Taconic Rehabilitation And Nursing At Ulster

In the surveyor’s words

From the most serious findings on record at Taconic Rehabilitation And Nursing At Ulster, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 7, 2022

  Based on observations, record review and interviews conducted during a Recertification Survey and Abbreviated Survey (#NY 2), the facility failed to ensure that resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents. This has the likelihood to cause harm due to lack of supervision during meals for residents who are at risk for choking, and lack of provision to ensure the proper and accurate distribution of resident meal trays. Specifically, Resident #284 has diagnoses, which include Dysphagia, and Dementia. The physician's order indicated the resident was NPO (nothing by mouth) and received a gastrostomy tube (G-Tube) feeding. […]

• Actual harm, isolatedF684Mar 12, 2025

  REVISED 6/10/2025 IIDR Based on observation, record review, and interview conducted during the recertification survey from 3/5/2025 through 3/12/2025, the facility did not ensure residents received quality of care in accordance with professional standards of practice for one (1) of four (4) residents reviewed for accidents. Specifically, on 12/12/24, Resident #69 was observed ambulating to the bathroom in their room unassisted, as Certified Nurse Aide # 8 assisted the resident their legs became weak, and the resident was lowered to the floor. Certified Nurse Aide #8 left Resident #69 to seek help, upon return Resident #69 was found in a different position, complained of pain to the right side of lower back, and sustained a hematoma (bruise) to the face. […]

• No harm, potential for more than minimal, patternF760Aug 27, 2026

  Based on record review and interviews conducted during an Abbreviated Survey, the facility did not ensure that one (Resident #3) of three residents reviewed for medication administration was free of significant medication errors. Specifically, Licensed Practical Nurse #10 entered the wrong order for morphine for Resident #3 on 06/26/2026. The physician order entered by Licensed Practical Nurse #10 and transmitted to the pharmacy documented Morphine Sulfate Concentrate Solution 20 milligrams per milliliter to give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The pharmacy dispensed and delivered Morphine 10 milligrams/0.5 milliliter oral syringes with directions to give 0.25 milligram (one syringe) every four hours as needed for pain. […]

• No harm, potential for more than minimal, isolatedF684Aug 27, 2026

  Based on observations, record reviews and interviews conducted during the Abbreviated Survey, the facility did not ensure necessary care and services were provided to timely identify and monitor changes in skin integrity for one (Resident #2) of three residents reviewed for quality of care. Specifically, Resident #2 who was care planned as at risk for impaired skin integrity and needed daily skin monitoring and checks as well as weekly skin checks on shower days was identified with a small skin opening to the right buttock during a shower on 10/16/2025. The area was later evaluated by the facility's wound care doctor, a physician assistant, and identified as a Stage three pressure injury on 10/16/2025. […]

• No harm, potential for more than minimal, isolatedF689Aug 27, 2026

  Based on observations, record review, and interviews conducted during an Abbreviated Survey, the facility did not ensure the resident environment remained as free from accident hazards as possible and did not ensure residents received adequate supervision to prevent accidents for two residents (Residents #4 and #6) of five residents reviewed for accidents. Specifically, 1. On 06/26/2026, Licensed Practical Nurse #7 reported to Registered Nurse Supervisor #2 that Licensed Practical Nurse #8 left their medication cart opened and Resident #4 with moderately impaired cognition with documented wandering behaviors, accessed the cart and was found by Certified Nurse Aides #5 and #6 in the day room with medications in their lap. […]