Inspection Reports for
Hudson Valley Rehabilitation & Extended Care Center
260 Vineyard Ave, Highland, NY, 12528
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Deficiencies: 10
Date: Jul 23, 2025
Visit Reason
The survey was conducted as an abbreviated survey focusing on allegations of abuse, seclusion, and compliance with infection control and quality of care standards.
Findings
The facility failed to protect residents from abuse, including unauthorized video recording and posting on social media, and involuntary seclusion. There were deficiencies in timely reporting of abuse incidents to authorities, incomplete investigations, inaccurate resident assessments, medication administration errors, incomplete documentation of bowel movements, and lapses in infection control practices. The Quality Assurance committee did not adequately address or develop corrective plans for these issues.
Deficiencies (10)
F 0550: The facility failed to ensure Resident #5's right to dignity when staff video recorded them washing briefs and posted the video on social media.
F 0600: The facility failed to protect Residents #2 and #5 from abuse; Resident #2 was involuntarily secluded for approximately three hours, and Resident #5 was video recorded and mocked by staff.
F 0603: Resident #2 was involuntarily secluded by staff placing washcloths in the door to prevent exit, resulting in psychosocial harm; no physician order or assessment was documented.
F 0609: The facility failed to timely report abuse allegations involving Residents #2 and #5 to law enforcement; incidents were reported late and not to local authorities.
F 0610: The facility did not thoroughly investigate abuse allegations for Resident #2; no evidence of injury assessment or staff interviews beyond select individuals, and video footage was not retained.
F 0641: Resident #2's quarterly assessment did not document wandering behavior despite care plans indicating such; Resident #4's assessment did not reflect known rejection of care behaviors.
F 0684: Resident #3's wound care treatments were not consistently documented as completed on multiple dates; Resident #6's bowel movement documentation was incomplete with numerous omissions.
F 0760: Resident #3's narcotic pain medication was frequently administered outside the one-hour before or after scheduled times without documented physician notification or progress notes.
F 0867: The Quality Assurance and Performance Improvement committee did not discuss or develop action plans for incidents involving abuse and seclusion of Residents #2 and #5.
F 0880: Staff failed to follow enhanced barrier precautions for Residents #4 and #15; gowns were not worn during care and Resident #15 carried a Foley catheter drainage bag by hand without a leg bag.
Report Facts
Staff in-serviced on revised Abuse Policy: 76
Certified Nurse Aide documentation omissions: 44
Missed wound care treatment dates: 3
Late narcotic medication administrations: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Terminated for posting video of Resident #5 on social media violating abuse policy. | |
| Certified Nurse Aide #7 | Terminated for involuntary seclusion of Resident #2 by barricading door with washcloths. | |
| Director of Nursing | Reviewed abuse video, terminated CNA #3, and acknowledged deficiencies in investigation and reporting. | |
| Administrator | Reviewed abuse video, acknowledged lack of video retention, and quality assurance meeting omissions. | |
| Licensed Practical Nurse #7 | Acknowledged missed wound care documentation for Resident #3. | |
| Certified Nurse Aide #10 | Described bowel movement documentation process and responsibilities. | |
| Licensed Practical Nurse #9 | Admitted late medication administration for Resident #3 due to heavy med pass workload. | |
| Licensed Practical Nurse #8 | Discussed medication administration and pharmacy communication. | |
| Certified Nurse Aide #1 | Did not wear gown while providing care to Resident #4 on enhanced barrier precautions. | |
| Certified Nurse Aide #2 | Did not wear gown while providing care to Resident #4 on enhanced barrier precautions. | |
| Registered Nurse #1 | Acknowledged failure to update enhanced barrier precaution sign for Resident #4's roommate. | |
| Certified Nurse Aide #11 | Observed Resident #15 carrying Foley bag by hand without leg bag. | |
| Staff Educator | Described infection control policies and staff education on enhanced barrier precautions. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Aug 30, 2024
Visit Reason
Complaint survey with 5 health citations related to quality of care, all Level 2 and corrected by October 29, 2024.
Findings
Complaint survey with 5 health citations related to quality of care, all Level 2 and corrected by October 29, 2024.
Deficiencies (5)
Physician visits - review care/notes/order
Qapi prgm/plan, disclosure/good faith attmpt
Residents are free of significant med errors
Services provided meet professional standards
Sufficient nursing staff
Inspection Report
Abbreviated Survey
Census: 91
Capacity: 118
Deficiencies: 5
Date: Aug 30, 2024
Visit Reason
The survey was conducted as an abbreviated survey to assess compliance with medication administration standards and staffing adequacy following complaints and observations of late medication administration.
Complaint Details
The visit was triggered in part by complaints from the Resident Council about late medication administration on 07/20/2024 and 07/21/2024 and feedback from the Bureau of Narcotics regarding medication administration issues. The facility did not conduct thorough investigations or audits prior to surveyor intervention.
Findings
The facility failed to ensure timely administration of medications to residents, with 24 of 40 residents receiving medications late without physician notification. Staffing shortages on the second floor dementia unit contributed to medication delays. The facility also failed to notify physicians of late medication administration and did not adequately monitor or address these issues through their Quality Assurance and Performance Improvement (QAPI) program.
Deficiencies (5)
F0658: The facility did not ensure medication administration adhered to accepted standards, with nurses administering medications late without notifying physicians for 24 of 40 residents reviewed.
F0711: The facility failed to ensure resident physicians comprehensively reviewed care and medication orders, with no documented evidence of physician notification for late medication administration for 24 residents.
F0725: The facility did not provide sufficient nursing staff on the second floor dementia unit, resulting in one nurse passing medications to up to 40 residents and causing medication delays.
F0760: Residents were not free from significant medication errors, with 23 residents receiving late medications including critical drug classes such as antianxiety, anticoagulants, and insulin, without physician notification.
F0865: The facility failed to develop and implement effective QAPI plans to address medication administration deficiencies, despite complaints and documented late medication administration.
Report Facts
Residents reviewed: 40
Residents with late medications: 24
Residents with significant medication delays: 19
Medication doses late for Resident #4: 44
Medication doses late for Resident #14: 24
Medication doses late for Resident #19: 59
Medication doses late for Resident #18: 11
Facility census: 91
Facility total capacity: 118
Residents on second floor dementia unit: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed administering medications late to Resident #26 without notifying physician |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Failed to document resident asleep/refusal and did not communicate medication administration to Licensed Practical Nurse #1 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Assigned to second floor dementia unit, administered medications late to about 40 residents without assistance or physician notification |
| Licensed Practical Nurse #4 | Licensed Practical Nurse and Unit Manager | Administered medications late to Resident #18 and passed meds to 19 residents on second floor without notifying physician |
| Director of Nursing | Director of Nursing | Counseled nurses, acknowledged staffing issues, and responsible for medication administration oversight |
| Medical Director | Medical Director | Monitored residents after late medication administration was reported, stated awareness of time-sensitive medications |
| Administrator | Facility Administrator | Acknowledged staffing challenges and medication administration issues, responsible for QAPI oversight |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
Complaint survey with 1 health citation for free from abuse and neglect, Level 2 and corrected by August 29, 2023.
Findings
Complaint survey with 1 health citation for free from abuse and neglect, Level 2 and corrected by August 29, 2023.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations related to resident abuse and mistreatment following an incident involving Resident #1 on 05/04/2023.
Findings
The facility failed to ensure that Resident #1 was free from verbal abuse during a transfer on 05/04/2023. The investigation substantiated verbal abuse by CNA #1 towards Resident #1, with both parties exchanging curse words during care.
Deficiencies (1)
F 0600: The facility did not protect Resident #1 from verbal abuse during transfer on 05/04/2023. CNA #1 called the resident the devil and told them to shut up, which was substantiated by witness statements and interviews.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse finding towards Resident #1 |
| CNA #2 | Certified Nursing Assistant | Witness and involved in verbal altercation during transfer of Resident #1 |
| Director of Nursing | Director of Nursing | Conducted interviews and documented statements regarding the abuse incident |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Informed about the incident and asked CNAs to stay out of Resident #1's room |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jan 26, 2023
Visit Reason
Complaint survey with 6 health and 8 life safety code citations, all Level 2 and corrected by February or March 2023.
Findings
Complaint survey with 6 health and 8 life safety code citations, all Level 2 and corrected by February or March 2023.
Deficiencies (13)
Develop/implement comprehensive care plan
Drug regimen review, report irregular, act on
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Grievances
Infection prevention & control
Electrical systems - essential electric syste
Emergency lighting
Hvac
Smoke detection
Sprinkler system - installation
Standards of construction for new existing nh
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from January 19 to January 26, 2023, to assess compliance with regulatory requirements for Hudson Valley Rehabilitation & Extended Care Center.
Findings
The facility was found deficient in multiple areas including grievance resolution for missing resident property, inadequate supervision leading to resident accidents, failure to follow up on pharmacist medication review recommendations, improper food storage and temperature logging, and insufficient infection prevention and control practices related to Legionella risk assessment and water system testing.
Deficiencies (5)
F 0585: The facility failed to ensure grievances were resolved timely for a resident's missing shoe and lacked documentation of investigation and resolution.
F 0689: The facility did not provide adequate supervision to prevent accidents, resulting in a resident falling out of bed and inconsistent communication regarding a resident deemed unsafe to smoke.
F 0756: The facility failed to ensure the monthly medication review by the pharmacist was followed up by the attending physician for a resident's unnecessary medication.
F 0812: Food was stored on the floor in the refrigerator, freezer, and storage areas, and unit refrigerator temperature logs were incomplete.
F 0880: The facility did not complete the Legionella Risk Assessment or maintain a water system diagram, and only tested one water source annually for Legionella.
Report Facts
Residents reviewed for personal property: 3
Residents reviewed for accidents: 4
Residents reviewed for unnecessary medications: 5
Dates with incomplete refrigerator temperature logs: 7
Medication administration months reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Named in finding related to inadequate supervision leading to resident fall | |
| Director of Nursing | DON | Interviewed regarding medication review delay and supervision failure |
| Administrator | Interviewed regarding grievance process and supervision failures | |
| Pharmacist | Interviewed regarding medication regimen review recommendation | |
| Director of Recreation | DOR | Interviewed regarding smoker list management |
| Director of Maintenance | DOM | Interviewed regarding Legionella testing and water system assessment |
| Food Service Director | FSD | Interviewed regarding food storage and temperature log deficiencies |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 30, 2022
Visit Reason
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Findings
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 18, 2022
Visit Reason
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Findings
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 7, 2022
Visit Reason
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Findings
Covid-19 survey with 1 health citation for reporting to national health safety network, Level 2, not corrected as of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Feb 27, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including environmental maintenance, resident transfer notifications, timely completion and transmission of resident assessments, care plan implementation for pressure ulcer prevention, proper resident positioning, accident prevention, and compliance with fire safety codes.
Deficiencies (11)
F 0584: The facility did not ensure a safe, clean, and homelike environment due to multiple instances of disrepair in resident rooms including chipped paint, water stains, cracked tiles, and leaking faucets.
F 0623: The facility failed to provide timely written notification to residents, representatives, and the Ombudsman regarding hospital transfers for 1 of 4 residents reviewed.
F 0636: Four of 12 residents did not have required comprehensive Minimum Data Set (MDS) assessments completed within regulatory time frames.
F 0638: Seven of 12 residents did not have required quarterly MDS assessments completed within regulatory time frames.
F 0640: Eleven of 12 residents' MDS assessments were not electronically transmitted to CMS within 14 days of completion as required.
F 0642: Eleven of 12 residents' MDS assessments had completion dates signed by the RN coordinator prior to the actual completion dates, indicating inaccurate documentation.
F 0656: The facility did not implement pressure ulcer prevention interventions, specifically failure to use heel lift booties as ordered for 1 of 5 residents reviewed.
F 0684: The facility failed to provide proper leg rests for positioning for 1 of 6 residents, resulting in legs dangling and discomfort.
F 0686: The facility did not implement pressure ulcer care interventions as ordered, failing to use heel booties for offloading heels for 1 of 5 residents reviewed.
F 0689: The facility did not ensure the call bell was within reach for 1 of 2 residents reviewed, contributing to a fall and injury.
F 0836: The facility was not in compliance with fire safety codes requiring carbon monoxide detectors in the generator room housing a diesel-powered emergency generator.
Report Facts
Residents reviewed for Resident Assessment: 12
Residents with late Comprehensive MDS assessments: 4
Residents with late Quarterly MDS assessments: 7
Residents with late MDS electronic submissions: 11
Residents with inaccurate MDS completion dates: 11
Residents reviewed for pressure ulcers: 5
Residents with pressure ulcer care deficiencies: 1
Residents reviewed for positioning and mobility: 6
Residents with positioning deficiencies: 1
Residents reviewed for accident prevention: 2
Residents with call bell accessibility issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in pressure ulcer prevention deficiency for Resident #71 |
| Registered Nurse-Unit Manager #1 | RN-UM | Named in pressure ulcer prevention and positioning deficiencies |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding faucet leak issue |
| Director of Maintenance | DOM | Interviewed regarding environmental maintenance issues |
| Director of Social Work | DSW | Interviewed regarding hospital transfer notification |
| Director of Nursing | DON | Interviewed regarding MDS assessment completion and transmission |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding faucet repair |
| Registered Nurse Manager #1 | RNM | Interviewed regarding resident positioning and care |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding resident positioning and wheelchair leg rests |
| Unit Manager | Unit Manager | Interviewed regarding call bell accessibility for Resident #81 |
| Director of Facilities | Director of Facilities | Interviewed regarding lack of carbon monoxide detectors in generator room |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 21, 2017
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for the nursing home facility.
Findings
The survey identified multiple deficiencies including failure to inform the physician timely about a resident's medication refusal, failure to respect resident choices regarding assistive devices and room temperature, unsafe food storage and handling practices, and improper labeling of insulin medications.
Deficiencies (4)
F 0157: The facility did not ensure timely communication to the physician about a resident's request to discontinue a stool softener medication, and no assessment was conducted to determine the reason for refusal.
F 0242: The facility did not ensure a resident's preferences for assistive positioning device use and room temperature were considered, compromising the resident's right to make choices.
F 0371: The facility failed to ensure safe food storage and handling; refrigerators on four resident units contained unlabeled, undated, or expired foods, and no temperature monitoring of reheated food was conducted.
F 0431: Multi-dose insulin pens in use on two nursing units were opened and undated, violating accepted professional standards for drug records and labeling.
Report Facts
Residents affected: 1
Residents affected: 1
Resident units with food storage issues: 4
Nursing units with insulin labeling issues: 2
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