Troy Victorian Rehab: Care Plan Failures Leave Residents Untreated - NY
The May inspection at Troy Victorian Rehabilitation & Nursing Care Center found that half of the 32 residents reviewed lacked proper care plans to address their medical needs. Sixteen residents had incomplete or missing care plans for conditions ranging from severe leg swelling to untreated pressure sores.
Resident 28, who suffered from chronic lung disease and heart problems, had legs so swollen that inspectors described them as "severely edematous." When asked what the facility did to help, the resident said staff would occasionally wrap the legs "but not very often." The resident added that sometimes the legs would weep fluid.
Despite the obvious severity of the condition, inspectors found no care plan interventions for the resident's swelling or cellulitis. The facility's medication and treatment records for May showed no documentation addressing either condition.
"There should have been an assessment and plan for residents' edema and cellulitis," Registered Nurse 3 told inspectors on May 6. The nurse admitted not knowing why no plan existed and said interventions should have been listed in both the comprehensive care plan and treatment records.
The care planning failures extended far beyond a single resident. Inspectors documented systematic breakdowns across the facility's 16 violations.
Resident 415's care plan contained only blank templates with prompts like "Resident is at risk for/has skin impairment due to:" followed by empty spaces. The baseline plan stated the resident "has an ostomy" without any evidence this was true. Meanwhile, the resident developed a stage 2 pressure sore in March that progressed to an unstageable wound by late March, but the care plan was never updated.
A nursing note from March 6 documented that Resident 415 had developed "moisture-related redness and maceration" to their buttocks. The wound care specialist noted the pressure sore had increased in size and progressed from stage 2 to stage 3 with moderate drainage by March 21. By March 27, the wound had become unstageable.
None of these developments triggered updates to the resident's care plan.
"I worked on the care plans but was severely in need of help," Registered Nurse 1 told inspectors. "I was told I would receive an assistant last year, but it had not happened. I worked passing medications, acted as an aide, and spent most of my time working to provide resident care on the unit."
The inspection revealed care plans that endangered residents through incomplete implementation. Resident 72's fall prevention plan called for bedside floor mats and keeping the bed in a low position. Yet incident reports from March showed the resident fell from bed twice when floor mats weren't in place, and once when the bed was left in the high position rather than low as directed.
"I had not been aware that interventions on the comprehensive care plan were not flowing automatically to the certified nursing assistant Kardex," Registered Nurse 1 said when asked why safety measures weren't followed. The nurse said the low bed for the resident had been ordered but was on back order.
Some residents faced risks from care plans that contained no actual interventions. Resident 103's "Risk for Abuse" care plan, initiated April 26, contained no interventions whatsoever for preventing abuse. The registered nurse responsible for care plans told inspectors they "did not know why there were no interventions listed."
The facility's screening failures compounded the care planning problems. Resident 31, admitted with bipolar disorder, had a pre-admission screening that incorrectly listed dementia instead of the serious mental illness. Resident 103, who lived in a group home overseen by the New York State Office of Mental Health and carried a schizophrenia diagnosis, received no Level II mental health evaluation despite federal requirements.
"I would consider the diagnosis of schizophrenia as a serious mental illness," Social Worker 1 told inspectors. "I was surprised there was no Level II referral for Resident 103."
Corporate Social Worker 1 acknowledged that "a diagnosis of schizophrenia should have triggered the request for a Level II evaluation" and said appropriate referrals would be made after compiling a list of residents with mental health diagnoses.
The medication management reflected the broader care planning chaos. Resident 13's allergy care plan, last updated April 16, listed cholecalciferol as a medication allergy. Yet physician orders from April 15 prescribed the same medication, and medication records showed the resident received it throughout April and May.
Registered Nurse 1, responsible for updating care plans, said they "were not aware of the conflicting allergy care plan."
Care plan meetings, required to review and update resident needs, had been abandoned for some residents entirely. Resident 97 hadn't attended a care conference since admission in November 2024.
"I had not been invited to a care conference but would like to attend one," the resident told inspectors in April.
Social Worker 1 initially said care plan meetings were held quarterly and annually as required, but later admitted they "weren't aware Resident 97 hadn't had a care meeting" and would investigate.
The inspection found residents receiving inadequate treatment for visible medical conditions. Resident 6 had feet described as "dry, scaly, and peeling" with no documented treatment. Resident 61 showed signs of cellulitis on February 19, but nursing staff failed to monitor the condition for two weeks until the resident was finally seen by a provider on March 4.
Resident 262 was supposed to receive ace wraps as ordered by their provider, but the facility failed to administer them.
The systematic failures left the facility's most vulnerable residents without proper oversight. Registered Nurse 1's admission of being overwhelmed with multiple duties while lacking promised assistance highlighted the resource constraints that contributed to the widespread care planning breakdowns.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, but the scope affected many residents across fundamental aspects of care planning and treatment implementation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Troy Victorian Rehabilitation & Nursing Care Cntr from 2025-05-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TROY VICTORIAN REHABILITATION & NURSING CARE CNTR in TROY, NY was cited for violations during a health inspection on May 9, 2025.
Sixteen residents had incomplete or missing care plans for conditions ranging from severe leg swelling to untreated pressure sores.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.