New York State Veterans Home At Montrose

In the surveyor’s words

From the most serious findings on record at New York State Veterans Home At Montrose, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 24, 2026

  Based on observations, interviews, and record review conducted during survey (2695131), the facility failed to ensure that a resident received supervision and devices necessary to prevent accidents for one (1) (Resident #6) of three (3) residents reviewed for accidents. Specifically, Resident #6 had eight (8) falls between 10/06/2025 and 03/17/2026. On 03/17/2026 Resident #6 fell and sustained a laceration to the back of their head requiring six (6) stitches. This resulted in actual harm to Resident #6 that was not Immediate Jeopardy.The findings are:The undated facility policy titled Accident and Incident Reporting documented fall risk assessments were completed by registered nurses quarterly, annually, upon significant change, and after a fall. […]

• Actual harm, isolatedF600Mar 11, 2026

  Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure a resident's right to be free from physical abuse. This was evident for one (1) (Resident #1) of four (4) residents reviewed for abuse. Specifically, on 03/01/2026 Certified Nurse Aide #1 is observed on video surveillance that was provided by Resident #1's representative, in Resident's #1 room striking the resident on the top of their head with a broom, grabbing Resident #1 by the neck and placing them in a reclining back wheelchair, and using their left hand to strike Resident #1 on the left side of their neck. Facility staff confirmed they observed recorded video footage on 03/02/2026 of Certified Nurse Aide #1 striking Resident #1 on the left side of their neck on 03/01/2026. […]

• Actual harm, isolatedF604Apr 3, 2025

  Based on record review and interviews during an abbreviated survey (NY00375411), the facility did not ensure that a resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for one (1) of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 Resident #1 was seen on Facility Surveillance Camera Footage wandering the hallway to the adjacent unit. Resident #1 was seen going in and out of other resident's rooms. Security Officer #1 was observed grabbing Resident #1 by their wrist to keep the resident in one place. Resident #1 is observed on surveillance camera footage in a wheelchair and trying to propel themselves away from the staff. […]

• Actual harm, isolatedF605Apr 3, 2025

  Based on record review and interviews during an abbreviated survey (NY00375411) the facility did not ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) out of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 the facility staff administered intramuscular anti-psychotic medication to Resident #1. Resident #1 was seen on a surveillance camera wandering on the unit and going in and out of other resident's rooms. […]

• No harm, potential for more than minimal, patternF725Jun 4, 2025

  Based on record review and interview conducted during the Recertification and Abbreviated surveys (NY 00350287) from 05/28/25 to 06/04/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 3 of 21 days from 7/15/24 through 8/4/24 and 2 of 31 days from 5/1/25 through 5/31/25 the facility did not meet minimum staffing requirements for Certified Nurse Aides as documented in the Facility Assessment. The findings included: The Facility Assessment, revised 1/2025, documented the following minimum requirements. Day shift: five Registered Nurses, one Licensed Practical Nurse, and twenty-two Certified Nurse Aides. […]