Troy Victorian Rehabilitation & Nursing Care Cntr

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (2) of three (3) residents (Residents #1 and #6) reviewed. Specifically, Resident #1 was not assisted with their meals as planned, had significant weight loss, their nutritional needs were not reassessed, weights were not obtained as ordered, and there was no documented evidence a medical provider addressed the resident's weight loss; and Resident #6 had was not assisted as their meals as planned and had significant weight loss.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) for four (4) of nine (9) residents (Residents #2, #47, #97, and #119) reviewed. Specifically, Resident #2's 11:30 AM dose of Renvela (used to lower blood phosphorus levels and taken with meals) was not regularly administered and there was no documented evidence the physician was notified of the missed doses, and no documented evidence the pharmacist reviewed the missed doses during their monthly medication reviews; and Residents #47, #97, and #119 were not provided their carbidopa-levodopa (used to treat Parkinson's disease-a progressive neurological disorder) timely; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen and one (1) of two (2) kitchenettes (2nd Floor kitchenette). Specifically, in the main kitchen food was not labelled, the walk-cooler floor was unclean with food debris, the walk-in freezer floor was unclean with food debris on the floor and reach in cooler wire racks were sticky and had a pink substance on them; and the 2nd floor kitchenette was unclean.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for two (2) of two (2) residents (Residents #1 and #132) reviewed. Specifically, Residents #1 and #132 had bright colored signage hung prominently in their room that disclosed personal information regarding the resident's care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #47) reviewed. Specifically, Resident #47 had one (1) plastic bottle of over-the-counter calcium carbonate (antiacid medication), an inhaler (for lung disease), and a medication cup with several unidentified pills on their nightstand. There was no documented evidence of assessments and/or physician orders for the resident to safely self-administer medications.

Inspectors wroteBased on observations, record review, and interviews (iQIES intake 2626678) the facility failed to ensure a clean, comfortable, and homelike environment for two (2) of five (5) resident halls (South Wing and [NAME] Wing halls) and the Second Floor common area. Specifically, the South Wing and [NAME] Wing resident halls and the Second Floor common area had unclean floors.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #97) reviewed. Specifically, Resident #97 did not have their fall mat (a cushioned floor mat placed next to the bed) in place while in bed as planned.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure services provided met professional standards of clinical practice for two (2) of six (6) residents (Residents #2 and #5) reviewed. Specifically, Resident #2 had multiple medications not documented as administered; and Resident #5 had multiple medications not documented as administered and units of insulin administered per sliding scale coverage were not consistently documented.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intakes 2626678, 2727573, and 2970379) the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (1) of six (6) residents (Resident #9) reviewed. Specifically Resident #9 did not receive showers as planned.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #19) reviewed. Specifically, Resident #19 had leg wounds, and their dressings were not changed as ordered or as scheduled.

Inspectors wroteBased on observations, record review, and interviews (iQIES intake 2727573), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of one (1) resident (Resident #17) reviewed. Specifically, Resident #16 had an existing Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum (large bone at the base of the spine) and treatments were not administered as ordered and the wound was not monitored consistently.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure that each resident received adequate supervision to prevent accidents for four (4) of six (6) residents (Residents #1, #6, #115, and #119) reviewed. Specifically, Residents #1 and #6, were at risk for aspiration (inhaling food or liquids into the lungs) and were not supervised or monitored when eating; Residents #115 and #119 had mattresses that were not adequately fitted to the bed frame and their beds tilted laterally causing a downward slope; and Resident #119 had a loose enabler bar on their bed.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide the necessary care and services to prevent urinary tract infections, to the extent possible, for one (1) of one (1) resident (Resident #26) reviewed. Specifically, Resident #26 had an indwelling urinary catheter (a tube that removes urine from the bladder), wore a urinary collection leg bag (a small, wearable, and discreet bag) and was not provided with a large capacity urinary collection bag. The urinary collection leg bag was not positioned below the level of the bladder to prevent backward urine flow.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #2) reviewed. Specifically, Resident #2 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments; there was no documented evidence the resident's dialysis access site was routinely assessed; and the resident did not receive a bagged lunch for missed meal during their dialysis treatment.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of five (5) residents (Resident #12 and #101) reviewed and for legionella (a bacteria causing Legionnaires' disease-a respiratory disease) testing. Specifically, Residents #12's and #101's transmission-based precaution orders were not followed; and the facility did not perform legionella testing as required based on positivity rate and a legionella positivity rate greater than 30% was not reported to the Department of Health as required.

Inspectors wroteBased on record review and interviews, the facility failed to 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 facility did not provide the Medicare/Medicaid Application (CMS-671), Civil Rights Questionnaire (DOH-1506), Facility Assessment, Equipment Inventory Form, Legionella policies and procedures, menus for the duration of the survey, admission packet, and documentation of the Infection Preventionist's specialized training in infection prevention and control in a timely manner as required.

Inspectors wroteBased on record reviews and interviews during survey, the facility failed to ensure residents at risk of elopement remained under supervision for two (2) (Resident's #5 and #9) of four (4) residents reviewed for elopement risk. Specifically, (a.) Resident #5 left the faciity on [DATE] without the facility's knowledge and was not located until hours later; and (b.) Resident #9 was able to exit the facility on 11/16/2025 and was located shortly after on facility grounds. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #5's health and safety, and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy for Resident #9. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that alleged violations involving elopement were reported immediately, but not less than two hours later to the State Survey Agency for one (Resident #5) of two residents reviewed for elopement. Specifically, the facility was unable to locate Resident #5 until Health Care Proxy #1 informed the facility that Resident #5 had left the facility and was in a local hospital emergency department. The incident was not reported to the New York State Department of Health. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that comprehensive care plan interventions were implemented, for 2 (two) (Resident #5 and Resident #9) of 18 residents reviewed for care plans. Specifically, Resident #5 and Resident #9 were not adequately supervised as per their care plans resulting in elopement. Cross reference F689 This is evidenced by:Care Plan Policy and Procedure dated 06/20/2025 documented:INTENT: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. PROCEDURE: 1. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #s NY00344251 and NY00355131), the facility did not ensure residents were free from abuse and neglect for three (3) (Resident #s 48, 78, and 416) of nine (9) residents reviewed. Specifically, (a.) Resident #416, who was a two (2)-person maximum assist with mechanical lift for transfers, was transferred by two (2) Certified Nurse Aides via stand pivot on 6/04/2024. Resident #416 was reportedly lowered to the floor during the transfer from chair to bed and later that evening diagnosed with a left femur (leg bone) fracture. (b.) Resident #48, who was known to have aggressive behaviors, struck Resident #78 on their eye while grabbing a personal item from Resident #78 on 9/22/2024. This resulted in actual harm for Resident #416 that was not Immediate Jeopardy. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00353853, NY00355929, NY00356190, and NY00357360), the facility did not provide effective housekeeping and maintenance services on two (2) of two (2) resident units. Specifically, floors, walls, ceilings and tables were not clean or maintained. This is evidenced by: During observations on 5/05/2024 at 10:00 AM, the second-floor unit corridor floors were sticky when walked upon. During observations on 5/06/2025 from 10:17 AM through 1:49 PM: 1) The floors in the following areas were soiled with dirt or grime next to walls and/or in corners: 1a- Resident room #s 171, 173, 175, 177, 180, 189, 191, 199, 201, 203, 220, 305, 326, 328, 334, 338, 340, 342, 344, 346, 348, 402, 404, 406, 408, 410, 422, 418, 416, 414, 424, 426, 428, 430, 434, 436, 438, and 440. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and abbreviated survey (case # ' s NY00362000 and NY00379563), the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 16 (Residents #s 6, 10, 13, 28, 31, 37, 52, 61, 70, 72, 86, 103, 107, 262, 413, and 415) of 32 residents reviewed for Care Plans. Specifically, (a.) Resident #6 ' s, care plan did not address foot care; (b.) Resident #13 ' s care plan did not include person centered interventions for behavior and diabetes mellitus management; [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case # ' s NY00371796, NY00358669, NY00357360, NY00363370, NY00371256, NY00353853, NY00347329 and NY00378103), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents stated they were not assisted with care when requested; staff stated they were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed; and an analysis of the actual staffing schedule showed that on multiple occasions from 3/01/2025 to 4/28/2025, the facility did not ensure minimum staffing levels were met based on the facility assessment. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, timeframes for the different steps in the process. Additionally, the drug regimen of each resident was not reviewed at least once a month by a licensed pharmacist. Specifically, the facility policy titled, Medication Regimen Review, did not identify time frames for steps in the medication review process. Additionally, there was no documented evidence of a pharmacist's review of the medication regimens for January, February, and March of 2025, affecting all residents. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5 percent for one (1) (Resident # 6) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 36 percent. This is evidenced by: The facility ' s Policy and Procedure titled, Administering medications, effective 3/13/2024, documented medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification and abbreviated survey (Case #'s NY00344251, NY00348580, NY355929, NY00347329 and NY00371796), the facility failed to ensure residents were free of significant medication errors for six (6) (Resident #s 10, 70, 82, 86, 107 and 416) of six (6) residents reviewed for medication administration. Specifically, (a.) Residents #s 10 and 70 had orders for antibiotic eye ointment that were not administered as ordered. (b.) Resident #82 had an order for narcotic pain medication that was not administered as ordered. (c.) Residents #s 86 and 107 had orders for antibiotics that were not administered as ordered. (d) Resident #416 was given medication that was not ordered for them. This is evidenced by: [...]

Inspectors wroteRegulation §483.45(h)(2): The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) Medication Rooms (2nd floor); and for two (2) of three (3) medication carts (first floor unit 100 and second floor unit 300) reviewed. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey and abbreviated survey (Case #NY00373240), the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for five (5) (Resident #'s 4, 8, 22, 61, and 265) of 32 residents reviewed. Specifically, (a) Resident #'s 4, 8, and 22 who resided on the same nursing unit, expressed feeling degraded when they would ask for help; [...]

Inspectors wroteBased on record review and interview conducted during the Recertification and Complaint Survey (NY00355131 and NY00349007), the facility did not report the results of all investigations to the administrator or 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. This was evident in three (3) (Resident #48, #78 and 416) out of seven (7) residents reviewed for abuse and neglect. Specifically, Resident #48 struck Resident #78 in the face while grabbing a personal item from Resident #78. Resident #416 ' s transfer status was two-person maximum mechanical lift; two Certified Nurse Aides transferred resident via stand pivot on 6/03/2024. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during a recertification and abbreviated survey (Case #NY00377938), the facility did not ensure that Comprehensive Care Plans were reviewed after each assessment and revised based on the changing goals, preferences, and needs of the resident and in response to current interventions for four (4) (Residents # ' s 13, 37, 97, and 415) of 32 residents reviewed. Specifically, (a) for Resident #13, the resident ' s allergy care plan was not updated to reflect the resident ' s current medication allergies; (b) for Resident #37, the resident ' s comprehensive care plan was not updated to reflect the resident's safety concerns regarding other residents entering their room; (c) for Resident #97, there was no care plan meeting held to review and revise the comprehensive care plan with the resident/resident ' s representative; [...]

Inspectors wroteBased on record review and interview during a recertification and abbreviated survey (Case # ' s NY00348580; NY00355929; NY00348873; NY00351874 and NY00347329), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #s 6, 28, 61, and 262) of 32 residents reviewed. Specifically, (a.) Resident #61 was noted by nursing staff on 2/19/2025 to have signs and symptoms of cellulitis (bacterial skin infection) on the left leg. The facility did not have evidence of monitoring of the resident ' s condition from 2/20/2025 to 3/3/2025; there was no order for periodic skin checks. The resident was not seen by the provider until 3/04/2025 and was diagnosed and treated for cellulitis of the left leg. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) the facility did not document receipt of Oxycodone (narcotic pain medication) by the pharmacy for Resident #82, and (b.) did not document nursing unit narcotics as having been counted by two licensed staff members and signed as appropriate on the facility-provided narcotic record sheets for two (2) of two (2) nursing units. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) (First Floor Unit and Second Floor Unit) of two (2) kitchenettes. Specifically, the dishwashing machine final rinse water pressure was too low, equipment was not in good repair, and surfaces were not clean. This is evidenced by: During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM: • The water pressure during the final rinse of the automatic dishwashing machine was zero pounds per square inch; the dishwashing machine data plate stated that the water pressure was to be between 15 and 25 pounds per square inch. [...]

Inspectors wroteBased on observation and interviews conducted during a Recertification Survey, handrails were not maintained on two (2) of two (2) resident units. Specifically, handrails had broken plastic and missing pieces exposing sharp edges. This is evidenced by: During observations on 04/29/2025 at 7:51 PM through 8:58 PM: • The Second Floor Unit south corridor handrail had a six (6)-inch section of broken plastic with sharp edges. • The Second Floor Unit Elevator one (1) corner guard had broken plastic with sharp edges. • The First Floor Unit handrail had six (6) areas where the edge turn pieces missing exposing sharp edges. During an interview on 5/07/2025 at 3:03 PM, Director of Maintenance #1 stated that they would repair the broken plastic and install the missing pieces on the handrails. 10 New York Codes, Rules, and Regulations 713-1.8(a)

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00354621, NY00355929, NY00356190, and NY00357360), the facility did not maintain a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas. This is evidenced by: During observations on 4/29/2025 at 8:45 PM, a resident was heard yelling, ' There is a bee in my room, ' and a wasp was found flying in resident room [ROOM NUMBER]. Director of Maintenance #1 immediately found and killed the wasp. During observations on 5/05/2025 at 1:55 PM, gnat-like flies were found in the conference room. [...]

Inspectors wroteBased on record review and interviews conducted during a recertification and abbreviated survey (Case #NY00371796), the facility did not ensure it consulted with the resident ' s physician and notified the resident ' s representative when there was a significant change in the resident ' s physical status for two (2) (Resident #s 61 and 10) of two (2) residents reviewed. Specifically, (a) the facility did not immediately notify the provider on 2/19/2025, when Resident #61 developed new wounds on the left leg. The changes in the resident ' s condition were documented in the Nurse Practitioner communication book and were not reported to the provider until 3/04/2025; [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure the facility conducted initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity and completed not less than once every 12 months for two (2) (Resident #s 28 and 415) of 32 residents reviewed for Comprehensive Resident Assessments. Specifically, (a) for Resident # 28, the Comprehensive Resident Assessments were not completed to assess the patient's edema, and (b) for Resident #415, the Comprehensive Resident Assessments were not completed to assess items from their baseline care plan. This is evidenced by: Cross reference to F656: [...]

Inspectors wroteBased on a record review and staff interviews conducted during a recertification survey, the facility did not ensure that Preadmission Screening was complete for two (2) (Resident #s 31 and 103) of the 32 residents reviewed. Specifically, an accurate Preadmission, Screening and Resident Review (PASARR) was not completed or corrected. This is evidenced by: The Policy and Procedure for admission Screening and Approval Process for Long Term Care (New York State) documented the admission process to the facility from a hospital or other health facility. A qualified Registered Professional Nurse assessor must complete a Patient Review Instrument, and the Preadmission Screening must be completed and signed by a qualified assessor. [...]

Inspectors wroteThe facility policy and procedure titled, Pressure Ulcer Prevention, dated 3/01/2024, documented it was the policy of the facility to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation included reviewing the resident ' s care plan and identifying risk factors as well as interventions designed to reduce or eliminate those considered modifiable. Inspect the skin daily when performing or assisting with personal care or activities of daily living. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. [...]

Inspectors wroteBased on observations and interviews during a recertification survey the facility did not ensure food and drink were palatable and attractive for two of two units test trays and one (1) (Resident #61) of one (1) resident reviewed for palatable and appealing food and drink. Specifically, (a) resident #61 complained that the food was usually inedible, often unidentifiable, and not what was on the meal ticket. (b) Test trays on two (2) of two (2) units were identified by surveyors as unpalatable. This is evidenced by: The Minimum Data Set, dated [DATE], documented the Resident #61 was cognitively intact, was able to make themselves understood and understood others. During an interview on 4/30/2025 at 12:28 PM, Resident #61 stated the quality of the food was not good. They stated they were served a mystery meat patty covered with gravy and vegetables are overcooked. [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was not closed, and garbage littered the area. This is evidenced by: During observations on 4/29/2025 at 7:03 PM, the side door of the garbage dumpster was not closed, and garbage littered the area around the dumpster and side of the parking lot. During an interview on 4/29/2025 at 7:30 PM, Food Service Director #1 stated that they would re-educate staff to keep the dumpster doors closed and would speak with the maintenance and housekeeping departments regarding picking up the litter. 10 New York Codes, Rules, and Regulations 415.14(h)

Inspectors wroteBased on observation and interview conducted during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. Specifically, carbon monoxide detection was not installed in main kitchen by gas fuel fired equipment (e.g., stove). This is evidenced by: During observations in the main kitchen on 4/29/2025 at 6:26 PM, a carbon monoxide detector was found on the shelf below the steamtable and not installed as required in the stove area. During an interview on 5/07/2025 at 3:14 PM, Director of Maintenance #1 stated that they would consult with corporate maintenance and reinstall the carbon monoxide detector. 10 New York Codes, Rules, and Regulations 400.2 2015 International Fire Code, Section 915

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure resident medical records contained an accurate representation of the actual experiences of the resident and included enough information to provide a picture of the resident ' s progress, including their response to treatments and services, and changes on their condition, plan of care, objectives, and/or interventions. Specifically, (a.) for Resident #61, the facility did not ensure Daily Medicare Notes accurately documented the resident ' s wounds and, (b.) for Resident #s 70 and 86, the facility did not ensure documentation of the residents ' condition that required antibiotic treatment. This is evidenced by: Resident #61: [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during a recertification survey, the facility did not ensure an infection control program was implemented to prevent the transmission of communicable diseases to residents. Specifically, (a.) for Resident #64, enhanced barrier precautions were not implemented for the resident who had an indwelling catheter; (b.) for Resident #97, the resident's nebulizer equipment was not stored to prevent contamination of the equipment. This is evidenced by: Resident #64 Resident #64 was admitted to the facility with the diagnoses of polyneuropathy (peripheral nervous system disorders that impact nerve function), chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), and type 2 diabetes mellitus. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case #NY00354621), 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 two (2) of two (2) units. Specifically, the facility nurse call system did not function in resident room #s 203 and 320. This is evidenced by: During observations on 4/29/2025 at 8:03 PM, the call bell device in the resident room [ROOM NUMBER] bathroom was missing from the mounting hardware and the wires were hanging out of the mounting hardware. During an observation on 05/06/2025 at 1:02 PM, the call bell device was hanging by wires and not mounted to wall in resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building, and grounds were not clean and maintained. This is evidenced by: During observations on 5/05/2025 from 12:04 PM through 12:31 PM: Sections of the lower portion of the building façade was covered with moss and algae. Piles of old construction materials and accumulations of leaves and litter were found on the grounds along the building. The garbage dumpsters were not seated in the designated fenced area; vegetation was encroaching on the fencing. [...]

Inspectors wroteBased on observation and interviews conducted during the recertification, the facility did not ensure adequate ventilation of one (1) (second floor) of (2) resident units. Specifically, the Second Floor Unit Soiled Holding Room and shower room were not adequately ventilated. This is evidenced by: During observations on 4/29/2025 at 8:47 PM, unpleasant odors were found in the Second Floor Unit Soiled Holding Room and a heavy must odor was found in the Second Floor Unit shower room. During an interview on 5/07/2025 at 3:10 PM, Director of Maintenance #1 stated that the motors servicing the ventilation system for the Second Floor Unit Soiled Holding Room and the Second Floor Unit shower room were not powerful enough to remove the odors and required replacement. 10 New York Codes, Rules and Regulations 483.90(i)(2)

Inspectors wroteBased on observations, record review, and staff interviews during an abbreviated survey (Case #'s NY00364049 and NY00364977), the facility did not ensure the environment remained free of accident for 1 (Resident #1) of 1 reviewed for accident hazards. Specifically, for Resident #1, who had Nothing by Mouth (NPO) diet order was due to high risk for aspiration pneumonia was fed pizza. This is evidenced by: Policy and Procedure for nutrition and diet dated 12/13/2024, documented residents who are designated as nothing by mouth (NPO) need to be closely monitored to ensure no access to food is allowed. Resident #1 entered on 11/04/2024 with diagnoses of Cerebral Palsy, Parkinson ' s Disease, and developmental disabilities. [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00348162 and NY00348192), the facility did not ensure the provision of sufficient nursing staff 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's staffing minimum staffing levels were not met each day from 7/01/2024 through 7/16/2024 per facility assessment. This is evidenced by: Upon entrance to the facility on 7/16/2024 there were 113 residents residing on 2 units. The Facility Assessment conducted on 5/14/2024 documented, the facility's staffing plan for direct residential care. The assessment documented that they were to have at a minimum for Licensed Practical Nurses and Certified Nurse Aides for the day, evening, and night shifts. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during an Abbreviated survey (Case # NY00345181), the facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement. Specifically, on 6/11/2024, Resident #1 was observed leaving the facility through the front entrance. The facility did not put any measures in place to prevent further elopements. Subsequently, on 6/14/2024, Resident #1 was observed in the parking lot by facility staff and was brought back into the facility. On 6/14/2024 an electronic monitoring device was placed on the resident; however, the facility did not implement a system to monitor the resident for elopement or for the placement of the electronic monitoring device. [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated Survey (Case #NY00345181), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #1) of 1 resident reviewed for abuse and neglect. Specifically, the facility did not ensure supervision and oversight was provided following an attempted elopement on 6/11/2024. This resulted in an actual elopement on 6/14/2024. This is evidenced by: The Policy and Procedure titled, Elopement, effective 4/01/2024, documented it was the responsibility of all personnel to report any resident attempting to leave the premises to the Unit Manager and/or Charge Nurse immediately. The Policy and Procedure titled, Wander Guard, effective 4/1/2024, documented any resident with a new elopement attempt was to have an electronic monitoring device applied and care plan updates immediately. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00345181), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #1) of 1 resident reviewed [...]

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint NY00334205), the facility did not ensure residents were free from physical abuse for two (Residents #8 and 9) of three residents reviewed. Specifically, the facility did not implement interventions following resident-to-resident abuse (Resident #8, 9) incidents on 12/18/2023 and 2/06/2024 resulting in third incident on 2/23/2024.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the abbreviated survey (Case #NY00333272), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #7) of 9 residents reviewed. Specifically, the facility did not ensure that Resident #7's property was secured in a locked drawer. This is evidenced by: Resident #7 Resident #7 was admitted to the facility with the diagnoses of Guillain-Barre syndrome (a rare disorder of the immune system), chronic kidney disease and type 2 diabetes. The Minimum Data Set (an assessment tool) dated 2/9/2024 documented the resident was able to be understood and was able to understand others. The Brief Interview for Mental Status documented a score of 12/15, significant for a moderate cognitive impairment. [...]

Inspectors wroteBased on observation, record review and interviews during the abbreviated survey (NY00332433), the facility did not ensure care plans were reviewed and revised in a timely manner for 1 (Resident #6) of 9 residents reviewed for Comprehensive Care Plans. Specifically, for Resident #6's Comprehensive Care Plan for at risk for falls was not reviewed and revised after a fall in which the intervention of a floor mat was added on the Accident and Incident report. This is evidenced by: Resident #6 Resident #6 was admitted with the diagnoses of aftercare following joint replacement surgery, muscle weakness, and dysphagia (difficulty swallowing). The Minimum Data Set (an assessment tool) dated 1/17/2024 documented the resident was able to be understood and was able to understand others. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00322286), the facility did not ensure - in accordance with accepted professional standards and practices - it maintained medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #8) of 4 residents reviewed. Specifically, for Resident #8, the facility (1) did not document observations made during suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) care; (2) did not document an evaluation of the resident's condition on 9/18/2023 in the nursing progress notes when on 9/18/2023, the resident was admitted to the hospital with diagnoses of suprapubic catheter obstruction and complicated urinary tract infection, and did not document that the physician was notified; [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00307000), the facility did not ensure it treated each resident with respect, dignity, and care for 1 (Resident #3) of 7 residents reviewed. Specifically, Resident #3 received undignified statements about them and their care needs by Certified Nurse Aide #2 on 12/14/2022. Director of Nursing #2 saw the resident following the incident and documented the resident presented with weepiness, sadness, and embarrassment. This is evidenced by: Resident #3: Resident #3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, depression, and pain in left lower leg. The Minimum Data Set (an assessment tool) dated 12/19/2022 documented the resident with a Brief Interview of Mental Status score was cognitively intact. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00297444), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #6) of 7 residents reviewed. Specifically, the facility did not ensure that an allegation of physical abuse reported by Resident #6 on 6/12/2022 at 9:45 AM was reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 6/13/2022 at 11:47 AM. This is evidenced by: Refer to F610 Resident #6: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00297444), the facility did not ensure that in response to an allegation of abuse, that it had evidence that all alleged violations were thoroughly investigated for 1 (Resident #6) of 7 residents reviewed. Specifically, the facility did not maintain documentation that an allegation of physical abuse reported by Resident #6 on 6/12/2022 was thoroughly investigated. This is evidenced by: Resident #6: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00322286), the facility did not ensure that a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1 (Resident #8) of 4 residents reviewed. Specifically, Resident #8 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) and was admitted to the hospital on [DATE] with diagnoses of sepsis, complicated urinary tract infection, and obstruction of suprapubic catheter. During readmission to the facility on [DATE], the facility did not ensure orders were in place for daily care of the suprapubic catheter to prevent infection until [DATE]. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey dated 04/16/23 through 04/20/23, the facility did not provide effective housekeeping services on two (2) of 2 resident units, the lobby, the service corridor to the Beauty Salon, the main kitchen, 2 of 2 kitchenettes, and 2 of 2 elevator cars. Specifically, the ceiling in the main kitchen was soiled with food splatters; the corridor floors were soiled with old wax build-up next to walls and door thresholds in the lobby, on Unit One and Unit Two, and in the service hallway to Beauty Salon; old gum was found in the handrails in elevator car #1 and elevator car #2; the Unit One and Unit Two kitchenette floors were soiled with dirt and food particles; a dried red/brown substance was dripping on the wall next to room [ROOM NUMBER]; dried brown food splatters soiled the corridor floor between room #'s 402 and #404; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented to meet the needs of each resident for 5 (Resident #'s 13, 59, 60, 95, and #109) of 25 residents reviewed for CCP. Specifically, for Resident #13, the facility did not ensure care plans were developed for multiple conditions the resident was currently receiving treatment for (SOB/wheezing, anticoagulation, hyperlipidemia, high blood pressure, constipation, A-fib, and alcohol abuse), and care plans for antidepression medication and depression did not include person-centered interventions; for Resident #59, the facility did not ensure a CCP was developed to address the resident's shortness of breath and wheezing; [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated 4/16/2023 - 4/20/2023, the facility did not ensure policies and procedures were developed and maintained for the monthly Drug Regimen Review (DRR), that included timeframes for the different steps in the process. Specifically, the facility's DRR policy did not include timeframes for steps in the DRR process and steps the pharmacist must take when an irregularity required urgent action. This was evidenced by: The Policy and Procedure (P&P) titled Drug Regimen Reviews, dated 10/24/2022, documented if irregularities were found during the DRR, the consultant pharmacist would provide the administrator with a written, signed, dated copy of the report, listing the irregularities found and their recommendations. [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey, it was determined that the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, for two (Residents #'s 47 and #77) of four residents reviewed for medication administration the facility did not ensure medication was administered within their prescribed time frame as ordered by the physician for 14 of 28 observations of medication administration opportunities with an error rate of 50 percent. This is evidenced by the following: The facility Policy and Procedure (P&P) titled Medication Administration dated 9/15/2022 stated medications must be administered in accordance with the orders, including any required time frame and medications must be administered within one hour of their prescribed time. [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 04/16/23 through 04/20/23, the facility did not dispose of garbage and refuse properly. Specifically, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with plastic and paper waste. This is evidenced as follows: During observations on 04/16/23 at 9:50 AM, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with plastic and paper waste. During interviews on 04/16/23 10:11 AM, the Administrator and Director of Food Service stated that the dumpsters and grounds will be cleaned, and staff will be in-serviced on closing the dumpster door. [...]

Inspectors wroteBased on record review and interviews during a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure the resident and the resident's representative(s) were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and did not send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident # 38) of 1 resident reviewed for hospitalization. Specifically, for Resident #38, the facility did not ensure the resident and the resident's representative were provided with written notification upon the resident's transfer to the hospital on 1/13/2023, 2/12/2023, and 4/9/2023 and did not ensure a copy of the notice was sent to the Ombudsman. This is evidenced by: Resident #38: [...]

Inspectors wroteBased on interviews and record review during the recertification survey on 4/16/2023 to 4/20/2023, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #38) of 1 resident reviewed for hospitalization. Specifically, for Resident #38, the facility did not ensure a written notice of the facility's bed hold policy was provided to the resident and/or their representative upon transfer to the hospital on 1/13/2023, 2/12/2023, and 4/9/2023. This is evidenced by: Resident #38: Resident #38 was admitted with diagnoses of epilepsy, Alzheimer's disease, and Parkinson's disease. [...]

Inspectors wroteBased on interview and record review during a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 25 residents reviewed. Specifically, for Resident #65, the facility did not ensure physician ordered acidophilus (probiotics- bacterium) was available to administer in accordance with the physician order and comprehensive care plan and did not ensure the physician was notified when the acidophilus was not available to administer. This is evidenced by: Resident #65: Resident #65 was admitted with diagnoses of diabetes, atrial fibrillation, and irritable bowel syndrome (IBS) without diarrhea. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #59) of 5 residents reviewed for accidents. Specifically, for Resident #59, the facility did not ensure the resident had a physician order to self-administer medication, a care plan to self-administer medication, or a nursing assessment that documented the resident was able to self-administer medication that was left at bedside. This is evidenced by: Resident #59: Resident #59 was admitted with diagnoses of Schizophrenia, diabetes, and congestive heart failure. The Minimum Data Set (MDS-an assessment tool) dated 1/31/2023 documented the resident was cognitively intact, could understand others and could make themselves understood. [...]