abuse for three (Resident #129, #104 and #122) of seven residents reviewed for resident-to-resident abuse. Specifically, Resident #129 was verbally and physically threatened by Resident #74 on 4/16/2024 with a large pair of scissors. The facility failed to provide protection for Resident #129 by allowing Resident #74 ongoing access to Resident #129. This resulted in mental anguish for Resident #129 as they stated on 4/19/2024 to Social Worker #1 that they were fearful for their life as they recounted the events of 4/16/2024. [...]

Inspectors wroteBased on interview and record review conducted during an Extended Recertification and Complaint (reference #NY00339732 and #NY00325989) survey from 5/13/2024 to 5/23/2024 the facility failed to ensure that all alleged violations of abuse are reported immediately, but not later than 2-hours after the allegation is made to the administrator of the facility and to appropriate officials (including the State Survey Agency) for three (Resident #104, #122, and #129) of fourteen residents reviewed for abuse reporting. Specifically, Registered Nurse #1 did not report alleged resident-to-resident abuse that occurred between Resident #74 and #129 to the Administrator. The lack of reporting resulted in continued access to each other and mental anguish for Resident #129. [...]

Inspectors wroteBased on observation and interview and record review during a compliant investigation (#NY003266278, #NY00332285) completed during an extended survey ending 5/23/24, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, four (1st, 2nd, 3rd, 4th) of four floors had environmental concerns. The issues involved the lacked hot water in resident rooms; lack of adequate resident access to bathrooms, plastic bags over sinks, and call bells that were not functioning in a shared resident bathroom. Additionally, observed were soiled walls, dirty window shades, dirty utility hoppers, mold in shower rooms, foul odors, windows, and ceilings in disrepair/stained.

Inspectors wroteBased on observation, interview, and record review conducted during the Extended Recertification and Complaint (#NY00333644) survey completed on 5/23/24, the facility did not provide food and drink that was at a safe and appetizing temperature for three (Second floor Unit, Third floor Unit, and Fourth floor Unit) of three test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #21, #27, #41, #82, #125, #134, #359, and #506, were involved.

Inspectors wroteBased on observation, interview, and record review conducted during an Extended survey completed on 5/23/24, the facility did not store food in accordance with professional standards for food safety for three (Second floor Unit, Third floor Unit, and Fourth floor Unit) of three nourishment unit refrigerators reviewed. Specifically, the nourishment kitchen refrigerators contained undated, unlabeled, expired food and drink items, and had liquid spills and dried substances on surfaces; the Fourth floor Unit refrigerator was not holding a safe food storage temperature and subsequently lacked a thermometer; the Second floor Unit refrigerator had no thermometer.

Inspectors wroteBased on interview and record review conducted during an Extended survey completed on 5/23/24, the facility did not ensure that each resident had the right to participate in the development and implementation of their person-centered care plan and facilitate the inclusion of the resident for one (Resident #134) of four residents reviewed. Specifically, Resident #134 was not informed, in advance to participate in their scheduled care plan meeting. The finding is: The policy and procedure titled Resident Participation - Assessment/ Care Plans dated February 2021, documented the resident has the right to participate in the development and implementation of their plan of care. The facility staff supports and encourages resident to participate in the care planning process by providing sufficient notice in advance of the meeting; [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Extended Recertification and Compliant (#NY00332285, #NY00329276) survey completed on 5/23/24, the facility did not ensure that each residents had the right to be treated with respect and dignity for three (Resident #1, #101 and #134) of six residents. Specifically, a resident was treated disrespectfully and without dignity when a staff member acted in an unprofessional and undignified manner (#134). In addition, a multi stall bathroom was shared by both male and female residents on the dementia unit without privacy door and/or curtains (#1 and #101).

Inspectors wroteBased on interview and record review conducted during an Extended Recertification and Complaint (#NY00339732) survey completed 5/23/24 the facility did not ensure that all alleged allegations of abuse, were thoroughly investigated for two (Resident #74 and #129) of fourteen residents reviewed. Specifically, there was a delay in the initiation of an investigation for a reported allegation of resident- to- resident abuse. Additionally, the facility did not complete a thorough investigation to include interviews of residents involved and other potential witnesses. The finding is: The policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating revised September 2022 documented all reports of resident abuse are thoroughly investigated by facility management. The individual conducting the investigation as a minimum: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey and Complaint (#NY00326278) survey completed on 5/23/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for three (Resident #27,102, 105) of six residents reviewed for Activities of Daily Living. Specifically, Resident #27 was not provided with timely incontinence care that resulted in their brief and bed linens saturated with urine through to the mattress, also the Certified Nurse Aide performed incomplete incontinence care (lack of washing bilateral buttocks and hips and removal of saturated brief) with improper hand hygiene, glove changes, and touched items in the resident's room with soiled gloves. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Extended Survey completed on 5/23/24, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for four (Resident #16, #154, #305, #360) of thirty three residents reviewed for quality of care. Specifically, the issues involved inaccurately transcribed physician's orders resulting in delay in treatment and there was no comprehensive care plan developed for indwelling foley catheter use and urinary tract infections (#16). In addition, PICC (peripheral inserted central catheter) line dressing changes (#305, #360), and supplements were not administered in accordance with physician's orders (#154).

Inspectors wroteBased on interview and record review conducted during the Extended Survey completed on 5/23/24, the facility did not ensure each resident was offered the pneumococcal and influenza immunizations. Additionally, the facility did not ensure the residents medical record includes documentation that indicates education regarding the benefits and the potential side effects of the immunizations was provided for four (Resident #10, #54, #406, #456) of five residents reviewed. Specifically, there was no documented evidence that residents #10, #54, #406, and #456 were offered/declined, and educated on the influenza, pneumococcal immunizations.

Inspectors wroteBased on interview and record review conducted during a complaint investigation (#NY00328621) completed 1/25/2024, the facility did not ensure that all alleged allegations of abuse, were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, the facility did not complete a thorough investigation into an injury of unknown origin, a bruise to Resident #1 face to include staff interviews. The finding is: Review of the policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised in 9/2022 documented all reports of resident abuse (including injuries of unknown origin) neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. [...]

Inspectors wroteBased on observation, record review, and interview conducted during an Abbreviated survey (Complaint #NY00301582) completed 9/18/23, the facility did not provide a homelike environment, allowing residents to use their personal belongings to the extent possible and exercise reasonable care for protection of the resident's property from loss for one (Resident #2) of three residents reviewed. Specifically, Resident #2 was observed wearing the same clothes for three days and had no other clothing available that belonged to them. Additionally, the clothes that were in Resident #2 closet belonged to the previous resident. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (Complaint #NY00304843) completed during the Standard survey completed 2/9/23, the facility did not maintain an effective pest control program so that the facility is free of rodents. One of one kitchen and three (Unit 2, 3 & 4) three units had issues with rodents. There were multiple observations of evidence of mice (droppings) and traps. In addition, multiple complaints of mouse siting's in resident rooms, hallways, kitchen, and food storage areas. This involved Residents #59, 67, 93, 104, 138, 139, and 452.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 2/9/23, the facility did not protect, promote, and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, there was a lack of dignity with dinning. Two (Resident #138 and #450) of two residents reviewed had issues with a delay in assistance with eating, standing while feeding (#450) and not receiving preferences (#138). Additionally, three (Units 2, 3 and 4) of three resident units had issues with the use of plastic utensils or no utensils, no glasses or straws provided for beverages in cartons, no condiments, and coffee was not served on the lunch and dinner trays. This involved Residents # 83,138, 451, and 452.

Inspectors wroteBased on observation, record review, and interview conducted during a Standard survey completed 2/9/23, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, three (Units #2, #3 and #4) of three resident units reviewed for food temperatures during meals had issues involving trays being passed on the units with long wait times, food items that were not palatable and not served at safe and appetizing temperatures. Residents' #58, #83, #104, #138, #452 and #453 were involved.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint Investigation (Complaint #NY00304843) completed during the Standard survey completed 2/9/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had floors that were sticky, not swept and had a thick black substance buildup along the walls of the perimeter of the kitchen and in the grout between the tiles. Wire shelves and equipment had a thick layer of sticky grease buildup. There were multiple tiles missing on the walls and floor throughout the kitchen. Threshold to a door entering the kitchen had a one foot by one foot hole in the concrete. Ceiling was leaking near the air conditioning unit with a liquid substance dripping onto the floor. [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 2/9/23, 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 (CO) detection shall be installed in residential buildings and commercial buildings in all rooms and occupiable spaces, that contain a fuel burning appliance and the facility did not have a policy and procedure for the installation, inspection, testing, and maintenance of carbon monoxide (CO) detectors. This affected one (First floor) of four resident use floors.

Inspectors wroteBased on observation, interview and record review conducted during a Complaint Investigation (Complaint #NY00307276) completed during the Standard survey completed on 2/9/23, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft and maintain a sanitary, orderly, and comfortable interior. Specifically, one (Resident #452) of four residents reviewed for personal property was transferred to the hospital on 1/23/23 and returned to the facility on 1/31/23 and has not been given their personal property back that was left at the facility during hospitalization. In addition, two (Units #2 and #3) of three units had issues with dirty linen, dirty floors, dirty tub rooms to include but not limited to dirty grout, peeling paint and soiled linen and paper debris all over the floor. This involved Residents #101 and #138.

Inspectors wroteBased on observation, interview and record review conducted during a Complaint Investigation (Complaint #NY00291178 and NY00298606) completed during a Standard survey completed 2/9/23, the facility did not ensure the resident environment was free of accident hazards and adequate supervision was provided for two (Resident's #28 and #94) of four residents reviewed for accidents. Specifically, staff reheated coffee in a microwave, did not take the temperature of the beverage before they served it, and the resident sustained a burn (Resident #28); the facility did not have an effective system in place for monitoring the wander guard (device to detect wandering) functionality and presence of bracelets, and the care plan did not include use of a wander guard (Resident #94).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 2/9/23, the facility did not maintain resident call bell systems in working order. Specifically, call bells in resident rooms did not activate the light above the room's door or the indicator of the call bell system at the Nurses' Station. This affected two (third floor and fourth floor) of three resident floors. This involved Residents # 35,38, 58, 298 and 398.