Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Troy Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer covered in eschar. After an initial RN assessment and a high-risk team meeting noting referral to the in-house wound provider, there was no documented evidence of completed wound treatments on several ordered days and no ongoing interdisciplinary discussion of the wound. Due to a standing conflict between the wound provider’s single weekly visit and the resident’s dialysis schedule, the resident was never seen by the wound specialist or the NP, and no alternative arrangements (such as schedule changes or wound center referral) were made. Weekly wound evaluations were at times done by an LPN without RN oversight, and when the wound began to separate and show drainage, the RN notified a provider and obtained new orders but did not thoroughly document the worsening condition. When the resident later reported increased foot pain, there is no clear documentation that the dressing was removed or the wound fully assessed. The DON was unaware of the scheduling conflict, the physician’s admission note omitted the ulcer, and leadership did not ensure qualified weekly wound assessments. The wound ultimately progressed to sepsis, osteomyelitis, a pathological heel fracture, bacteremia, and a right BKA, causing actual physical and psychosocial harm and constituting neglect.
Surveyors found that the facility failed to provide timely and consistently documented pressure ulcer care for three residents admitted with existing pressure injuries. One resident’s unstageable heel ulcer was assessed on admission without any treatment order entered for two days, and later daily wound treatments were repeatedly undocumented or recorded as applied to both heels despite only one documented wound. Two other residents with stage 3 sacral ulcers had delays of several days between wound identification and initiation of treatment orders, and their Treatment Administration Records showed multiple blank entries on days when ordered dressings or Santyl applications were scheduled. Nursing staff and leadership acknowledged that blank TAR entries meant treatments were not done and that wound treatments were expected to be in place upon wound identification, but the documentation demonstrated missed or undocumented care in violation of facility wound care policy and care plans.
A resident with end stage renal disease and other chronic conditions, who was cognitively intact, changed their advance directive from full CPR to DNR after admission. Although this decision and the resident’s understanding of its consequences were documented in a physician note, the existing CPR order remained active in the EHR for several days, and pre-dialysis notes continued to list the code status as CPR. A DNR order and signed MOLST were not entered until a week later. Staff interviews revealed reliance on a manual order book process and a failure to immediately enter the code status change into the EHR, resulting in the resident’s expressed wishes not being promptly reflected in physician orders or communicated to care staff.
The facility failed to report the results of an internal investigation of a resident-to-resident abuse incident to the State Survey Agency as required by policy and state regulations. During an acute psychotic and aggressive episode, a resident with vascular dementia, depression, and anxiety threw objects at staff, climbed into another resident’s bed while that resident was in it, and entered another resident’s room, where a tray table struggle occurred and a thrown chair struck the resident’s foot. An internal investigation was completed and skin assessments were performed, but the event was not reported to the state. In interviews, the DON stated they did not consider the incident reportable and believed the administrator was responsible for state reporting, while the administrator indicated the DON completed investigations.
A resident with diabetes, CKD stage 3A, and a documented stage 3 sacral pressure ulcer was admitted, and an RN recorded the wound size and characteristics. Facility policies required the IDT and RN to develop a comprehensive, person-centered care plan with measurable objectives and timetables, including specific plans for new skin impairments. However, the comprehensive care plan lacked measurable goals and interventions for treatment of the stage 3 sacral ulcer, containing only a nutritional care plan that noted the pressure injury without detailed wound care measures, resulting in a deficiency in care planning standards.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency had a right heel pressure injury with eschar and an existing skin integrity care plan. Facility policy required the IDT and RN to revise care plans with significant changes and to address new or changing wounds. An LPN documented that the unstageable heel ulcer had deteriorated and that the wound care provider could not complete weekly assessments due to conflicts with the resident’s dialysis schedule, resulting in multiple missed wound assessments. Despite these documented changes and missed visits, the comprehensive care plan was not updated to reflect the deterioration of the pressure ulcer or the interruption in weekly wound care assessments, as confirmed in interviews with the DON and an RN manager.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer with 100% eschar, which was initially assessed by an RN and care planned with interventions including ordered treatment and referral to a wound specialist. Facility policy required weekly wound rounds and assessment by qualified staff, but a subsequent weekly wound evaluation was performed and documented solely by an LPN acting in a leadership role, without an RN or wound provider present. The LPN recorded wound measurements and characteristics and noted treatment response, yet there was no documentation that a wound provider or RN assessed the ulcer at that time. Interviews and state scope-of-practice guidance confirmed that LPNs may collect wound data but may not perform nursing assessments, and leadership and the wound provider acknowledged that the weekly assessment should have been completed by an RN, demonstrating that the resident’s pressure ulcer was not assessed by a qualified person as required by the care plan and regulations.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer that nursing staff and the IDT documented, including wound measurements and a plan to refer to an in‑house wound provider. At a required initial H&P visit, the attending physician documented no skin breakdown and described the skin as warm and dry, omitting any mention of the known heel ulcer and failing to document a plan of care or treatment for it, contrary to facility policy requiring review and documentation of the resident’s total program of care at each visit.
The facility failed to provide sufficient nursing staff, resulting in long waits for call lights, missed showers, and delays in morning care. Residents reported inadequate assistance with activities of daily living, and observations confirmed these issues. The staffing schedule often showed insufficient staff to meet resident needs.
The facility failed to provide a functional nurse call system in three resident rooms on the North Unit. Observations and interviews confirmed that the call bells did not activate, and residents were using tap bells instead. Repair requisitions were documented, and a quote for repairs was obtained, with the repairs completed by the end of the survey period.
The facility failed to report allegations of abuse involving a resident to the New York State Department of Health in a timely manner. Incidents on two separate occasions were not reported promptly, despite being witnessed and acknowledged by staff. The facility's policy mandates immediate reporting, which was not followed.
The facility failed to develop comprehensive care plans for two residents, neglecting to address an indwelling urinary catheter for one and dental care for another. Interviews with staff confirmed these omissions, indicating a lapse in adherence to care planning policies.
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. One resident was not provided with adequate incontinence supplies, another lacked clean clothing and timely assistance, and a third did not receive scheduled showers. Staff were unaware of these issues, and the facility's policies were not followed, resulting in significant deficiencies in resident care.
Neglect of Wound Care for Dialysis Patient Leading to Amputation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to the assessment and management of a known right heel pressure ulcer. The resident was admitted with significant comorbidities including end stage renal disease requiring dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency. On admission/readmission, an RN documented an unstageable pressure ulcer on the right heel with 100% black/brown eschar and an existing treatment. Facility policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or distress, and the wound policy required identification, assessment, and management of wounds in accordance with current standards of practice, including RN assessment and provider notification when wounds worsened. Following the initial assessment on 09/18/2025, there was no documented evidence that ordered wound treatments were completed on multiple dates, including 09/22/2025, 09/23/2025, 09/25/2025, and 09/29/2025. A high-risk team meeting on 09/19/2025 documented that the resident was being referred to the in-house wound provider for the right heel pressure ulcer, but there was no further documented discussion of this wound by the interdisciplinary team after that date. There was also no documented assessment of the right heel pressure ulcer by a qualified person after the 09/19/2025 team meeting through the period leading up to the resident’s subsequent decline. The designated in-house wound care provider only came to the facility one day per week, on a day that consistently conflicted with the resident’s dialysis schedule, and no alternate arrangements were made for wound evaluation, such as changing dialysis times, arranging virtual visits, or sending the resident to a wound care center. Nursing staff interviews revealed that weekly wound evaluations were sometimes performed by an LPN without an RN present, despite the expectation that initial and weekly wound assessments be completed by an RN. On 09/25/2025, the LPN conducted wound rounds without an RN and did not refer the resident to the wound care provider, stating there was no change in the wound, and the nurse practitioner who was notified should have seen and assessed the resident but did not. On 10/02/2025, the LPN and an RN observed that the wound bed had started to separate, remained covered with eschar, was pulling away from the edges, and had serosanguineous drainage; the RN notified the provider and obtained a new treatment order but did not thoroughly document the change in the wound or measurements. The resident was not seen by the wound care provider that day due to dialysis. On 10/06/2025, when the resident reported increased right foot pain, the RN did not recall removing the dressing or assessing the wound status, although the medical provider and physiatrist were contacted. The nurse practitioner later stated they never saw the resident because their schedule also conflicted with dialysis, and the medical director and wound care provider both indicated that the lack of weekly RN wound assessments and failure to arrange alternative wound care access were unacceptable. Ultimately, the resident was transferred from dialysis to the hospital with sepsis, a right pathological calcaneal fracture with acute osteomyelitis, and bacteremia, resulting in a right below-knee amputation and psychosocial trauma, which the surveyors determined constituted actual harm from neglect, though not Immediate Jeopardy. Additional interviews highlighted systemic failures in oversight and communication. The DON stated they were unaware of the conflict between the wound care provider’s schedule and the resident’s dialysis schedule and acknowledged missing documentation of a wound assessment on 10/09/2025. The DON also confirmed that LPNs could measure but not assess wounds and were expected to document observations in progress notes, and that the physician’s admission evaluation did not document the pressure ulcer. The administrator, who was not present at the time of admission, stated that high-risk meetings should have been held weekly for residents with wounds and that the DON and corporate nurse consultant were responsible for nursing oversight, while the physician or nurse practitioner were responsible for overall care. The nurse practitioner reported not realizing that the staff member performing weekly wound assessments was an LPN rather than an RN. The wound care provider and medical director both stated that the resident should have had weekly RN wound assessments and that alternative arrangements, including virtual visits or wound center referrals, could have been made when the resident was unavailable due to dialysis. The medical director emphasized that the resident’s frequent dialysis schedule did not excuse the lack of assessment by a qualified person. These combined failures—missed and undocumented wound treatments, lack of ongoing interdisciplinary review, absence of timely RN wound assessments, failure to coordinate provider schedules with dialysis, and failure to arrange alternative wound care access—resulted in the resident’s right heel pressure ulcer not being adequately monitored or managed. The resident’s condition progressed to sepsis, osteomyelitis, a pathological calcaneal fracture, bacteremia, and the need for a right below-knee amputation, causing both physical and psychosocial harm. The surveyors cited this as neglect under the facility’s abuse and neglect policy and cross-referenced deficiencies related to pressure ulcer treatment, use of qualified persons, and physician supervision and visits.
Failure to Provide Timely and Consistent Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards of practice and care-planned interventions, for three residents who were admitted with existing pressure injuries. Facility policy titled “Wound Identification and Wound Rounds” required that new admissions and newly discovered pressure ulcers receive a complete skin assessment by an RN, notification of the health care provider, and prompt treatment orders based on wound care guidelines. For Resident #1, the admission assessment on 09/18/2025 documented an unstageable right heel pressure ulcer with 100% black/brown eschar measuring 2.5 cm by 2.2 cm, with the wound bed not visible. Although the assessment noted that a treatment was in place, there was no corresponding treatment order in the medical record on 09/18/2025, and no order was entered until 09/20/2025. This gap meant the resident’s documented wound existed without an active physician order or documented treatment for at least two days. Once a treatment order for TheraHoney Gel to the right heel was entered for Resident #1, the Treatment Administration Record (TAR) showed multiple missed or undocumented treatments. The ordered daily dayshift treatment was not documented as administered on 09/22, 09/23, 09/25, and 09/29/2025. On several other dates (09/26, 09/27, 09/30, 10/01, and 10/02/2025), the TAR documented the treatment as being applied to both heels, even though there was no documented evidence of a wound on the left heel. A subsequent order starting 10/03/2025 for Anasept gel with collagen powder and an island dressing to the right heel was also not consistently carried out as ordered. The TAR showed that this treatment was not documented as administered until 10/04/2025, despite a start date of 10/03/2025, and was not documented on 10/06/2025. For several days (10/04, 10/05, 10/07, 10/08, and 10/09/2025), the location of administration was not recorded. Resident #6 and Resident #7 also had documented pressure ulcers present on admission that did not receive timely or consistently documented treatment. For Resident #6, an admission evaluation on 02/24/2026 documented a stage 3 sacral pressure ulcer measuring 2 cm by 2 cm by 0.1 cm, but there was no treatment order until 02/27/2026, creating a delay of several days between identification and initiation of ordered care. When a daily dayshift order for a calcium alginate-silver dressing to the sacrum began on 02/27/2026, the March TAR showed blank entries on 03/03, 03/08, and 03/18/2026, indicating the treatment was not documented as administered on those days. For Resident #7, an admission nursing evaluation on 02/18/2026 documented a stage 3 sacral pressure ulcer measuring 2.5 cm by 2.5 cm by 0.2 cm, and the care plan called for treatment per order. A Santyl ointment treatment every shift to the sacrum was ordered starting 03/06/2026, but the March TAR contained blank entries on 03/08 and 03/12/2026, again indicating missed or undocumented treatments. Interviews with nursing leadership and staff confirmed that blank entries on the TAR indicated treatments were not done and that a treatment should be in place whenever a wound is identified. The RN manager stated they were not aware that Resident #1 had no treatment order until 09/20/2025 and that missed treatments should have been reported. The DON acknowledged that Resident #1’s unstageable heel ulcer was documented on admission but that no treatment order appeared in the record until two days later, and they observed missing treatments on the TAR. LPNs and RNs interviewed described the expectation that wound care be completed during their shifts, documented in the electronic record, and communicated via nursing notes and 24-hour reports if not completed. Despite these stated expectations and the facility’s wound care policy, the records for Residents #1, #6, and #7 showed delays in obtaining initial treatment orders and multiple days where ordered pressure ulcer treatments were not documented as administered.
Failure to Promptly Implement and Document Resident Code Status Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s advance directive and code status change were promptly converted into a physician order and accurately documented and communicated to staff. A cognitively intact resident with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency initially requested full resuscitation at admission but later changed their mind and chose not to be resuscitated in the event of cardiorespiratory arrest. An encounter note documented that advance care planning was voluntarily discussed, the resident was alert, oriented, competent, and understood the consequences of choosing do not resuscitate (DNR). Despite this documented decision, there was no corresponding physician order entered to change the resident’s code status at that time. Record review showed that the electronic health record continued to carry an active order to attempt cardiopulmonary resuscitation (CPR) for several days after the resident’s decision to change to DNR. The Order Recap Report reflected an order to attempt CPR with an end date that extended seven days beyond the date of the documented change in the resident’s wishes. Pre-dialysis notes on multiple subsequent dates also documented the resident’s code status as CPR: attempt resuscitation, directing staff to “please see MOLST,” even though the resident had already expressed a desire not to be resuscitated. A DNR order and a completed and signed Medical Orders for Life-Sustaining Treatment (MOLST) form were not documented until a week after the resident’s decision. Interviews with staff confirmed that the process for implementing code status changes relied on the physician writing orders in a book and handing it to nursing or medical records staff, who were then responsible for entering the orders into the electronic medical record. The RN interviewed acknowledged that the code status change to DNR was documented in the physician’s note but did not recall an order being entered at that time and stated that a seven-day delay for a code status change should never occur. The Medical Director stated that a verbal order for a code status change was valid and that the facility should not have waited for the MOLST form to be completed and signed before entering the DNR order, noting that some nursing homes mistakenly believe code status is not official until the MOLST is finalized. This sequence of events resulted in the resident’s expressed change in advance directive not being promptly reflected in physician orders or in the clinical record, contrary to facility policy and regulatory requirements.
Failure to Report Resident-to-Resident Abuse Incident to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report the results of an investigation of resident-to-resident abuse to the State Survey Agency within the required timeframe. Facility policy, last reviewed on 07/18/2025, required the Administrator and Director of Nursing to investigate and report alleged or suspected abuse, neglect, or misappropriation to the appropriate State Agency immediately, and no later than two hours after identification of the allegation. On 10/14/2025 at 8:30 PM, a resident with vascular dementia, depression, anxiety, moderate cognitive impairment, and documented psychotic and aggressive behaviors threw objects, including a chair, during an escalated behavioral and psychotic episode. During this episode, the resident threw soda cans and an object at a nurse, climbed into another resident’s bed while that resident was lying in it, and then entered a third resident’s room, pushed a tray table, and threw a chair that struck the third resident’s right foot. The facility completed an internal investigation and documented that the event was the result of an acute psychosis episode in which the resident became belligerent, aggressive, violent, and at very high risk of harm to others. The investigation noted that two CNAs were present when the chair was thrown and that both affected residents received RN skin assessments. The investigation concluded there was no evidence of abuse, neglect, exploitation, mistreatment, or intentional misconduct by staff. However, there was no documented evidence that the facility reported this resident-to-resident abuse incident to the New York State Department of Health as required. During interviews, the DON stated they did not believe the incident was reportable because no one was hurt and indicated that the Administrator was responsible for reporting to the State Agency, while the Administrator stated that the DON completed investigations. The surveyors cited this as a failure to report the results of all investigations to the resident’s representative and to other officials in accordance with State law, including the State Survey Agency, within five working days of the incident.
Failure to Develop Measurable Care Plan for Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident with a stage 3 pressure ulcer on the sacrum. The resident was admitted with diagnoses including right tibia/fibula orthopedic surgery aftercare, diabetes, and stage 3A chronic kidney disease, and was documented as cognitively intact and able to communicate. On admission/readmission evaluation, an RN documented a stage 3 sacral pressure ulcer measuring 2 cm by 2 cm by 0.1 cm. Facility policies required that the IDT, in conjunction with the resident and representative, develop a comprehensive care plan with measurable objectives and timetables to meet the resident’s needs, and that an RN/IDT develop a care plan for new skin impairments, including prevention interventions as necessary. Despite these policies and the documented presence of the stage 3 sacral pressure ulcer, the resident’s comprehensive care plan did not contain measurable goals and interventions specifically addressing the care and treatment of this wound to promote healing and prevent infection. The only related documentation was a nutritional care plan noting the presence of a sacral pressure injury, without evidence of detailed, measurable wound care goals or interventions. During interviews, the DON and an RN stated that care plans were initiated by an RN or the IDT and updated when a wound or status change was identified, but the record review showed that this process did not result in a comprehensive, measurable care plan for the resident’s stage 3 sacral pressure ulcer, in violation of facility policy and 10 NYCRR 415.11(c)(1).
Failure to Revise Care Plan After Deterioration of Pressure Ulcer and Missed Wound Assessments
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised and updated according to professional standards for one resident with complex medical conditions, including end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency. The facility’s policies required that comprehensive care plans be revised as residents’ conditions changed, that the IDT review and update care plans with significant changes, and that RNs/IDT develop and initiate care plans for new skin impairments. The resident had an actual pressure injury on the right heel with eschar, and a care plan for alteration in skin integrity was created and initiated with interventions such as applying treatment per order, and referrals to PT/OT and a wound care specialist as needed. On a weekly wound evaluation dated 10/02/2025, an LPN documented an unstageable right heel pressure ulcer with 100% black/brown eschar, scant serous drainage, no odor, and that the wound had deteriorated, with treatment re-evaluated or changed and a note that the wound care provider was unable to see the resident due to a dialysis schedule conflict. The resident was not seen by the wound care provider for weekly wound assessments on three separate dates when the resident was out of the facility for scheduled dialysis. Despite these missed weekly wound assessments and the documented deterioration and significant change in the pressure ulcer, there was no evidence that the comprehensive care plan was updated or revised to reflect these changes. Interviews with the DON and an RN Manager confirmed that care plans were expected to be initiated and updated when resident status changed, but the care plan for this resident’s pressure ulcer was not revised in response to the missed wound care visits and deterioration of the wound.
Unqualified Wound Assessment for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s pressure ulcer was assessed by a qualified person in accordance with the written plan of care and facility policy. The resident was admitted with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency, and had an unstageable pressure ulcer with 100% black/brown eschar on the right heel identified on admission by a registered nurse. The care plan for alteration in skin integrity documented an actual pressure injury to the right heel with eschar and included interventions such as applying treatment per order and referring to a wound care specialist as needed. Facility policy on Wound Identification and Wound Rounds required that residents with pressure injuries be identified, assessed, and managed in accordance with current standards of practice, with the Wound Nurse/Designee, wound care provider, and registered dietitian notified and the resident scheduled for weekly wound rounds. On 9/19/2025, an interdisciplinary high-risk meeting was held for the resident, during which it was documented that the resident had a right heel pressure ulcer and would be referred to the in-house wound provider. The initial wound evaluation on 9/18/2025 was completed by a registered nurse, who documented the unstageable right heel ulcer with 100% eschar and no visible wound bed. However, the weekly wound evaluation dated 9/25/2025 was documented by an LPN, who recorded the same measurements, 100% black/brown eschar, no exudate or odor, and noted that treatment was in place with an improved response, adding a comment to refer to the wound care provider. There was no documented evidence that the in-house wound care provider or any other qualified person, such as a registered nurse, assessed the resident’s right heel pressure ulcer on that date. Interviews confirmed that the LPN who completed the 9/25/2025 weekly wound evaluation was functioning as a travel resource nurse and acting Assistant Director of Nursing, and that a registered nurse was not present with them during the wound assessment for this resident. The LPN stated they evaluated the wound alone, documented what they observed, and did not refer the resident to the wound care provider on that date because there was no change in the wound, although they indicated the nurse practitioner should have been notified and should have assessed the resident. The DON acknowledged that LPNs could measure but could not assess wounds and were supposed to document observations in a nursing progress note, and the wound care provider stated it was unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider did not see the resident. Information from the New York State Education Department clarified that LPNs may collect and report clinical data but may not perform nursing assessments or determine nursing diagnoses, and that RNs are responsible for assessing wounds and determining the plan of care, underscoring that the 9/25/2025 wound assessment was not performed by a qualified person as required.
Physician Failed to Address Documented Pressure Ulcer in Required Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure the attending physician reviewed a resident’s total program of care, including medications and treatments, and documented an appropriate plan at a required visit. A cognitively intact resident with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency was admitted with an unstageable pressure ulcer on the right heel. Nursing documentation on admission noted the heel ulcer measured 2.5 cm by 2.2 cm with 100% black/brown eschar and an existing treatment in place. An interdisciplinary team meeting the following day, attended by nursing, social services, rehab/therapy, dietary, administration, and a nurse practitioner, documented that the resident had a right heel pressure ulcer and would be referred to the in‑house wound provider. Despite this, when the attending physician conducted the initial history and physical visit several days later, the progress note documented no rashes or skin breakdown in the review of systems and described the skin as warm and dry on physical exam. The physician’s note did not mention the known unstageable right heel pressure ulcer and did not include any documented plan for its care or treatment, contrary to the facility’s Physician Visits policy requiring review of the resident’s total program of care and appropriate documentation at each visit. During interviews, the medical director stated that the physician, who was preparing to retire, did not always write notes about all resident concerns and that the medical team needed to be aware of residents’ wound status and review wound care notes. The administrator stated that the physician/nurse practitioner was responsible for residents’ overall care and that the physician was not resident centered.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility did not ensure sufficient nursing staff to provide necessary care to residents, resulting in unmet needs in activities of daily living. Multiple residents reported long waits for call lights to be answered, delays in receiving showers, and not being assisted out of bed and dressed until late morning. Observations confirmed that residents were often left in bed wearing hospital gowns and waiting for assistance with morning care. One resident was noted to have breakfast remnants on their face and disheveled hair, indicating a lack of timely personal care. Another resident, who required assistance with activities of daily living due to limited mobility and other health conditions, filed a grievance about waiting an hour and a half for assistance during the night. Observations showed that the resident's call light remained on for 20 minutes without being answered, despite staff being in the vicinity. The resident also reported waiting for hours on the toilet and not receiving showers or overnight care. During an interview, a Licensed Practical Nurse initially claimed the resident refused their hearing aids, but later found and applied them, which the resident appreciated. The facility's daily staffing schedule revealed that the number of staff on duty was often insufficient to meet the needs of the residents. Interviews with staff and residents indicated that there were missed showers, long wait times for assistance, and inadequate care during the night shift. Residents expressed frustration with the lack of timely response to call lights and the insufficient number of staff available to provide necessary care. The facility's policies on staffing and call light response were not effectively implemented, leading to significant deficiencies in resident care.
Non-Functional Nurse Call System in Resident Rooms
Penalty
Summary
The facility did not adequately provide for residents to call for staff assistance through a communication system on one of the two units. Specifically, the nurse call system was non-functional in resident rooms 5, 7, and 11 on the North Unit. During observations, it was noted that the call bell did not activate when tested in room 5 for beds A and B. Additionally, rooms 7 and 11 were using tap bells and did not have nurse cords to activate the nurse call system. A resident confirmed that they would use the nurse call cord if one were provided. Record reviews indicated that repair requisitions for the nurse call systems in rooms 5, 7, and 11 were documented on 12/26/2023 and 12/30/2023. A quote for repairs was obtained on 1/09/2024. Interviews with the Maintenance Life Safety Consultant and the Administrator confirmed that the facility had contracted with a vendor to repair the systems and was awaiting the scheduling of the repairs once the replacement parts were available. The repairs were reported to be completed by 2/12/2024.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving a resident to the New York State Department of Health in a timely manner. Specifically, the facility did not report an incident on 8/09/2023 where a staff member made derogatory comments to a resident, which was witnessed by two individuals. The Administrator ruled out verbal abuse because the resident did not hear the comments, and no report was made to the State Agency until 8/21/2023. Additionally, another incident on 12/05/2023 involving a resident-to-resident verbal altercation and a physical threat was not reported to the State Agency until 2/08/2024. The Administrator did not believe the incident rose to an abuse situation since no physical contact was made, and the resident did not feel uncomfortable. The facility's policy on abuse, last revised in 2/2019, mandates immediate reporting of any alleged violations of abuse, neglect, or mistreatment to the appropriate State Agency. Both the Administrator and the Director of Nursing acknowledged that the incidents should have been reported according to the facility's policy. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's compliance with state regulations regarding the reporting of abuse, neglect, or mistreatment.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical and dental needs. Resident #327, who was admitted with metabolic encephalopathy, severe sepsis with septic shock, and cirrhosis of the liver, had an indwelling urinary catheter placed by an outside provider. Despite this, the facility did not include the presence or maintenance of the urinary catheter in the resident's comprehensive care plan. Interviews with nursing staff and the Director of Nursing confirmed that the care plan should have addressed the urinary catheter but did not, indicating a lapse in the facility's adherence to its own policies and procedures for comprehensive care planning. Resident #14, admitted with diagnoses of Diabetes type 1 and partial limb amputation, had multiple missing and broken teeth and expressed a desire to see a dentist. However, the resident's comprehensive care plans did not include dental care, and no dentist appointment had been made. Interviews with the Director of Nursing and a Registered Nurse revealed that the care plan should have been updated to include dental care but was not, further highlighting the facility's failure to ensure all aspects of the residents' needs were addressed in their care plans.
Deficiency in Providing Necessary Services for Activities of Daily Living
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Resident #2, who was admitted with diagnoses including urinary tract infection, diabetes mellitus type 2, and hypertension, was observed multiple times in a hospital gown, unwashed, and with leftover food on their face. The resident reported that staff only provided care once a day, if at all, and that there was a shortage of extra-large incontinence briefs, leading to inadequate care. Interviews with staff revealed a lack of awareness about the resident's needs and the shortage of supplies, with the Medical Records/Supply Officer confirming that briefs were rationed and locked after hours to prevent misuse by staff for other residents who did not require them. The Director of Nursing and Registered Nurse also stated they had no knowledge of the issues reported by the resident and their family members. The resident's son had to bring in personal supplies to ensure the resident could be changed when needed. The facility's policy on Activities of Daily Living Support was not followed, resulting in the resident not receiving the necessary assistance for personal hygiene and incontinence care. The facility's failure to provide adequate care and supplies for Resident #2 highlights a significant deficiency in meeting the resident's needs and maintaining their dignity and comfort. Resident #32, admitted with diagnoses including osteoarthritis, difficulty walking, chronic obstructive pulmonary disease, weakness, and depression, was observed waiting for assistance with personal hygiene and wearing a hospital gown due to a lack of clean clothing. The resident reported waiting hours for assistance, especially during the night, and not receiving showers or care overnight. The resident's hearing aids were not applied, and staff did not assist in applying them despite the resident's requests. Interviews with staff revealed that the resident's grievances about waiting for assistance and not having clean clothing were known but not adequately addressed. The facility's new laundry service had issues, resulting in residents not receiving their clothing back, and the facility had recently hired an in-house laundry person to address these concerns. The facility's failure to provide timely assistance and clean clothing for Resident #32 demonstrates a deficiency in meeting the resident's needs and ensuring their comfort and dignity. Resident #327, admitted with diagnoses including metabolic encephalopathy, severe sepsis with septic shock, and cirrhosis of the liver, did not receive their scheduled weekly showers. The Kardex Report documented that the resident was to receive a shower or bath every Tuesday and Thursday, but the Bathing document showed that no bath or shower was given on the specified dates. Interviews with staff revealed that the Certified Nurse Aide was expected to inform the nurse if a resident refused a shower, and the nurse was to check at the end of the shift to ensure tasks were completed. The Director of Nursing stated that audits should be performed to ensure resident care was completed, but this was not done for Resident #327. The facility's failure to provide the scheduled showers for Resident #327 indicates a deficiency in meeting the resident's hygiene needs and ensuring their well-being.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 171 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Van Rensselaer Manor | 1 mi | ★★★★★ | 22 | 0 |
| Eddy Memorial Geriatric Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Eddy Heritage House Nursing And Rehabilitation Ctr | 3 mi | ★★★★★ | 9 | 2 |
| Hudson Park Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Rosewood Rehabilitation And Nursing Center | 4 mi | ★★★★★ | 55 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.