Troy Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Troy Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 19, 2022

  Based on observations, medical record review, review of the facility's investigation, interviews with facility staff, and review of the facility's policy on elopement, the facility failed to ensure staff provided adequate supervision to prevent a resident, with a history of exit seeking behavior, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#64) was placed at potential risk for serious life-threatening harm and injury when she eloped from the facility without staff knowledge. Resident #64 was missing for approximately 30 minutes and was found by the local police approximately 0.2 miles from the facility at an apartment complex, knocking on the door of a residence asking to be let in. […]

• Actual harm, isolatedF760Dec 16, 2024

  Based on medical record review, staff, Nurse Practitioner (NP) #447, Physician #448 and Neurologist #449 interviews, review of medication information from Medscape, and policy review, the facility failed to appropriately reconcile medications following a hospital re-admission resulting in a significant medication error. This resulted in Actual Harm when Resident #96 was readmitted from the hospital on 10/03/24 and the facility failed to appropriately reconcile the resident's transfer orders resulting in the resident's anticonvulsant medication being abruptly stopped on 11/06/24 and Resident #96 subsequently began having seizure activity on 11/11/24 which resulted in re-hospitalization . This affected one (#96) of one resident reviewed for hospitalization . […]

• No harm, potential for more than minimal, widespreadF880Jan 8, 2025

  Based on record review, review of hospital documentation, staff interview, local health department interview, review of Legionella water testing, review of electronic mail (email) correspondence, and policy review, the facility failed to implement their water management policy and respond to the local health department (LHD) recommendations to remediate their water system to reduce the presence of microorganisms including Legionella. This affected one (#129) of three residents reviewed for Legionella and had the potential to affect all 128 residents residing in the facility. The facility census was 128. Findings include: Review of medical record for Resident #129 revealed an admitted [DATE] and discharge date of [DATE]. […]

• No harm, potential for more than minimal, patternF689Apr 7, 2026

  Based on observation, review of medical records, resident and staff interviews, and review of facility policy, the facility failed to ensure residents smoked only in the designated smoking areas and failed to ensure the safety of a vulnerable resident while on leave of absence (LOA). This affected four (#16, #73, #108, and #131) of twenty-eight residents reviewed for smoking and one (#50) of six residents reviewed for accidents. The census was 133.Findings include: 1. Review of Resident #50's medical record revealed an admission date of 09/26/25. Diagnoses included schizophrenia, bipolar disorder, left below the knee amputation, and peripheral vascular disease. […]

• No harm, potential for more than minimal, patternF921Apr 7, 2026

  Based on observation and resident and staff interviews, the facility failed to provide a safe and sanitary environment for residents. This affected #1, #29, and #91 and had the potential to affect the 48 residents who utilized the B-hall shower rooms. The facility census was 133.Findings include: 1. Observation on 04/06/25 at 8:21 A.M. of the B-hall shower rooms, left and right shower rooms, revealed in the right shower room, it was observed to have large brown/black spots on the floor around the toilet and into the shower area which appeared to have a wheel pattern streak on the floor. The shower stall had missing tiles near the floor and a hole approximately 12 inches by 12 inches, six inches above the floor in one of the corners of the stall. […]