N Y S Veterans Home

In the surveyor’s words

From the most serious findings on record at N Y S Veterans Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Oct 6, 2023

  Based on record review and interview during the recertification survey conducted 10/2/2023-10/6/2023, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility annual water Legionella (a type of bacteria usually found in water causing Legionnaires' disease) testing was not completed in 2022 through September 2023; and the annual facility risk assessment and environmental assessment of water systems in healthcare settings was not completed in 2022 as required. […]

• No harm, potential for more than minimal, isolatedF690May 16, 2025

  Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not provide the necessary services and treatment for indwelling urinary catheter use for one (1) of three (3) residents (Resident #8) reviewed. Specifically, Resident #8 was not receiving staff assistance with changing or emptying their urinary drainage collection bag as planned. Findings include: The facility policy Indwelling Urinary Catheter Care and Management, revised 11/18/2024 documented to monitor for changes in urine output, notify the medical provider of abnormal findings, empty the drainage bag reguarly, inspect the catheter system to ensure it was a sterile continous closed system, and replace the system with a sterile no-touch technique if… […]

• No harm, potential for more than minimal, isolatedF692May 16, 2025

  Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #33) reviewed. Specifically, Resident #33 had poor oral intake with significant weight loss and was not assessed by the registered dietitian and the facility medical providers were not made aware of the weight loss. Findings include: The facility policy Mealtime Monitor and Nourishment Monitor Records, revised 1/27/2025, documented the unit meal and nourishment intakes were recorded by the nursing staff in the electronic medical record which was used for resident clinical assessments. […]

• No harm, potential for more than minimal, isolatedF610Jun 11, 2024

  Based on interview, observation, and record review during the abbreviated survey (NY00331758), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were investigated or reported to the New York State Department of Health as required for 1 of 4 resident (Resident #1) reviewed. Specifically, Resident #1 had a bruise and fracture of unknown origin and an investigation to rule out abuse, neglect, or mistreatment was not initiated. In addition, the injuries of unknown origin were not reported to the New York State Department of Health as required. Findings include: The facility policy Abuse, Neglect, Mistreatment dated 11/28/2017, documented the facility was to ensure all residents were free from abuse, neglect, or exploitation. […]

• No harm, potential for more than minimal, isolatedF805Oct 6, 2023

  Based on observation, record review, and interview during the recertification and abbreviated (NY00317113) surveys conducted 10/2/2023-10/6/2023, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #79) reviewed. Specifically, Resident # 79 was provided food items that were not consistent with their physician ordered diet. Findings include: The facility policy Communication of Dietary Orders and Resident Nutrition revised 7/6/2023 documented that purpose of the policy was to ensure accurately prescribed diets are followed. The medical provider writes the diet order in the activities of daily living (ADL) Optimum Order Entry section of the electronic medical record. […]