Ten Broeck Commons

In the surveyor’s words

From the most serious findings on record at Ten Broeck Commons, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 12, 2026

  Based on observation and interview the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated foods were stored in the kitchen refrigerator and unit pantry, and eight (8) cups of pre poured undated almond milk at the bedside of Resident #160; 2) expired foods were stored in the dry pantry, walk in cooler, and reach-in refrigerator; 3) staff were observed not wearing hair and beard restraints while in the kitchen; 4) ice packs were observed in the Catskill unit pantry freezer; and 5) staff were observed not changing gloves between tasks.The findings include: The policy last revised 10/2025 titled Storage of Non-Perishable Foods documented, Dry goods (grains) shall be stored for a period… […]

• No harm, potential for more than minimal, widespreadF880Jan 12, 2026

  F880 AMBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the annual water sampling report for the year 2025 was missing, the annual facility assessment for legionella and required components were missing and not provided at time of survey. The findings are: During a review of facility records on 01/05/2026 at 10:00 AM, a water temperature log documented chlorine was added. A vendor service report dated 11/2025 had a sticker attached that documented the water report was due 12/2024. A lab report for legionella testing was dated 11/27/2024. […]

• No harm, potential for more than minimal, isolatedF550Jan 12, 2026

  Based on observations, interviews, and record review conducted during the recertification survey from 1/5/2026-1/22/2026 the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life for 1 of 1 resident (Resident #43) reviewed for Dignity. Specifically, Resident # 43 was observed out of bed wearing socks that were labeled with the resident's name in front of the sock clearly visible to other residents, visitors and staff. […]

• No harm, potential for more than minimal, isolatedF657Jan 12, 2026

  Based on observations, interviews, and record review during the recertification survey from 01/05/2026-01/12/2026, the facility did not ensure that the Comprehensive Care Plan was revised to reflect changes and/or new interventions for one (1) of six (6) residents (Resident #71) reviewed for Accidents, and one (1) of three (3) residents (Resident #139) reviewed for Activities. Specifically, 1) Resident #71 had a behavior of wandering, entering other residents' rooms and laying in other residents' beds, and the behavior care plan did not reflect this behavior or interventions for the behavior; 2) Resident #139's care plan had not been revised to reflect their current activities they participated in.The findings included:The facility policy Care Planning last reviewed 02/2025 documented that… […]

• No harm, potential for more than minimal, isolatedF686Jan 12, 2026

  Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care was provided to prevent pressure ulcers for 1 of 5 residents (#9) reviewed for pressure ulcers. Specifically, Resident #9 had a physician order for offloading gel boots, to be worn at all times, and was observed without the gel boots. The findings include: Resident #9 had diagnoses including Cerebral Infarction, Type 2 diabetes mellitus, hemiplegia. The Quarterly Minimum Data Set, dated [DATE] documented the resident's cognition was intact, the resident required substantial to max assist with all activities of daily living. The resident was at risk for pressure ulcers and pressure relieving devices for both the chair and bed were used. […]