Troy Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure the resident's right to be free from neglect for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 had a pressure ulcer on the heel of their right foot known to the facility on [DATE]. There was no documented evidence the facility completed wound assessments or management from a qualified wound care provider after 09/19/2025. The designated in-house wound care provider completed rounds on days when the resident was scheduled to be out of the facility for dialysis and no alternate arrangements were made. On 10/06/2025, Resident #1 reported increased right foot pain and was transferred to the hospital from the dialysis center on 10/10/2025. [...]

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for three (3) (Resident #s 1, 6, and 7) of three (3) residents reviewed. Specifically, the facility failed to provide daily care/treatment of a pressure ulcer in accordance with professional standards of practice and care planned interventions for (a.) Resident #1's unstageable pressure ulcer on the right heel, (b.) Resident #6's stage 3 pressure ulcer on the sacrum, and (c.) Resident #7's stage 3 pressure ulcer on the sacrum, that were present upon admission.

Inspectors wroteBased on record reviews and interviews conducted during a survey, the facility failed to ensure residents were afforded the right to formulate advanced directives including having a physician order related to their code status (level of medical interventions a person wishes to have started if their breathing stopped such as cardiopulmonary resuscitation or do not resuscitate), and establishing mechanisms for documentation and communicating the residents' choices to staff responsible for their care for one (1) (Resident #1) of three (3) residents reviewed. Specifically, when the resident no longer wanted cardiopulmonary resuscitation on [DATE], there was no physician order for the change in code status and advance directive until [DATE].

Inspectors wroteBased on observation, interview and record review conducted during a Survey, the facility failed to report the results of all investigations to his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action was taken for one (1) of one (1) residents reviewed. Specifically on 10/14/2025, Resident #3 threw objects including a chair that resulted in the chair hitting Resident #5's right foot. Resident #3 also climbed on top of Resident #4's bed while Resident #4 was laying in their bed. There was no documented evidence this incident involving Resident #3 was reported to the State Survey Agency as required.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure comprehensive care plans were developed and implemented for residents according to professional standards for one (1) (Resident #6) of three (3) residents reviewed. Specifically, Resident #6's comprehensive care plan did not contain measurable goals and interventions for the care and treatment of the stage three (3) pressure ulcer on the sacrum (triangular bone at the base of the spine).

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were revised and updated according to professional standards for one (1) (Resident # 1) of three (3) residents reviewed. Specifically, for Resident #1, the comprehensive care plan was not updated (a.) to reflect weekly wound assessments were not done by the wound care provider when the resident was out for dialysis treatment on 09/25/2025, 10/02/2025, and 10/09/2025, and (b.) when there was a significant change in the pressure ulcer on 10/02/2025 and had deteriorated.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure services provided or arranged by the facility as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1's unstageable pressure ulcer on the right heel was assessed on 9/25/2025 by a Licensed Practical Nurse who was not qualified to do so within their scope of practice.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments at each visit for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the Attending Physician saw Resident #1 on 09/24/2025 for admission evaluation and their progress note did not include a plan for care and treatment of an unstageable pressure ulcer on the right heel.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, residents were observed to wear hospital gowns instead of personalized clothing; and staff entered resident rooms without knocking or conducting themselves in a way of dignified care and respect to the residents on 2 of 2 units. This is evidenced by: A facility policy titled Resident Rights dated 2/2020, documented residents had a right to a dignified existence; to be treated with respect, kindness and dignity; to have self-determination, and be free from abuse, neglect, misappropriation of property and exploitation. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure the Minimum Data Set (an assessment tool) was an accurate assessment reflective of each resident status at the time of assessment. Specifically, the discharge tracking Minimum Data Set was not accurately completed for 5 of 74 residents reviewed for accuracy related to proper discharge placement. This is evidenced by: During a review of records on 2/07/2024 for Resident #73 discharge for hospitalization, the resident was discharged to home and not to the hospital. The Medication Administration Record Section A documented that Resident #73 was discharged to a short-term general hospital. The nursing progress notes dated 11/10/2023 documented that Resident #73 was discharged to their family member's home with all belongings. [...]

Inspectors wroteBased on interview and record review conducted during a Recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure that residents receive proper treatment and assistive device to maintain hearing abilities. Specifically, Resident #32 did not receive assistance with applying and removing bilateral hearing aids, and did not receive follow up Otolaryngology (a medical specialty which is focused on the ears, nose, and throat) visits for maintenance of hearing aids as recommended. This was evident for 1 of 27 residents reviewed for Communication/Sensory. This is evidenced by: Resident #32 Resident #32 had diagnoses including osteoarthritis (degeneration of joint cartilage and the underlying bone. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case # NY00312707) from 2/05/2024 to 2/12/2024, the facility did not ensure the residents were free from significant medication errors for 1 (Resident #327) of 1 resident reviewed for medication reduction. Specifically, for Resident #327, medication reduction was not properly transcribed and administered as ordered in a timely manner. This is evidenced by: Resident #327 Resident #327 was admitted to the facility with the diagnoses of metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), severe sepsis with septic shock (a condition in which the body responds improperly to an infection including possible organ failure), and cirrhosis of the liver (a condition where scar tissue gradually replaces liver tissue); [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification and abbreviated survey (Case # NY00327311 and NY00315143) from 2/05/2024 to 2/12/2024, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was not sufficient staff to meet resident needs in activities of daily living; multiple residents stated there were long waits for call lights showers were not given, not gotten out of bed and dressed until late morning, long waits to return to bed, and not enough staff to provide care. This is evidenced by: The facility's staffing policy revised on 11/2023, documented staffing numbers and skills requirements of direct care staff were determined by the needs of the resident's care plan. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on one (1) of 2 units. Specifically, the facility nurse call system did not function in resident room #s 5, 7, and 11 on the North Unit. This is evidenced by: During observations on 2/08/2024 at 9:33 AM, the call bell did not activate when tested in resident room # 5 for beds A and B. Additionally, room [ROOM NUMBER] was utilizing tap bells and did not have nurse cords to activate the nurse call system. room [ROOM NUMBER] was utilizing a tap bell and did not have a nurse call cord to activate the nurse call system. [...]

Inspectors wroteBased on record review and interviews during recertification and abbreviated survey (Case #NY00322407) from 2/05/2024 to 2/12/2024, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source, were immediately reported to the State Agency for 1 (Resident #51) of 3 residents reviewed for abuse. Specifically, the facility did not report the allegations of abuse involving Resident #51 to the New York State Department of Health after becoming aware of the allegations on 8/09/2023 at 7:20 AM. This is evidenced by: Resident #51 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis with unspecified peripheral vascular disease, type II Diabetes, and vascular Dementia with other behavioral disturbances. [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure the development of comprehensive person-centered care plans - that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs - as identified in the comprehensive assessment for 2 (Resident #s 14 and 327) of 27 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #327, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; and (2) for Resident #14, the facility did not ensure a comprehensive care plan was developed to address the resident's dental care. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey from 2/05/2024 to 2/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 3 (Resident #s 2, 32 and 327) of 27 residents reviewed for Activities of Daily Living. Specifically, (A) Resident #'s 2 and 32 were not provided assistance with personal hygiene during morning care; (B) Resident #32 did not have a clean change of clothing and Resident # 2 was not provided sufficient extra-large incontinence briefs; (C) Resident #327 was not provided their weekly shower. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00294027), the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #4) of 4 residents reviewed. Specifically, for Resident #4 who was care planned for floor mats next to bed when in bed, floor mats were not placed when the resident fell from the bed, resulting in a fall with fractures of the 8th and 9th right ribs. This was evidenced by: The facility policy Falls Management and Prevention, revised 01/2021, documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey, the facility did not ensure each resident was treated with respect and dignity and each resident was cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 2 (North Unit and South Unit) of 2 units and 2 (Resident #s 50 and 32) of 4 residents reviewed for dignity. Specifically, in a Resident Council Meeting held on 10/22/2021, residents stated incontinence care was not provided timely, call bells were not answered timely, and staff were rude and lacked compassion. For Resident #50, staff used inappropriate language in their presence, and staff turned off their call bell without addressing their needs. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, the facility did not ensure the views of a resident group were promptly acted upon and the recommendations of such groups that concerned issues of resident care and life in the facility. Specifically, the facility did not ensure concerns voiced during Resident Council Meetings were promptly acted upon and did not ensure the Resident Council was provided with facility responses, actions, and rationale regarding their concerns. This is evidenced by: A review of Resident Council Minutes documented: -7/19/2021- documented a concern related to wandering residents and a question asking when podiatry would be coming. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, door frames and baseboards were not clean and in good repair on 2 of 2 resident units. This is evidenced as follows. A selection of rooms were inspected on 10/26/2021 at 9:15 AM revealing that the paint on the door frames of resident rooms 1, 3, 6, 11, 12, 13, 17, 23, 24, 26, 31, 34, 37, 39, and 41 were heavily chipped, and the baseboards in resident rooms 6, 18, 36, and 37 were covered in a brownish debris. During an interview on 10/25/2021 at 1:00 PM, the Director of Maintenance and the Environmental Services Manager stated the facility would repaint the door frames and clean the baseboards in the resident rooms. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey and abbreviated survey (Case #NY00279792) the facility did not ensure baseline care plans were developed within 48 hours of a resident's admission and provided to the resident and their representative with a summary of the baseline care plan for 4 (Resident #s 22, 25, 67 and 175) of 17 residents reviewed. Specifically, for Resident #32, the facility did not ensure a baseline care plan was completed, for Resident #175, the facility did not ensure that the baseline care plan was fully completed and did not ensure the resident or representative were provided with the baseline care plan. For Resident #25 and #67, the facility did not ensure the baseline care plan was reviewed with, and a copy provided to, the resident and/or their representative. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated survey (Case #s NY00283415 and NY00285016) the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs for 8 (Resident #'s 14, 17, 27, 30, 32, 67, 74, and 225) of 33 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #14, the facility did not ensure the CCP for Activities of Daily Living (ADLs) addressed the resident's ambulation status; for Resident #17, did not ensure a care plan was developed to address the resident's bowel and bladder incontinence; for Resident #27 did not ensure a CCP was developed to address the diagnosis of anxiety; [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the Monthly Medication Regimen Review (MRR) that included timeframe's for the different steps in the process. Specifically, the facility did not ensure there were timeframe's established and documented in the policy for steps in the MRR process concerning actions the physician needed to take when an irregularity was identified. This is evidenced by: The Policy and Procedure (P&P) titled Medication Regimen Review (MRR) dated 3/2020, documented the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that it's medication error rate did not exceed 5% of greater for 3 (Resident #s 13, 29 and 62) of 4 residents reviewed for medication errors. Specifically, during an observed medication pass the facility did not adhere to provider orders during 8 of 26 total opportunities, resulting in a final medication error rate of 30.77%. This was evidenced by: The facility policy titled Medication Administration last revised 12/2019 documented medications must be administered in accordance with the orders, including any required timeframe. Vital signs, if necessary, must be checked/verified for each resident prior to administering medications. Medications must be administered within one hour of their prescribed time, unless otherwise specified. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and abbreviated survey (Case #s NY00279792 and NY00280289), the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 4 (Resident #'s 17, 67, 175 and #177) of 19 residents reviewed. Specifically, for Resident #17, the facility did not ensure Certified Nurse Aide (CNA) documentation for Bladder/Bowel incontinence was complete, for Resident #67, the facility did not ensure documentation in the resident record accurately reflected the provision of wound care or when oxygen was administered, for Resident #67, the facility did not ensure daily CNA documentation of Activities of Daily Living (ADL) care was complete and accurate. [...]

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 1 (Resident #67) of 1 resident reviewed. Specifically, for Resident #67, the facility did not ensure a physician's order for the prescribed flow rate for oxygen administration was followed. This is evidenced by: Resident #67: The resident was admitted to the facility with the diagnoses of congestive heart failure (CHF), atrial fibrillation and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 9/14/2021, documented the resident was cognitively intact, could understand others and could make self understood. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #17) of 3 residents reviewed for laboratory services. Specifically, for Resident #17, the facility did not ensure a physician ordered urinalysis (UA- a test of the urine used to detect and manage a wide range of disorders, such as urinary tract infections) and Culture and Sensitivity (CS- a laboratory test to detect and identify bacteria and yeast in the urine, which may be causing a urinary tract infection) dated 9/19/2021 was obtained. This was evidenced by: Resident #17: Resident #17 was admitted to the facility with the diagnoses of seizures, stroke, and hydrocephalus. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Resident #'s 12, 23, 52, 54, 58, 59, 63, 66, and #67) of 18 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #12, the facility did not ensure that the CCP for Psychotropic Medications and Behaviors included person centered interventions; for Resident #23, the CCP for Cognitive Loss and Mood did not include resident centered interventions; [...]

Inspectors wroteBased on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure that the minimum staffing levels for Certified Nursing Assistants (CNA) was met on 14 out of 14 calendar days from 1/25/20 to 2/7/20; that each resident received care for their incontinence during the night shift and specifically, for Resident #4, that the resident received incontinence care from 7:00 PM on 2/5/20 to 10:30 AM on 2/6/20; [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies, intolerances, and preferences, and appealing options of similar nutritive value to residents who choose not to eat food that was initially served or who requested a different meal choice for 2 (Resident #54 and #227) of 3 resident's reviewed for nutrition. Specifically, for Resident #54, the facility did not ensure the resident's food preferences were printed on the resident's meal ticket and did not ensure the resident was offered an option of similar nutritive value when he/she declined the main meal provided; for Resident # 227, the resident's food preferences provided at meals were not consistent with the resident's printed meal tickets. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure a nourishing bedtime snack was provided when there was a greater than 14-hour time span between the evening meal and breakfast. This was evidenced by: The Policy and Procedure titled Nourishments- Supplements- Snacks, last revised 3/2019, documented residents may request a snack at any time, however nursing personnel would offer at least a bedtime snack to residents. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition and shall protect the integrity of the contents so food is not exposed to adulteration or potential contaminants, paper towels must be supplied at handwashing stations, and non-food surfaces are to be kept clean. Specifically, cans of food were dented, paper towels were missing from the handwashing station, and the shelves and walls in the walk-in cooler were not clean. This is evidenced as follows. The main kitchen was inspected on 02/06/2020 at 8:45 AM. One can of sweet potatoes and one can of cranberry sauce found in the common stock had dents on the hermetic seals. [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey the facility did not ensure Medical Records were maintained in accordance with accepted professional standards and practices that were complete, accurately documented, readily accessible and systematically organized for 6 (Resident #'s 4, 7, 23, 54, 66, and #227) of 18 residents reviewed. Specifically, for Resident #'s 4 & 23 the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care; for Resident #7, who received dialysis, the facility did not ensure the resident's fistula (a connection located under the skin and used during dialysis to access the bloodstream) site was monitored daily per the physician's order for signs and symptoms of infection/inflammation/bleeding and for the presence of bruits/thrills; [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, for one (Resident #63) of one resident reviewed for a dressing change, the facility did not ensure gloves were changed when contaminated, handwashing was performed between glove changes and supplies were not removed from the resident's room during a dressing change to an unstageable pressure ulcer of the right heel; the facility did not ensure face masks were properly worn by two employees while in resident areas. [...]

Inspectors wroteBased on observation, record review and staff interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #66) of 1 resident reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #66, the facility did not ensure the directions documented on the care card ensured the resident, who could not carry out activities of daily living independently, had her hair washed weekly to maintain good personal hygiene. This is evidenced by: Resident #66: The resident was admitted to the facility with the diagnoses of necrotizing fasciitis, diabetes and heart failure. The Minimum Data Set (MDS - an assessment tool) dated 1/10/20, documented the resident was cognitively intact, could understand others and could make self understood. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not ensure the director of nursing served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing served as a charge nurse when there were 77 residents residing on 2 units (North Unit and South Unit). This was evidenced by: Upon entrance to the facility on 2/6/20 at 8:30 AM, there were 77 residents residing on 2 units (North Unit and South Unit). During the Survey Entrance Conference on 02/06/20 at 08:41 AM, the facility Assistant Administrator stated that Registered Nurse #2 was the Director of Nursing (DON) for the facility and the Registered Nurse Manager (RNM) for the North Unit. [...]

Inspectors wroteBased on observations, interviews and record reviews during a recertification survey, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principals for 1 (Resident #1) of 6 residents reviewed for medication administration. Specifically, for Resident #1, the facility did not ensure that the resident's narcotic record for pregabalin (Lyrica) (a controlled substance used for pain) documented the current physicians order. This is evidenced by: A policy titled Medication-Narcotic Management with a last revised date of 4/2019 documented that the information required on the bound narcotic book included resident name, the name of the medication, and the directions for administration. A policy titled Medication Administration with a last revised date of 12/2019 documented: [...]