Ten Broeck Commons

Inspectors wroteBased on observation and interview the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated foods were stored in the kitchen refrigerator and unit pantry, and eight (8) cups of pre poured undated almond milk at the bedside of Resident #160; 2) expired foods were stored in the dry pantry, walk in cooler, and reach-in refrigerator; 3) staff were observed not wearing hair and beard restraints while in the kitchen; 4) ice packs were observed in the Catskill unit pantry freezer; and 5) staff were observed not changing gloves between tasks.

Inspectors wroteF880 AMBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the annual water sampling report for the year 2025 was missing, the annual facility assessment for legionella and required components were missing and not provided at time of survey.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 1/5/2026-1/22/2026 the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life for 1 of 1 resident (Resident #43) reviewed for Dignity. Specifically, Resident # 43 was observed out of bed wearing socks that were labeled with the resident's name in front of the sock clearly visible to other residents, visitors and staff.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 01/05/2026-01/12/2026, the facility did not ensure that the Comprehensive Care Plan was revised to reflect changes and/or new interventions for one (1) of six (6) residents (Resident #71) reviewed for Accidents, and one (1) of three (3) residents (Resident #139) reviewed for Activities. Specifically, 1) Resident #71 had a behavior of wandering, entering other residents' rooms and laying in other residents' beds, and the behavior care plan did not reflect this behavior or interventions for the behavior; 2) Resident #139's care plan had not been revised to reflect their current activities they participated in.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care was provided to prevent pressure ulcers for 1 of 5 residents (#9) reviewed for pressure ulcers. Specifically, Resident #9 had a physician order for offloading gel boots, to be worn at all times, and was observed without the gel boots.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 01/05/2026 through 01/12/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, the garbage/recycle dumpster was left open and there were cardboard boxes spilling over the top and debris on the ground around the dumpster.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00371242) the facility did not ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents. Specifically, on 02/04/2025 Resident #1 who was severely cognitively impaired and required a two person assist for transfers via mechanical lift as per their care plan, was transferred by Certified Nurse Aide #1 from chair to bed alone and unassisted. Resident #1 was found with flaccidity and deformity to right hip/leg and was ordered by the Nurse Practitioner to be transferred to the hospital. According to report received by the facility from the hospital, Resident #1 sustained a right spiral hip fracture requiring surgical intervention. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, it was determined the facility did not ensure all residents had the right to a dignified existence for 1 of 2 residents (Residents #116) reviewed for personal property. Specifically, the facility did not ensure Resident #116 received a dignified existence as they were transferred to the facility from an assisted living home without their belongings, and actions were not taken to ensure the resident was able to receive their personal property.

Inspectors wroteBased on observations, interviews and record review during the recertification survey completed on 9/20/23, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #226) of six residents reviewed for skin care. Specifically, Resident #226 received active ice temporary pain relief cream to the perineal area by a certified nurse aide (CNA). There was no order for this cream; the treatment cart was not locked, and were no documented evidence that the resident was assessed by a registered nurse (RN) or Resident #226's physician was notified.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification and abbreviated surveys (NY00313960), the facility did not ensure 1 of 5 residents (Residents #450) reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #450 had a pressure ulcer worsen, there was no documented turning and positioning and the medical provider was not notified timely of a change in condition.

Inspectors wroteBased on observation, record review, and interview during the recertification survey and an abbreviated survey (# NY00311693, NY00321960) completed on 9/21/2023, the facility did not ensure that 2 of 3 residents (Resident #84 and #354) reviewed for accidents, received adequate supervision and assistance to prevent accidents. Specifically Resident #84 was not transferred as care planned and sustained a fracture of the right leg. Resident # 354 who has a history of behavior hit resident #135 with a wet floor sign on the head that resulted in a laceration to his head.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that each resident's right to privacy and confidentiality of personal health information was maintained. Specifically, positioning profiles (photographs of residents wearing assistive / positioning devices) were observed on closet doors in resident rooms. This was evident for 3 of 3 residents (Resident #5, #31 and #109) reviewed for privacy.

Inspectors wroteBased on observation, record review and interview conducted during the most recent recertification survey and an abbreviated survey (# NY00247956), the facility did not: A. Implement a person centered care plan for 1 of 7 residents (#49) reviewed for accidents, 1 of 4 residents (#86) reviewed for positioning and 1 of 5 residents reviewed for nutrition (#199). Specifically, 1.) hip protectors were not applied as per the care plan for Resident #49; 2.) wheelchair leg rests were not applied as per the care plan for Resident #86; and 3) weekly weights were not done for the first 4 weeks after admission for Resident #199. B. Develop a care plan for 2 of 2 residents (#49 and #48) reviewed for incontinence. Specifically, a care plan with measureable goals and timetable was not developed to address increased bladder incontinence for Resident #49; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were provided adequate supervision to prevent resident to resident alteration that could possibly result in injury. Specifically, a cognitively impaired resident (Resident #106) threatened to harm another resident (Resident #23) and this threat was not promptly investigated and measures were not put in place promptly to prevent reoccurrence.

Inspectors wroteBased on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that 2 of 2 residents reviewed for bowel and/or bladder incontinence were provided the necessary treatment or services to restore continence to the extent possible. Specifically: 1.) For Resident #48, no person-centered goals and interventions were put in place to address bowel incontinence and no measures addressing voiding patterns, use of diuretic and supplies to promote urinary continence were identified in the resident's plan of care to ensure implementation across all shifts. 2.) For Resident #49, specific measures were not put in place to attempt to decrease the frequency of urinary incontinence.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, it was determined that for 3 of 7 residents (Residents #166, #199 and #216) reviewed for Nutrition and Hydration the facility did not ensure that each resident was provided the necessary care to either maintain, to the extent possible, acceptable body weight or proper hydration. Specifically, for Resident #199 there was a lack of weekly weight monitoring for the first 4 weeks following admission as indicated in the facility's weight policy and the plan of care; and for Residents #166 and #216, there was a lack of adequate monitoring of daily fluid intake to assess the adequacy of daily fluid consumption.