Wesley Gardens Corporation

F-F677: Activities of Daily Living (ADL) Care Provided for Dependent Residents

F-F760: Residents are Free of Significant Medication Errors

F-F908: Essential Equipment, Safe Operating Condition

Review of the Facility Assessment, dated 5/15/24, revealed the facility's average daily census was 120 residents. Information regarding the residents based on facility characteristics included Minimum Data Set Resident Assessment results from 1/20/23. Services and care offered by the facility included, but was not limited to, assistance with activities of daily living, management of medical conditions and medication-related issues causing psychiatric symptoms and behavior, the administration of medications that residents needed, and the prevention of abuse and neglect. The Assessment included the facility resources needed to provide competent support and care daily to its residents included, but were not limited to; Administration (e.g., Administrator, Environmental Services, and Social Services), behavioral, psychiatric, and mental health providers, and support staff (e.g., maintenance and housekeeping staff). The staffing plan to meet the needs for care and support of the residents did not include positions such as social work, maintenance staff, and housekeeping staff. Additionally, the Assessment did not include a process to ensure the adequate supply, appropriate maintenance, or the replacement of physical equipment and other physical plant needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 335488 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335488 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 For five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and Level of Harm - Minimal harm or comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit ( F), floors, potential for actual harm walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul Residents Affected - Some odors, ice machines were dirty, ready stand lifts were dirty, plumbing fixtures were not maintained and/or working properly, there were ceiling plumbing leaks, overhead lights were not functional or functioning properly, light lenses and covers were missing, there were damaged electrical fixtures with exposed wiring, there was standing water on floors, and furniture and window blinds were in disrepair and dirty.

During an interview on 5/31/24 at 10:45 AM, the Corporate Maintenance Director stated that for maintenance

it was just themself, because one of the maintenance staff was out on medical leave and the other one left about two weeks ago.

For six residents reviewed for allegations of resident abuse and injuries with unknown origin, the facility could not provide evidence that the allegations were thoroughly investigated.

During an interview on 6/3/24 at 10:05 AM, the Corporate Infection Preventionist stated it was identified in either February or March 2024 that investigations were missing, likely due to changes in facility leadership.

For three residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene as related to nail care, shaving, bathing, hair washing and hair trimming.

Resident #52 did not receive consistent psychiatric services, did not receive medication changes as recommended, and did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs.

During an interview on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services stated that there had been a discrepancy with telepsychiatry visits as the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments and issues with the providers not being made aware of the telepsychiatry recommendations.

For four residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors as they related to omissions of significant medications being administered and incorrect doses of narcotic pain medication being administered.

For five of five occupied resident-use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, and ventilation systems were not maintained in working order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 335488 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335488 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the first-floor laundry room were not functional. During an interview at that time, a Level of Harm - Minimal harm or laundry staff member stated the middle dryer had not worked in about a year and the smaller residential style potential for actual harm washing machine (used for resident personal clothing) had not worked in about three to four weeks.

Residents Affected - Some During an interview on 6/4/24 at 11:05 AM, the Corporate Director of Maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the corporate maintenance director at 11:16 AM included two exhaust motors on the roof were not functional.

During an interview on 6/6/24 at 10:13 AM, with the Administrator and Director of Nursing, the Administrator stated they were aware of environmental concerns due to turnover and had been working to address the areas of concern and continued to recruit maintenance staff. The Administrator stated they were not aware of concerns related to investigations of alleged abuse and that the facility had a process in place that once an incident was reported the facility completed and documented a thorough investigation. The Director of Nursing stated there had previously been a backlog of investigations, however, the facility was now current in their investigations. The Director of Nursing stated there was an ongoing Quality Assurance and Performance Improvement initiative to ensure that activities of daily living (including nail care, hair care, and showers) were being maintained and documented. The Director of Nursing stated they were aware the facility had concerns related to medication errors. When an error was discovered, each case was investigated and staff were given the opportunity to improve their performance, and if no improvement was achieved, the staff member would be terminated.

10 NYCRR 415.26

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 335488 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335488 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm 46880 Residents Affected - Few Based on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are:

On 5/30/24 at 10:00AM, records for inspection and testing of facility carbon monoxide detectors were provided to the surveyor for review. The logs included a monthly signoff and listing of the locations of carbon monoxide detectors in the following areas: boiler room, kitchen, generator, and laundry.

Observations on 5/31/24 from 11:10 AM to 11:24 AM included carbon monoxide detectors were not present

in the first-floor laundry room and kitchen. Further observations at this time included three natural gas-powered dryers were in the laundry room and a natural gas range was present in the kitchen. During an

interview at this time, a laundry employee stated that they did not know if they had carbon monoxide detectors in the laundry room. In another interview at this time in the main kitchen, the Assistant Food Service Director pointed at the wall and stated that there was one (a carbon monoxide detector) but it is not where it should be.

The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in

an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance.

10NYCRR: 415.29(a)(2), 711.2(a)(1);

42 CFR: 483.70(b),

2015 IFC: Section 915, 915.1, 915.1.4, 915.3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 335488 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335488 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45200 potential for actual harm Based on observations, interviews, and record review conducted during the Recertification Survey, it was Residents Affected - Some determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five resident use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, an oxygen concentrator, and ventilation systems were not maintained in working order. The findings are:

Observations during the initial tour of the facility on 5/28/24 from 9:52 AM to 2:30 PM included multiple exhaust vents in the ceilings were not drawing air out of the following rooms, which included, but were not limited to: the 3rd, 4th and 5th floor soiled utility rooms across from the nurse stations, bathroom in room [ROOM NUMBER], and the 2nd floor shower room near 218. There were significant urine and fecal odors noted throughout the facility on all five resident-use floors. Additionally, the main fire alarm annunciator panel behind the reception desk in the 1st floor lobby displayed several supervisory trouble signals related to the penthouse exhaust fans for toilets and lounges.

In an interview on 5/28/24 at 9:47 AM resident #42 stated that it was difficult to breathe. It was observed at

this time that an oxygen concentrator was running and set at 8-liters and was connected to resident #42 via tubing. The licensed practical nurse read the pulse oximetry of resident #42 at a concentration of 86% and stated that a lot of equipment does not work. The licensed practical nurse then and attached a mask to an oxygen cylinder for the resident and the pulse oximetry of resident #42 was observed to immediately increase to a concentration of 96%.

Observations on 5/28/24 at 11:30 AM included two hoyer lifts in the 5th floor shower room (between the dining room and the nurse station) were marked with tags listing broken. There was no documentation to show that the lifts were taken out of service or were being repaired.

During an interview on 5/31/24 at 10:45 AM, the regional maintenance director stated that currently two of

the three hot water boilers are working and they are waiting on a circulating pump that has been ordered to fix the other one. Further observations included that the basement hot water boilers serve the entire facility.

The regional maintenance director also stated that for maintenance it is just themself, because one of the maintenance staff is out on medical leave and the other one left about two weeks ago. Further record review at 2:52 PM revealed another maintenance technician was hired 5/2/24 and was terminated from employment 5/21/24.

Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the 1st floor laundry room were not functional. During an interview at this time, a laundry staff member stated that the middle dryer has not worked in about a year and the smaller residential style washing machine (used for resident personal clothing) has not worked in about three to four weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 335488 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335488 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wesley Gardens Corporation 3 Upton Park Rochester, NY 14607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During an interview on 6/3/24 at 11:40 AM the Director of Dining Services stated that on Sunday 5/26/24

they reported no hot water to the New York State Department of Health. The Director of Dining Services also Level of Harm - Minimal harm or stated that they (the kitchen) had their own boiler, but something happened on Sunday, and they went to potential for actual harm serving meals on paper because their boiler was being shared with the rest of the building and had to be turned down. The Director of Dining Services also stated that their dish machine was not getting hot enough Residents Affected - Some to sanitize the dishes.

During an interview on 6/4/24 at 11:05 AM the regional director of maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the regional maintenance director at 11:16 AM included two exhaust motors on the roof were not functional.

10NYCRR: 415.29, 415.29(b), 415.29(f)(3), 415.29(h), 415.29(j)(1), 415.29(k)(9)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 335488