New York State Veterans Home at Montrose

Inspectors wroteBased on observations, interviews, and record review conducted during survey (2695131), the facility failed to ensure that a resident received supervision and devices necessary to prevent accidents for one (1) (Resident #6) of three (3) residents reviewed for accidents. Specifically, Resident #6 had eight (8) falls between 10/06/2025 and 03/17/2026. On 03/17/2026 Resident #6 fell and sustained a laceration to the back of their head requiring six (6) stitches. This resulted in actual harm to Resident #6 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey from 03/11/2026 to 03/24/2026, the facility did not ensure the resident's right to self-determination. This was evident for one (1) (Fair Haven Unit) of six(6) resident units reviewed for resident rights. Specifically, on 03/07/2026 and 03/08/2026 the Fair Haven Unit (which is also the memory care unit with residents with impaired cognitive abilities) Day room, needed to undergo repairs. The day room had a sensory room and two bathrooms. The twenty (20) residents on the Fair Haven Unit including Resident #3, #4, and #5, were placed in the dining room causing an interruption of their daily routine and how the residents spent their leisure time before and after lunch and dinner on 03/07/2026 and 03/08/2026. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the abbreviated survey from 03/11/2026 to 03/23/2026, the facility did not ensure the resident's right to resolve grievances. This was evident for two (Resident #1 and #6) of four residents reviewed for resident rights. Specifically, 1) Resident #1's Representative was not provided with an opportunity to file a written grievance in relation to concerns with the resident's medication regime and care received, and 2) Resident #6's Representative was not provided the opportunity to file a written grievance in relation to concerns with medication regime and care received.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure a resident's right to be free from physical abuse. This was evident for one (1) (Resident #1) of four (4) residents reviewed for abuse. Specifically, on 03/01/2026 Certified Nurse Aide #1 is observed on video surveillance that was provided by Resident #1's representative, in Resident's #1 room striking the resident on the top of their head with a broom, grabbing Resident #1 by the neck and placing them in a reclining back wheelchair, and using their left hand to strike Resident #1 on the left side of their neck. Facility staff confirmed they observed recorded video footage on 03/02/2026 of Certified Nurse Aide #1 striking Resident #1 on the left side of their neck on 03/01/2026. This resulted in psychosocial harm to Resident #1 that is not immediate jeopardy.

Inspectors wroteBased on record review and interview conducted during the Recertification and Abbreviated surveys (NY 00350287) from 05/28/25 to 06/04/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 3 of 21 days from 7/15/24 through 8/4/24 and 2 of 31 days from 5/1/25 through 5/31/25 the facility did not meet minimum staffing requirements for Certified Nurse Aides as documented in the Facility Assessment.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey NY 00331181 from 5/28/25 to 6/4/25 the facility did not ensure residents received adequate supervision to prevent accidents for one (1) of four (4) residents (Resident #254) reviewed for accidents. Specifically, a two (2) person assist during transfers was not provided as per care plan which resulted in Resident # 254 sustaining two (2) skin tears to their right upper arm and a 1 cm by 1 cm abrasion to their head.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00375411), the facility did not ensure that a resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for one (1) of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 Resident #1 was seen on Facility Surveillance Camera Footage wandering the hallway to the adjacent unit. Resident #1 was seen going in and out of other resident's rooms. Security Officer #1 was observed grabbing Resident #1 by their wrist to keep the resident in one place. Resident #1 is observed on surveillance camera footage in a wheelchair and trying to propel themselves away from the staff. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00375411) the facility did not ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) out of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 the facility staff administered intramuscular anti-psychotic medication to Resident #1. Resident #1 was seen on a surveillance camera wandering on the unit and going in and out of other resident's rooms. Resident #1 was observed on surveillance camera being held against the wall by four (4) staff members (Certified Nurse Aide #2, Licensed Practical Nurse #1, Security Officer #1 and Registered Nurse #2) and administered the intramuscular injection. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00375411) the facility did not ensure the resident was free from abuse for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 3/15/2025 Resident #1 was seen on Facility Surveillance Camera Footage wandering the hallway to the adjacent unit. Resident #1 was seen going in and out of other resident's rooms. Security Officer #1 was observed grabbing Resident #1 by their wrist to keep the resident in one place. Licensed Practical Nurse #1 was observed grabbing both of Resident #1's wrists and Certified Nurse Assistant #2 and Registered Nurse #2 grabbed Resident #1's right arm while Registered Nurse #1 was seen administering an injection to the resident while staff hold the resident in place against the wall in the hallway. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00375411) , the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 24 hours if the events that cause the allegation do not result in serious bodily injury, to the administrator of the facility for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 3/17/2025 Resident #1's representative emailed the facility and informed them Resident #1 stated they were assaulted by staff on 3/15/2025 and requested to view the surveillance camera footage. The Administrator was not informed of the alleged incident that occurred on 3/15/2025 until 3/17/2025. The Administrator reviewed the video surveillance footage on 3/18/2025 and the incident was reported to the New York State Department of Health on 3/18/2025.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00365964), the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 residents (Resident #3) reviewed for abuse. Specifically, Resident # 3 sustained a skin tear to left hand on 12/17/2024 that was not thoroughly investigated by the facility.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey and abbreviated survey (NY00301732), the facility did not consider the views of the family council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not ensure that members of the family council, including new admissions were notified of an upcoming quarterly meeting scheduled for 6/22/22.

Inspectors wroteBased on record review and interview during a recertification and abbreviated survey (# NY00303218) conducted from 7/20/2023-7/6/2023 the facility did not ensure the resident representative was notified, provided education and given an opportunity to consent or decline prior to changing the residents pain medication regime for 1 (Resident #184) of 1 resident reviewed for notification of change. Specifically,the resident representative was not notified when a scheduled dose of Roxanol was changed to an as needed administration schedule. This was evidenced by: Resident # 184 had diagnosis of dementia, atrial fibrillation, and thyroid cancer A review of the Significant Change Assessment Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition. A review of the physician orders documented 6/21/23 Roxanol 5 mg q 2 hours as needed for pain. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey, from 7/20/2023-7/27/2023 it was determined that for 1 of 38 residents reviewed for Comprehensive Care Plans (CCP), the facility did not ensure that each resident had a CCP that included measurable objectives and interventions to meet the resident's medical and nursing needs to attain or maintain the resident's highest practicable well-being. Specifically, there was no care plan for anticoagulants (blood thinner) for Resident #172. This is evidenced by the following: Resident # 172 had diagnosis including but not limited to coronary artery disease, colostomy, and atrial Fibrillation The Quarterly Minimum Data Set (MDS) an assessment tool dated 6/8/2023 documented Resident # 172 had severely impaired cognition. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team. This was identified for 1 (Resident # 30) of 6 residents reviewed for unnecessary medications. Specifically, Resident # 30's psychotropic care plan was not revised to reflect that the resident's brother refused psychiatric follow up and there was no documented evidence of a plan for psychiatric follow up. The finding is: Resident # 30 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia, Seizure Disorder, Bipolar Disorder, and Psychotic disorder. The Quarterly Minimum Data Set (MDS an assessment tool) dated 7/5/23 documented resident had modified independence in cognition, and there were no mood or behaviors changes noted. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the recertification survey from 7/20/23 to 7/27/23, it was determined that the facility did not ensure that drugs and biological's were securely stored. Specifically, 2/6 medication carts reviewed (Both carts located on the Bear Mountain Unit) were discovered with unlocked internal narcotic medication lock boxes.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 7/20/2023 - 7/27/2023, the facility did not ensure food was stored in accordance with professional standards for food safety to ensure prevention of foodborne illness. Specifically, 1 (Bear Mountain) of 4 resident refrigerators used for storing nourishments and food brought in by the resident's families contained multiple outdated perishable food items. The finding is: A policy and procedure dated 3/2023 and titled Guidelines for Proper Food Storage for Meals/Foods Brought in by Family Members documented the policy was to provide guidelines for the safe handling and storage of food brought in by family members/friends. Procedures documented that perishable/cooked food will be labeled with the resident name and room number and dated to be discarded in 2 days of being brought into the facility. [...]

Inspectors wroteBased on record review and interview during the 7/20/23-7/27/23 recertification survey, the facility did not ensure that a facility-wide assessment was conducted and documenetd to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents both during its day-to-day operations and during emergencies. The assessment include, but are not limited to, evaluation of diseases, conditions, physical, functional or cognitive status and acuity of its resident population.

Inspectors wroteBased on observations, record review and interviews during the recertification survey from 7/20/2023 - 7/27/2023, the facility did not ensure a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. This was evident for one resident (Resident #180) . Specifically, 1. the control unit for the resident's alternating mattress was on the floor, and 2. the cord to the resident's alternating mattress control unit extended beyond the left, lower side of the bed to a wall outlet, which created an accident hazard.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure that the call bell system was accessible for 1 of 2 residents reviewed for Environment. Specifically, the facility did not ensure that Resident #83 had his call bell within reach on two observed occasions. The finding is: Resident #83 was admitted to the facility with diagnoses of multiple sclerosis, quadriplegia, neuropathy, and neurogenic bladder. The MDS (minimum data set- a resident assessment tool) annual review dated 4/15/2019 show a BIMS (brief interview of mental status) of 15 indicating the resident was cognitively intact. Resident #83 is unable to move his left arm or both legs; he is only able to move his right arm. The resident had a right fibula/tibia fracture first noted 5/23/2019. He is totally dependent on staff for all care except feeding. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that a resident's wishes for advance directives in the event of the resident's incapacitation were clear and unambiguous. This was evident for 1 of 41 residents (Resident #210) sampled for advance directives.

Inspectors wroteBased on observations, record reviews and interviews conducted during a recertification survey, the facility did not insure that: (1) the interdisciplinary team reviewed and revised the nutrition care plan in a timely manner to prevent further weight loss for 1 of 6 residents (Resident #153) reviewed for nutrition. Resident #153 had an unplanned weight loss of 15.5 pounds (lbs.) in a period of three months and monitoring of the resident's consumption of a nutritional supplement to prevent further weight loss was not performed, and (2) the reasons or causes of bladder incontinence for 1 of 1 resident (Resident #12) reviewed for bladder and bowel incontinence were not determined in order to develop an appropriate patient-centered care plan to assist the resident improve or prevent decline of the existing level of continency as possible.