Inspection Reports for
Troy Victorian Rehabilitation & Nursing Care Center
100 New Turnpike Road, Troy, NY, 12182
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
33.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
563% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
94% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Capacity: 120
Deficiencies: 24
Date: May 9, 2025
Visit Reason
Recertification and abbreviated survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, notification of significant changes, housekeeping and maintenance, abuse prevention, comprehensive assessments, care planning, medication administration, infection control, food quality, environmental safety, and staffing adequacy.
Deficiencies (24)
F0550: The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple residents reporting undignified care and staff behavior.
F0580: The facility did not notify residents' physicians and representatives promptly of significant changes in condition for two residents.
F0584: The facility failed to provide effective housekeeping and maintenance services, with soiled floors, peeling wallpaper, stained ceiling tiles, and broken fixtures in resident areas.
F0600: The facility did not protect residents from abuse and neglect, with documented incidents of resident-to-resident and staff-related abuse.
F0609: The facility failed to timely report the results of abuse investigations to the State Survey Agency within required timeframes.
F0636: The facility did not conduct comprehensive resident assessments timely and completely for two residents, missing key health issues.
F0656: The facility did not develop and implement comprehensive, person-centered care plans for 16 residents, lacking measurable goals and interventions.
F0684: The facility failed to provide appropriate treatment and care according to orders and resident needs for four residents, including delayed wound care and untreated foot conditions.
F0725: The facility did not provide sufficient nursing staff to meet resident needs, with documented staffing shortages and resident complaints of delayed care.
F0755: The facility failed to maintain accurate controlled substance records, including missing signatures and undocumented receipt of narcotics.
F0761: The facility did not ensure drugs and biologicals were labeled and stored properly, with expired or unlabeled medications and broken narcotic box locks.
F0759: The facility's medication error rate exceeded 5%, with multiple residents experiencing missed or late medication doses.
F0804: The facility did not ensure food and drink were palatable and attractive, with resident complaints and test trays showing poor quality food.
F0812: The facility did not store, prepare, distribute, or serve food in accordance with professional standards, with equipment in disrepair and unsanitary conditions in kitchens and kitchenettes.
F0814: The facility did not dispose of garbage and refuse properly, with dumpster doors left open and garbage littering the area.
F0836: The facility was not licensed or operating in compliance with applicable laws, with carbon monoxide detector improperly installed in the kitchen.
F0842: The facility did not safeguard resident-identifiable information or maintain accurate medical records, with incomplete documentation of wounds and antibiotic treatments.
F0860: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers, with delayed treatment and lack of care plan updates for a resident's pressure ulcer.
F0880: The facility did not implement an infection prevention and control program adequately, failing to implement enhanced barrier precautions and properly store nebulizer equipment.
F0919: The facility did not provide a working call system in resident bathrooms, with call bells missing or broken in multiple rooms.
F0921: The facility environment was not safe, clean, or comfortable, with exterior building and grounds unmaintained and littered.
F0924: The facility did not provide adequate ventilation in resident units, with musty odors in soiled holding and shower rooms due to inadequate ventilation.
F0925: The facility did not maintain handrails in resident hallways, with broken plastic and missing pieces exposing sharp edges.
F0925: The facility did not maintain an effective pest control program, with insect infestations found in resident rooms, kitchen, and staff areas.
Report Facts
Medication error rate: 36
Facility bed capacity: 120
Residents reviewed for care plans: 32
Residents reviewed for medication administration: 4
Residents reviewed for medication errors: 6
Residents reviewed for abuse and neglect: 9
Residents reviewed for infection control: 2
Residents reviewed for food quality: 1
Residents reviewed for call system: 2
Residents reviewed for pest control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Mentioned in medication administration and care plan deficiencies | |
| Licensed Practical Nurse #7 | Mentioned in medication administration late pass and narcotic count | |
| Assistant Director of Nursing #1 | Mentioned in wound care, medication administration, and infection control | |
| Director of Nursing #1 | Mentioned in multiple interviews regarding deficiencies and policies | |
| Physician Assistant #1 | Mentioned in wound care and infection control | |
| Registered Nurse #2 | Mentioned in wound care documentation discrepancies | |
| Licensed Practical Nurse #2 | Mentioned in wound care and medication administration | |
| Director of Maintenance #1 | Mentioned in maintenance and environmental deficiencies | |
| Food Service Director #1 | Mentioned in food quality and sanitation deficiencies |
Inspection Report
Annual Inspection
Capacity: 120
Deficiencies: 11
Date: May 9, 2025
Visit Reason
The survey was a recertification and abbreviated annual inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, failure to notify physicians and representatives of significant changes, inadequate housekeeping and maintenance, abuse and neglect incidents, incomplete and outdated care plans, insufficient nursing staff, medication administration errors, malfunctioning call systems, and pest control issues.
Deficiencies (11)
F0550: The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple residents reporting undignified care and staff behavior.
F0580: The facility did not promptly notify physicians and representatives of significant changes in residents' conditions for two residents, delaying treatment.
F0584: The facility failed to provide effective housekeeping and maintenance services, with soiled floors, peeling walls, stained ceiling tiles, broken fixtures, and stained privacy curtains.
F0600: The facility failed to protect residents from abuse and neglect, including a resident fall causing a fracture and a resident-to-resident altercation resulting in injury.
F0609: The facility failed to timely report the results of abuse investigations to the State Survey Agency within five working days for three residents.
F0656: The facility did not develop and implement comprehensive, person-centered care plans with measurable goals for multiple residents, including missing interventions for abuse risk, falls, infections, and pressure ulcers.
F0684: The facility failed to provide appropriate treatment and care consistent with professional standards for residents with wounds, edema, dry skin, and pressure ulcers, including delayed wound treatment and lack of monitoring.
F0725: The facility did not provide sufficient nursing staff to meet residents' needs, resulting in delayed care, unmet needs, and staff reporting inability to provide showers and incontinence care.
F0760: The facility failed to ensure residents were free from significant medication errors, including missed antibiotic doses and administration of medication without orders.
F0919: The facility did not maintain a working call system in resident bathrooms, with call bells missing or hanging by wires in multiple rooms.
F0925: The facility failed to maintain a pest-free environment, with insect infestations found in resident rooms, kitchen, and staff areas, and lack of documented pest control treatments.
Report Facts
Residents reviewed: 32
Facility bed capacity: 120
Residents affected: 5
Certified Nurse Aides on duty: 8
Licensed Nurses on duty: 6
Medication doses missed: 11
Medication error dose: 40
Call bell disrepair instances: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in medication administration and care plan deficiencies |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in dignity and respect and medication administration deficiencies |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Named in wound care and staffing deficiencies |
| Director of Nursing #1 | Director of Nursing | Named in medication administration, wound care, and staffing deficiencies |
| Physician Assistant #1 | Physician Assistant | Named in wound care and medication administration deficiencies |
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in staffing and dignity and respect deficiencies |
| Director of Maintenance #1 | Director of Maintenance | Named in call bell and pest control deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 24
Date: May 9, 2025
Visit Reason
Multiple standard health and life safety code citations were issued, including deficiencies in care planning, abuse prevention, medication error rates, and physical environment. Most deficiencies were corrected by July 2025.
Findings
Multiple standard health and life safety code citations were issued, including deficiencies in care planning, abuse prevention, medication error rates, and physical environment. Most deficiencies were corrected by July 2025.
Deficiencies (24)
Care plan timing and revision
Comprehensive assessments & timing
Corridors have firmly secured handrails
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Drug regimen review, report irregular, act on
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Free of medication error rts 5 prcnt or more
General requirements
Infection prevention & control
License/comply w/ fed/state/locl law/prof std
Maintains effective pest control program
Notify of changes (injury/decline/room, etc. )
Nutritive value/appear, palatable/prefer temp
Pasarr screening for md & id
Pharmacy srvcs/procedures/pharmacist/records
Quality of care
Reporting of alleged violations
Resident records - identifiable information
Resident rights/exercise of rights
Residents are free of significant med errors
Sufficient nursing staff
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with safety regulations, specifically to ensure the nursing home environment was free from accident hazards and provided adequate supervision to prevent accidents.
Findings
The facility failed to ensure a safe environment for Resident #1, who was on a nothing by mouth (NPO) diet due to high aspiration risk, but was found eating pizza given by another resident. The incident was investigated, and no signs of aspiration were found after a chest X-ray, but corrective interventions were added to the resident's care plan.
Deficiencies (1)
F 0689: The facility did not ensure the environment remained free of accident hazards for Resident #1, who was on a nothing by mouth (NPO) diet but was fed pizza by another resident. The resident coughed up the pizza and required monitoring and a chest X-ray to rule out aspiration.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Documented the incident and resident condition after pizza feeding |
| Speech Language Pathologist #1 | Speech Language Pathologist | Conducted swallowing evaluations and follow-up assessments |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding supervision and monitoring of resident |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident behavior and monitoring |
| Director of Nursing #1 | Director of Nursing | Interviewed about incident response and resident care plan updates |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
One standard health citation issued for free of accident hazards/supervision/devices, corrected by March 2025.
Findings
One standard health citation issued for free of accident hazards/supervision/devices, corrected by March 2025.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
One standard health citation issued for sufficient nursing staff, corrected by October 2024.
Findings
One standard health citation issued for sufficient nursing staff, corrected by October 2024.
Deficiencies (1)
Sufficient nursing staff
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 1
Date: Jul 16, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with staffing requirements and ensure resident safety and well-being.
Findings
The facility failed to maintain minimum staffing levels for Licensed Practical Nurses and Certified Nurse Aides from 7/01/2024 through 7/16/2024, resulting in insufficient nursing staff to meet resident needs. Observations and interviews confirmed staff shortages and that residents sometimes did not receive appropriate care due to low staffing.
Deficiencies (1)
F 0725: The facility did not provide enough nursing staff every day to meet the needs of every resident and did not have a licensed nurse in charge on each shift. Staffing minimums for Licensed Practical Nurses and Certified Nurse Aides were not met from 7/01/2024 through 7/16/2024.
Report Facts
Residents present: 113
Staffing minimums for Licensed Practical Nurses: 6
Staffing minimums for Licensed Practical Nurses: 6
Staffing minimums for Licensed Practical Nurses: 3
Staffing minimums for Certified Nurse Aides: 11
Staffing minimums for Certified Nurse Aides: 11
Staffing minimums for Certified Nurse Aides: 6
Certified Nurse Aide assignment: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Discussed staffing issues and COVID impact on staffing levels |
| Licensed Practical Nurse Unit Manager #1 | Licensed Practical Nurse Unit Manager | Reported no Certified Nurse Aides present on unit at 2:35 PM on 7/16/2024 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported insufficient staffing and high resident assignment on 7/16/2024 |
| Assistant Director of Nursing | Assistant Director of Nursing | Present on unit during observation of staffing shortages |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jul 5, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, and elopement risks involving Resident #1 at Troy Victorian Rehabilitation & Nursing Care Center.
Complaint Details
The survey was complaint-related, investigating allegations of abuse, neglect, and mistreatment involving Resident #1. The complaint was substantiated as the facility failed to prevent elopement and failed to report the incident timely.
Findings
The facility failed to ensure Resident #1's right to be free from neglect and abuse, specifically inadequate supervision following an attempted elopement on 6/11/2024, which resulted in an actual elopement on 6/14/2024. The facility also failed to timely report the incident to the New York State Department of Health and did not implement proper monitoring or documentation for the electronic monitoring device.
Deficiencies (3)
F 0600: The facility did not ensure supervision and oversight following an attempted elopement on 6/11/2024, resulting in an actual elopement on 6/14/2024. Electronic monitoring device placement and care plan updates were not properly implemented or documented.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft related to Resident #1's elopement to the New York State Department of Health as required by state law.
F 0689: The facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for Resident #1, resulting in immediate jeopardy and substandard quality of care.
Report Facts
Residents Affected: 1
Distance from front door: 40
Date of elopement attempt: Jun 11, 2024
Date of actual elopement: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist #2 | Occupational Therapist | Observed Resident #1 in parking lot on 6/14/2024 and reported to nursing staff |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding electronic monitoring device placement and checks |
| Social Worker #3 | Social Worker | Observed elopement attempt on 6/11/2024 but did not report immediately |
| Registered Nurse #1 | Registered Nurse | Unaware of elopement attempt and electronic monitoring device placement |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Not informed of elopement attempt; stated they would have started an incident report |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Reported placement of electronic monitoring device and issues with documentation |
| Director of Nursing #1 | Director of Nursing | Reviewed surveillance video and commented on elopement incident |
| Administrator #1 | Administrator | Interviewed about awareness and reporting of elopement incidents |
| Rehabilitation Director #4 | Rehabilitation Director | Attended morning meetings and interviewed about elopement discussions |
| Medical Director #1 | Medical Director | Aware of elopements and requested psych consult; did not order electronic monitoring device |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jul 5, 2024
Visit Reason
Three standard health citations issued including free from abuse and neglect (Level 2), free of accident hazards (Level 4 immediate jeopardy), and reporting of alleged violations, all corrected by August 2024.
Findings
Three standard health citations issued including free from abuse and neglect (Level 2), free of accident hazards (Level 4 immediate jeopardy), and reporting of alleged violations, all corrected by August 2024.
Deficiencies (3)
Free from abuse and neglect
Free of accident hazards/supervision/devices
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Mar 25, 2024
Visit Reason
The abbreviated survey was conducted to investigate complaints related to resident abuse, misappropriation of resident property, and care plan deficiencies at Troy Victorian Rehabilitation & Nursing Care Center.
Complaint Details
The abbreviated survey was complaint-driven, investigating allegations of resident abuse (NY00334205), misappropriation of resident property (NY00333272), and care plan deficiencies (NY00332433).
Findings
The facility failed to prevent resident-to-resident physical abuse incidents involving Residents #8 and #9, did not secure Resident #7's property properly leading to misappropriation, and did not timely review and revise Resident #6's care plan after a fall incident.
Deficiencies (3)
F 0600: The facility did not ensure residents were free from physical abuse for Residents #8 and #9. Interventions following resident-to-resident abuse incidents on 12/18/2023 and 2/06/2024 were not implemented, resulting in a third incident on 2/23/2024.
F 0602: The facility did not ensure Resident #7's property was secured in a locked drawer. Resident reported $75 missing and was provided a locked drawer without a key, with delays in providing a replacement key or portable safe.
F 0657: Resident #6's comprehensive care plan for fall risk was not reviewed and revised timely after a fall on 1/23/2024. The intervention of a floor mat was added late on 3/5/2024 and was not included in the Certified Nurse Aide care card.
Report Facts
Residents reviewed: 9
Residents affected: 2
Residents affected: 1
Residents affected: 1
Missing money amount: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Discussed lack of 30-minute checks for Resident #8 and investigation of missing money for Resident #7 |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding 30-minute checks for Resident #8 and care plan review for Resident #6 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about awareness of 30-minute checks for Resident #8 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about documentation of 30-minute checks for Resident #8 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about Certified Nurse Aide care card and fall risk interventions for Resident #6 |
| Administrator #1 | Administrator | Discussed lock replacement and portable safe for Resident #7 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Mar 25, 2024
Visit Reason
Three standard health citations issued including care plan timing and revision, free from abuse and neglect, and free from misappropriation/exploitation, all corrected by June 2024.
Findings
Three standard health citations issued including care plan timing and revision, free from abuse and neglect, and free from misappropriation/exploitation, all corrected by June 2024.
Deficiencies (3)
Care plan timing and revision
Free from abuse and neglect
Free from misappropriation/exploitation
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Dec 7, 2023
Visit Reason
The facility underwent an abbreviated survey to assess compliance with resident rights, abuse reporting, investigation protocols, and care standards including catheter care.
Findings
The survey found deficiencies including failure to treat a resident with dignity, delayed reporting of abuse allegations, incomplete abuse investigations, and inadequate care and documentation related to a resident's suprapubic catheter leading to infection and hospitalization.
Deficiencies (5)
F 0550: The facility failed to ensure Resident #3 was treated with respect and dignity, as Certified Nurse Aide #2 made derogatory and offensive statements in the presence of the resident causing emotional distress.
F 0609: The facility did not timely report an allegation of physical abuse involving Resident #6 to the State Survey Agency within 2 hours as required.
F 0610: The facility failed to thoroughly investigate an allegation of physical abuse reported by Resident #6, lacking documentation of interviews with all relevant staff.
F 0690: The facility did not provide appropriate care to Resident #8 with a suprapubic catheter, failing to have orders in place for daily catheter care to prevent infection until after hospitalization for infection and catheter obstruction.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #8, lacking documentation of catheter care observations, condition evaluations on 9/18/2023, physician notification, and blood sugar and insulin administration for three days.
Report Facts
Residents reviewed: 7
Residents reviewed: 4
Suspension duration: 1
Dates of deficient catheter care orders: No orders in place for daily catheter care from admission date until later date (exact dates redacted)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in dignity violation and disciplinary action for making derogatory statements to Resident #3 | |
| Director of Nursing #2 | Director of Nursing | Documented incident and disciplinary actions related to dignity violation |
| Certified Nurse Aide #3 | Named in abuse allegation involving Resident #6 | |
| Director of Nursing #3 | Director of Nursing | Conducted abuse investigation and reported delays in notification |
| Regional Registered Nurse #1 | Regional Registered Nurse | Involved in abuse investigation and reporting |
| Administrator #3 | Administrator | Interviewed regarding abuse reporting and investigation |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding catheter care deficiencies and documentation |
| Registered Nurse Educator | Registered Nurse Educator | Interviewed regarding admission order errors and documentation education |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding admission order errors and documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Dec 7, 2023
Visit Reason
Five standard health citations issued including bowel/bladder incontinence, investigate/prevent/correct alleged violation, reporting of alleged violations, resident records - identifiable information, and resident rights/exercise of rights, all corrected by January 2024.
Findings
Five standard health citations issued including bowel/bladder incontinence, investigate/prevent/correct alleged violation, reporting of alleged violations, resident records - identifiable information, and resident rights/exercise of rights, all corrected by January 2024.
Deficiencies (5)
Bowel/bladder incontinence, catheter, uti
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Resident records - identifiable information
Resident rights/exercise of rights
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
One standard health citation issued for reporting - national health safety network, not corrected as of report date.
Findings
One standard health citation issued for reporting - national health safety network, not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 22, 2023
Visit Reason
One standard life safety code citation issued for egress doors, corrected by August 31, 2023.
Findings
One standard life safety code citation issued for egress doors, corrected by August 31, 2023.
Deficiencies (1)
Egress doors
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care related to pressure ulcer treatment and wound care management at the facility.
Findings
The facility failed to ensure a resident with a pressure ulcer received necessary treatment and services consistent with professional standards, resulting in hospitalization due to untreated infected wound. Documentation and physician orders for recommended tests and antibiotics were missing, and staff interviews revealed inconsistent communication and delayed treatment.
Deficiencies (1)
F 0686: The facility did not follow the wound care physician's recommendations for tests and treatment of an infected pressure ulcer wound for Resident #4, resulting in hospitalization. Documentation and orders for antibiotics, x-rays, blood work, and wound culture were not present in the medical record.
Report Facts
Residents affected: 1
Date survey completed: Apr 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided interview statements about wound care procedures and documentation | |
| Licensed Practical Nurse (LPN) #4 | Interviewed regarding wound care orders and documentation | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding wound treatment and MAR signing | |
| Assistant Unit Manager (LPN #5) | Interviewed regarding wound care order communication and documentation | |
| Registered Nurse (RN) #1 | Interviewed regarding wound rounds and order entry procedures | |
| Wound Care Consultant Physician | Interviewed regarding wound care treatment delays and administration issues |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
One standard health citation issued for treatment/services to prevent/heal pressure ulcer, corrected by June 28, 2023.
Findings
One standard health citation issued for treatment/services to prevent/heal pressure ulcer, corrected by June 28, 2023.
Deficiencies (1)
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 20, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory standards related to housekeeping and environmental cleanliness in the nursing facility.
Findings
The facility failed to provide effective housekeeping services on two resident units, the lobby, service corridor, main kitchen, kitchenettes, and elevator cars. Multiple areas including ceilings, floors, walls, and resident rooms were found soiled with food splatters, dirt, old wax build-up, and other substances.
Deficiencies (1)
F 0584: The facility did not maintain a safe, clean, comfortable, and homelike environment as evidenced by soiled ceilings, floors, walls, and equipment in multiple resident areas and common spaces.
Report Facts
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding cleaning and housekeeping issues | |
| Director of Housekeeping | Interviewed regarding cleaning and housekeeping issues | |
| Maintenance Consultant | Interviewed regarding cleaning and housekeeping issues |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Apr 20, 2023
Visit Reason
The survey was a recertification annual inspection conducted from April 16, 2023 through April 20, 2023 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including ineffective housekeeping services, failure to provide timely transfer/discharge notifications, incomplete comprehensive care plans, medication administration errors, inadequate supervision for self-administered medications, incomplete drug regimen review policies, improper disposal of garbage, and failure to ensure medication availability.
Deficiencies (9)
F 0584: The facility did not provide effective housekeeping services on two resident units, the lobby, service corridor, kitchen, kitchenettes, and elevator cars, with soiled ceilings, floors, walls, and equipment.
F 0623: The facility failed to provide timely written notification to Resident #38, their representative, and the Ombudsman regarding transfers to the hospital on three occasions.
F 0625: The facility did not provide written notice of the bed hold policy to Resident #38 or their representative upon hospital transfers on three occasions.
F 0656: The facility did not develop and implement comprehensive care plans addressing multiple medical and behavioral needs for five residents, including missing person-centered interventions.
F 0684: The facility failed to ensure Resident #65 received physician-ordered acidophilus as prescribed and did not notify the physician when it was unavailable.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Resident #59 who self-administered inhaler medication without physician order, care plan, or nursing assessment.
F 0756: The facility's Drug Regimen Review policy lacked required timeframes for process steps and pharmacist actions when irregularities require urgent attention.
F 0759: The facility had a medication error rate of 50% for two residents due to late administration without timely physician notification.
F 0814: The facility did not properly dispose of garbage and refuse; dumpster doors were left open and grounds littered with waste.
Report Facts
Medication administration observations: 28
Medication administration errors: 14
Medication error rate: 50
Residents reviewed for comprehensive care plans: 25
Residents with deficient care plans: 5
Hospital transfers for Resident #38: 3
Acidophilus doses not administered: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Named in relation to failure to provide transfer/discharge notification and medication administration |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in relation to failure to provide transfer/discharge notification and medication administration |
| Director of Nursing | Director of Nursing | Named in relation to multiple findings including notification failures, care plan deficiencies, and medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in relation to care plan deficiencies |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in relation to observation of resident behavior and medication self-administration |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in relation to medication administration and inhaler self-administration |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in relation to medication administration and inhaler self-administration |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in relation to medication administration |
| Registered Nurse #1 | Registered Nurse | Named in relation to medication administration delays |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named as assistant nurse manager in medication administration delay context |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Date: Apr 20, 2023
Visit Reason
Multiple standard health and life safety code citations issued including comprehensive care plan, garbage disposal, drug regimen review, accident hazards, medication error rates, safety standards, notice requirements, quality of care, safe environment, electrical equipment, fire alarm system, gas equipment, maintenance/testing of doors, smoke barriers, vertical openings, and others. Most corrected by June 2023.
Findings
Multiple standard health and life safety code citations issued including comprehensive care plan, garbage disposal, drug regimen review, accident hazards, medication error rates, safety standards, notice requirements, quality of care, safe environment, electrical equipment, fire alarm system, gas equipment, maintenance/testing of doors, smoke barriers, vertical openings, and others. Most corrected by June 2023.
Deficiencies (18)
Develop/implement comprehensive care plan
Dispose garbage and refuse properly
Drug regimen review, report irregular, act on
Free of accident hazards/supervision/devices
Free of medication error rts 5 prcnt or more
General safety standards of existing nh
Notice of bed hold policy before/upon trnsfr
Notice requirements before transfer/discharge
Quality of care
Safe/clean/comfortable/homelike environment
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Ep training program
Fire alarm system - installation
Gas equipment - qualifications and training
Maintenance, inspection & testing - doors
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards regarding accurate documentation and medication administration practices at the facility.
Findings
The facility failed to maintain accurate medical records for Resident #1, specifically documenting administration of narcotic pain medication that was unavailable. Medication administration records incorrectly showed Oxycodone ER 10 mg given when only Oxycodone 5 mg tablets were administered.
Deficiencies (1)
F 0842: The facility did not ensure accurate documentation on the medication administration record for Resident #1 on 2/15/2023, documenting administration of Oxycodone ER 10 mg when it was unavailable and an alternative medication was given instead.
Report Facts
Residents reviewed: 3
Residents affected: 1
Medication dosage: 10
Medication dosage: 5
Medication tablets: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Documented medication administration error on MAR |
| Registered Nurse Manager #1 | Registered Nurse Manager | Reported medication receipt and non-possession due to resident discharge |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Confirmed medication unavailability and alternative administration |
| Director of Nursing #2 | Director of Nursing | Provided explanation of documentation error and policy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
One standard health citation issued for resident records - identifiable information, corrected by June 19, 2023.
Findings
One standard health citation issued for resident records - identifiable information, corrected by June 19, 2023.
Deficiencies (1)
Resident records - identifiable information
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
One standard life safety code citation issued for electrical equipment testing and maintenance, corrected by March 31, 2023.
Findings
One standard life safety code citation issued for electrical equipment testing and maintenance, corrected by March 31, 2023.
Deficiencies (1)
Electrical equipment - testing and maintenanc
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
One standard health citation issued for reporting - national health safety network, not corrected as of report date.
Findings
One standard health citation issued for reporting - national health safety network, not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Census: 109
Capacity: 120
Deficiencies: 14
Date: Apr 27, 2021
Visit Reason
Annual recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide required notices to residents, inadequate housekeeping, failure to timely report and investigate abuse allegations, incomplete preadmission screening, incomplete and inconsistent care plans, insufficient staffing levels impacting resident care, medication errors, incomplete medical records, infection control deficiencies, and failure to provide substantial evening snacks.
Deficiencies (14)
F 0582: Facility failed to provide residents or representatives required Medicaid/Medicare coverage notices including expedited review rights and potential financial liability notices.
F 0584: Facility did not maintain a safe, clean, and comfortable environment; specifically, the 2nd floor East Hallway floor was visibly unclean with dirt and dust.
F 0609: Facility failed to timely report suspected abuse and neglect allegations involving Resident #209 to the Administrator and State Agency within required timeframes.
F 0610: Facility did not thoroughly investigate allegations of sexual abuse involving Resident #85 and failed to maintain complete investigation documentation.
F 0645: Facility failed to ensure complete and accurate PASARR Level I screening post admission for Resident #67 with mental illness.
F 0656: Facility did not develop and implement comprehensive care plans with measurable objectives for 7 residents, including failure to implement interventions and non-pharmacological approaches for psychotropic medication use.
F 0660: Facility failed to develop and implement an effective discharge planning process for Resident #56, including failure to reevaluate discharge potential and update plans based on resident's improved status and wishes.
F 0725: Facility staffing plan for LPNs and CNAs was not met on multiple shifts from 4/19/2021 to 4/26/2021, resulting in insufficient staff to provide timely ADL care and medication administration.
F 0756: Facility failed to ensure each resident's drug regimen was free from unnecessary drugs; Resident #39 did not have adequate TSH monitoring following elevated lab results.
F 0759: Facility medication error rate exceeded 5%; Resident #30 received Midodrine despite systolic blood pressure above ordered parameters on 67 occasions.
F 0761: Facility failed to maintain drugs and biologicals labeled per professional standards; multiple opened insulin pens and eye drops were unlabeled or undated.
F 0809: Facility did not ensure no more than 14 hours elapsed between dinner and breakfast without a substantial snack or resident council agreement.
F 0842: Facility failed to maintain complete, accurate, and accessible medical records including missing NP/MD notes and inconsistent CNA documentation.
F 0880: Facility failed to implement an effective infection prevention and control program on the 2nd floor unit including failure to maintain contact and droplet precautions, improper PPE use, inadequate hand hygiene, improper linen handling, and contamination of treatment cart.
Report Facts
Medication errors: 3
Medication administration opportunities: 31
Medication errors rate: 9.68
Midodrine administration errors: 67
Staffing shortfalls: 8
Staffing shortfalls: 5
Staffing shortfalls: 8
Staffing shortfalls: 4
Staffing shortfalls: 8
Residents: 109
Facility capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in medication administration errors and staffing insufficiency findings. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including staffing, medication errors, infection control. |
| Administrator | Administrator | Interviewed regarding staffing, infection control, and medical record deficiencies. |
| RNUM #2 | Registered Nurse Unit Manager | Interviewed regarding medication errors and staffing. |
| NP #6 | Nurse Practitioner | Interviewed regarding medication monitoring and errors. |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding infection control and PPE use. |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding infection control and PPE use. |
Viewing
Loading inspection reports...
