Inspection Reports for
New York State Veterans Home at Montrose
2090 Albany Post Rd, Montrose, NY, 10548
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jun 4, 2025
Visit Reason
Multiple standard health and life safety code citations identified including food sanitation, accident hazards, respiratory care, nursing staff sufficiency, pressure ulcer treatment, exit signage, and fire drills. All deficiencies were corrected by late July 2025.
Findings
Multiple standard health and life safety code citations identified including food sanitation, accident hazards, respiratory care, nursing staff sufficiency, pressure ulcer treatment, exit signage, and fire drills. All deficiencies were corrected by late July 2025.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Respiratory/tracheostomy care and suctioning
Sufficient nursing staff
Treatment/svcs to prevent/heal pressure ulcer
Exit signage
Fire drills
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 4, 2025
Visit Reason
The inspection was conducted as part of a Recertification and Abbreviated Survey to evaluate compliance with care and staffing regulations at the New York State Veterans Home at Montrose.
Findings
The facility failed to ensure adequate supervision during resident transfers, resulting in injuries to one resident. Additionally, the facility did not meet minimum staffing requirements for Certified Nurse Aides on multiple days, impacting resident care.
Deficiencies (2)
F 0689: The facility did not ensure residents received adequate supervision to prevent accidents, resulting in Resident #254 sustaining skin tears and an abrasion due to improper transfer without required two-person assistance.
F 0725: The facility did not provide enough nursing staff daily to meet resident needs and have a licensed nurse in charge on each shift, failing minimum staffing requirements on several days.
Report Facts
Days with insufficient Certified Nurse Aide staffing: 5
Certified Nurse Aides required on day shift: 22
Certified Nurse Aides present on day shift: 14
Certified Nurse Aides present on day shift: 18
Certified Nurse Aides present on day shift: 19
Certified Nurse Aides present on day shift: 19
Certified Nurse Aide care days for Resident #254: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in transfer incident causing resident injury | |
| Registered Nurse #1 | Observed resident injuries and interviewed staff regarding transfer incident | |
| Director of Nursing | Director of Nursing | Provided statements on staffing and resident care requirements |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident injury incident |
| Certified Nurse Aide #9 | Interviewed about staffing levels and work conditions | |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed about staffing reductions and impact on care |
| Staffing Coordinator | Staffing Coordinator | Interviewed about staffing compliance and distribution |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Apr 3, 2025
Visit Reason
Standard health citations for abuse prevention, investigation and reporting of violations, and rights to be free from chemical and physical restraints. All deficiencies corrected by May 23, 2025.
Findings
Standard health citations for abuse prevention, investigation and reporting of violations, and rights to be free from chemical and physical restraints. All deficiencies corrected by May 23, 2025.
Deficiencies (5)
Free from abuse and neglect
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Right to be free from chemical restraints
Right to be free from physical restraints
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Apr 3, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, improper use of restraints, chemical restraint use, failure to timely report abuse, and inadequate investigation of abuse allegations at the New York State Veterans Home at Montrose.
Findings
The facility failed to protect Resident #1 from abuse and improper physical and chemical restraints, failed to timely report an alleged abuse incident, and failed to thoroughly investigate abuse allegations for Resident #3. Surveillance footage and interviews documented staff physically restraining Resident #1 against their will and administering an intramuscular antipsychotic without documented medical necessity. Resident #3 sustained a skin tear that was not properly investigated.
Deficiencies (5)
F 0600: The facility did not ensure Resident #1 was free from abuse, as staff physically restrained the resident against their will, causing minimal harm or potential for actual harm.
F 0604: The facility did not ensure Resident #1 was free from physical restraints imposed for discipline or convenience, resulting in actual harm and psychosocial harm.
F 0605: The facility administered intramuscular antipsychotic medication to Resident #1 without documented medical symptoms or appropriate assessment, constituting chemical restraint and causing actual harm.
F 0609: The facility failed to timely report alleged abuse of Resident #1 to the administrator and state authorities, delaying notification until two days after the incident.
F 0610: The facility failed to thoroughly investigate an alleged abuse incident involving Resident #3 who sustained a skin tear, and did not complete an incident report or proper skin assessments.
Report Facts
Residents reviewed for abuse: 3
Date of incident: Mar 15, 2025
Date survey completed: Apr 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Involved in physically restraining Resident #1 and administering injection |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Involved in physically restraining Resident #1 and supporting injection administration |
| Certified Nurse Aide #2 | Certified Nurse Assistant | Involved in physically restraining Resident #1 |
| Security Officer #1 | Security Officer | Involved in physically restraining Resident #1 |
| Registered Nurse #2 | Registered Nurse | Witnessed and assisted in restraint of Resident #1 |
| Attending Physician #1 | Attending Physician | Ordered medications for Resident #1 and provided clinical input |
| Director of Nursing | Director of Nursing | Reviewed surveillance footage and participated in investigation |
| Administrator | Administrator | Received delayed notification of abuse incident and reviewed surveillance footage |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Provided care and skin protocol for Resident #3's skin tear |
| Social Worker #1 | Social Worker | Reported Resident #3's injury and family concerns |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 27, 2023
Visit Reason
The inspection was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for the New York State Veterans Home at Montrose.
Findings
The facility was found deficient in multiple areas including failure to notify family council members of meetings, inadequate notification to resident representatives about medication changes, incomplete care plans, unsecured controlled substances, improper food storage, inaccurate facility-wide assessment, and unsafe environmental conditions.
Deficiencies (8)
F 0565: The facility did not ensure family council members and new admissions were notified of the June 22, 2022 quarterly meeting as required.
F 0580: The resident representative was not notified or given an opportunity to consent prior to changing Resident #184's pain medication from scheduled Roxanol to as needed.
F 0656: The facility did not ensure Resident #172 had a comprehensive care plan including measurable objectives and interventions for anticoagulant use.
F 0657: Resident #30's psychotropic care plan was not revised to reflect refusal of psychiatric follow-up by the resident's brother and lacked a documented plan for psychiatric follow-up.
F 0761: Two medication carts on the Bear Mountain unit had unlocked internal narcotic medication lock boxes, violating secure storage requirements.
F 0812: The Bear Mountain resident refrigerator contained multiple outdated perishable food items, violating food safety standards.
F 0838: The facility-wide assessment did not accurately document the needs of residents requiring dialysis and laryngectomy care.
F 0921: Resident #180's alternating mattress control unit was on the floor and its cord extended creating an accident hazard.
Report Facts
Residents reviewed for Comprehensive Care Plans: 38
Medication carts reviewed: 6
Medication carts with unlocked narcotic lock boxes: 2
Perishable food items found outdated: 3
Residents reviewed for unnecessary medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Discussed family council notification and meeting scheduling | |
| Director of Nursing | Director of Nursing | Provided information on medication changes and care plan requirements |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding care plan initiation and psychiatric follow-up |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration and narcotic cart locking |
| Registered Nurse #5 | Registered Nurse | Interviewed regarding narcotic cart locking |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding outdated food items in refrigerator |
| Director of Social Work | Director of Social Work | Discussed family council liaison role |
| Medical Doctor #1 | Medical Doctor | Discussed psychiatric consult orders and resident stability |
| Plant Superintendent | Plant Superintendent | Discussed environmental safety hazards related to mattress control unit cord |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 27, 2023
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements related to resident rights and notification procedures.
Findings
The facility failed to ensure that family council members and new admissions were notified of a scheduled family council meeting in June 2022. Additionally, the facility did not notify the resident representative prior to changing a resident's pain medication from scheduled to as needed.
Deficiencies (2)
F 0565: The facility did not consider the views of the family council and failed to notify family council members and new admissions of the June 22, 2022, quarterly meeting as required.
F 0580: The facility did not notify the resident representative or obtain consent prior to changing the resident's pain medication from scheduled Roxanol to as needed administration.
Report Facts
Residents Affected: 1
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Interviewed regarding family council notification and meeting scheduling | |
| Director of Social Work | Interviewed regarding family council liaison role | |
| Administrator | Interviewed regarding family council involvement and meeting facilitation | |
| License Practical Nurse | Interviewed regarding medication administration and notification | |
| Director of Nursing | Interviewed regarding medication order change and notification |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Jul 27, 2023
Visit Reason
Multiple standard health and life safety code citations including care plan management, food sanitation, medication labeling, notification of changes, resident/family communication, environment safety, communication plan, electrical equipment, fire drills, hazardous areas, egress illumination, and physical environment. All deficiencies corrected by late 2023.
Findings
Multiple standard health and life safety code citations including care plan management, food sanitation, medication labeling, notification of changes, resident/family communication, environment safety, communication plan, electrical equipment, fire drills, hazardous areas, egress illumination, and physical environment. All deficiencies corrected by late 2023.
Deficiencies (14)
Care plan timing and revision
Develop/implement comprehensive care plan
Facility assessment
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Notify of changes (injury/decline/room, etc.)
Resident/family group and response
Safe/functional/sanitary/comfortable environ
Development of communication plan
Electrical equipment - power cords and extens
Fire drills
Hazardous areas - enclosure
Illumination of means of egress
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 22, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in ensuring the call bell system was accessible to a resident with severe physical limitations and in maintaining clear and unambiguous advance directives for another resident, potentially impacting resident safety and rights.
Deficiencies (2)
F 0558: The facility did not ensure that Resident #83 had his call bell within reach on two observed occasions, despite being totally dependent on staff for care except feeding.
F 0578: The facility did not ensure that Resident #210's wishes for advance directives were clear and unambiguous, resulting in conflicting documentation regarding DNR status.
Report Facts
Residents reviewed for Environment: 2
Residents sampled for advance directives: 41
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 13, 2018
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements related to care planning, nutrition, and continence management for residents.
Findings
The facility failed to develop a complete care plan addressing urinary incontinence for one resident and did not timely revise the nutrition care plan to prevent further weight loss for another resident. The care plans lacked appropriate assessments and interventions based on residents' actual conditions and preferences.
Deficiencies (2)
F 0657: The facility did not develop a complete care plan within 7 days of the comprehensive assessment for a resident with urinary incontinence. The care plan lacked assessment of the type of incontinence and did not include a toileting program based on the resident's voiding pattern.
F 0657: The facility did not timely review and revise the nutrition care plan to prevent further weight loss for a resident who lost 15.5 pounds in 3 months. Monitoring of nutritional supplement intake was not performed and interventions were delayed.
Report Facts
Weight loss: 15.5
Weight loss percentage: 9.6
Incontinence episodes: 7
Continence documentation: 26
Continence documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | MDS Coordinator | Completed the MDS and interviewed regarding incontinence assessment. |
| Director of Nursing | DON | Interviewed about incontinence assessment and Quality Assurance Performance Improvement program. |
| CNA #1 | Certified Nurse Aide | Interviewed and observed providing care to Resident #12. |
| CNA #2 | Certified Nurse Aide | Interviewed about toileting schedule for Resident #12. |
| RN #2 | Registered Nurse | Developed Resident #12's current care plan and interviewed about care plan goals. |
| RN Unit Manager | Registered Nurse Unit Manager | Interviewed regarding nutrition care plan and weight loss interventions. |
| RD/FSD | Registered Dietitian/Food Service Director | Interviewed about resident's weight loss and nutrition interventions. |
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