Troy Victorian Rehabilitation & Nursing Care CNTR

In the surveyor’s words

From the most serious findings on record at Troy Victorian Rehabilitation & Nursing Care CNTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 9, 2026

  Based on record reviews and interviews during survey, the facility failed to ensure residents at risk of elopement remained under supervision for two (2) (Resident's #5 and #9) of four (4) residents reviewed for elopement risk. Specifically, (a.) Resident #5 left the faciity on [DATE] without the facility's knowledge and was not located until hours later; and (b.) Resident #9 was able to exit the facility on 11/16/2025 and was located shortly after on facility grounds. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #5's health and safety, and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy for Resident #9.This is evidenced by:The policy and procedure titled, Elopement, dated 07/14/2021, stated if an employee… […]

• Immediate jeopardy, isolatedF689Jul 5, 2024

  Based on observations, interviews, and record reviews conducted during an Abbreviated survey (Case # NY00345181), the facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for 1 (Resident #1) of 3 residents reviewed for elopement. Specifically, on 6/11/2024, Resident #1 was observed leaving the facility through the front entrance. The facility did not put any measures in place to prevent further elopements. Subsequently, on 6/14/2024, Resident #1 was observed in the parking lot by facility staff and was brought back into the facility. […]

• Actual harm, isolatedF600May 9, 2025

  Based on record review and interviews during a recertification and abbreviated survey (Case #s NY00344251 and NY00355131), the facility did not ensure residents were free from abuse and neglect for three (3) (Resident #s 48, 78, and 416) of nine (9) residents reviewed. Specifically, (a.) Resident #416, who was a two (2)-person maximum assist with mechanical lift for transfers, was transferred by two (2) Certified Nurse Aides via stand pivot on 6/04/2024. Resident #416 was reportedly lowered to the floor during the transfer from chair to bed and later that evening diagnosed with a left femur (leg bone) fracture. (b.) Resident #48, who was known to have aggressive behaviors, struck Resident #78 on their eye while grabbing a personal item from Resident #78 on 9/22/2024. […]

• No harm, potential for more than minimal, widespreadF584May 9, 2025

  Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00353853, NY00355929, NY00356190, and NY00357360), the facility did not provide effective housekeeping and maintenance services on two (2) of two (2) resident units. Specifically, floors, walls, ceilings and tables were not clean or maintained. This is evidenced by: During observations on 5/05/2024 at 10:00 AM, the second-floor unit corridor floors were sticky when walked upon. […]

• No harm, potential for more than minimal, widespreadF656May 9, 2025

  Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (case # ' s NY00362000 and NY00379563), the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 16 (Residents #s 6, 10, 13, 28, 31, 37, 52, 61, 70, 72, 86, 103, 107, 262, 413, and 415) of 32 residents reviewed for Care Plans. […]