TROY, NY - Federal inspectors documented widespread care failures at Troy Victorian Rehabilitation & Nursing Care Center during a May 9, 2025 inspection, finding the facility consistently operated below required staffing levels while residents experienced dangerous medication errors and extended delays in basic care.
The 120-bed facility housed 108 residents during the inspection but operated with only six licensed nurses and ten certified nurse aides across both floors - falling significantly short of the facility's own staffing assessment requirements.
Residents Report Hours-Long Care Delays
During a surveyor-led group meeting, five residents reported that insufficient staffing prevented them from receiving adequate care. Resident #22 described waiting one to three hours after using their call light before receiving assistance, often involving urgent bathroom needs that resulted in prolonged periods lying in wet bedding.
"When they put their call light on, some Certified Nurse Aides would come into the room and tell them that they were not their aide, then turn the call light off, leave the room and not come back," according to the inspection report.
The facility's ombudsman confirmed that leadership turnover had created ongoing staffing challenges, directly impacting resident care quality. Staff members told residents they were too understaffed to provide showers, a basic hygiene requirement.
Chronic Violation of Minimum Staffing Standards
Federal regulations require nursing homes to maintain adequate staffing to meet resident needs. Troy Victorian's own facility assessment, last updated in September 2024, established minimum staffing requirements that included:
- 11 certified nurse aides for day shifts - 11 certified nurse aides for evening shifts - 6 certified nurse aides for night shifts - 5 licensed practical nurses per shift during days and evenings
Inspection records from March through April 2025 revealed the facility consistently failed to meet these minimums. For example, on March 16, day shift staffing included only 5 certified nurse aides instead of the required 11. Night shifts frequently operated with just 2-3 aides instead of 6.
Certified Nurse Aide #1 confirmed to inspectors that staff regularly reported their inability to provide basic services like incontinence care, showers, and bed baths due to inadequate staffing levels.
Dangerous Medication Administration Failures
The inspection revealed a 36 percent medication error rate for one resident, far exceeding the federal maximum of 5 percent. Licensed Practical Nurse #7 consistently administered medications 1 hour and 45 minutes late, affecting critical treatments including heart medications, blood thinners, and respiratory treatments for Resident #6.
When questioned about the delays, the nurse stated they were "always this late with their morning medication pass because they had 28 residents with a lot of medications" and were "unable to administer them on time."
Multiple residents received incorrect medications or missed doses entirely:
- Resident #416 received 40 units of Lantus insulin without a physician's order, requiring emergency intervention when blood glucose levels dropped dangerously low - Residents #10 and #70 did not receive prescribed antibiotic eye treatments as ordered - Resident #107 missed antibiotic doses due to claimed medication shortages
Critical Safety Violations in Drug Management
Inspectors discovered serious breaches in controlled substance protocols. Narcotic storage areas had broken locks, with some medications stored improperly on mobile carts rather than in secured compartments as required by federal law.
Staff failed to properly document narcotic counts during shift changes, creating potential for drug diversion. Multiple medication containers lacked proper expiration date labeling, including insulin pens and injectable solutions that could pose serious risks if administered beyond their effective timeframe.
The facility also lacked required monthly pharmacist reviews for January, February, and March 2025, meaning no qualified professional evaluated medication regimens for all residents during that period.
Food Safety and Infection Control Concerns
Kitchen facilities violated food safety standards with malfunctioning dishwashing equipment that failed to maintain proper sanitization temperatures. The automatic dishwasher's final rinse operated at zero pounds per square inch instead of the required 15-25 psi, potentially exposing residents to foodborne illness.
Test meals evaluated by inspectors were deemed "unpalatable," with overcooked vegetables, dry meat, and poor overall food quality. Resident #61 described meals as "usually inedible, often unidentifiable, and not what was on the meal ticket."
Infection control protocols were inadequately implemented. Resident #64, who had an indwelling catheter requiring enhanced barrier precautions, lacked proper protective equipment and signage. Medical equipment was stored improperly, with nebulizer masks left uncovered on bedside tables instead of being properly cleaned and stored in protective bags.
Facility Infrastructure and Safety Issues
Basic safety systems showed significant deficiencies. Call bell systems in resident rooms #203 and #320 were completely non-functional, leaving residents unable to summon help in emergencies. Work orders documented 10 instances of call bell repairs between October 2024 and April 2025, indicating ongoing maintenance problems.
Handrails throughout the facility had broken plastic sections with sharp edges that could injure residents. The building exterior showed signs of neglect with moss and algae growth, accumulated construction debris, and improperly positioned garbage dumpsters.
Carbon monoxide detection equipment in the main kitchen was found on a shelf rather than properly installed near gas-fired equipment, violating fire safety codes.
Medical Record Documentation Failures
Nursing documentation failed to accurately reflect resident conditions and treatments. For Resident #61, daily Medicare notes incorrectly stated the resident had "no wounds" while physician assistant notes from the same period documented multiple wounds on extremities and buttocks requiring active treatment.
Residents receiving antibiotic treatments for infections had no corresponding nursing progress notes documenting their condition, treatment response, or recovery progress, making it impossible to track care quality or treatment effectiveness.
Regulatory Response and Ongoing Oversight
The violations carry potential penalties including fines, increased oversight, and possible restrictions on new admissions. Federal regulations require nursing homes to maintain minimum quality standards to participate in Medicare and Medicaid programs.
Families evaluating care options should verify current staffing levels, review recent inspection reports, and ask specific questions about medication administration protocols and safety procedures. The full inspection report provides detailed documentation of each violation and the facility's required corrective action plan.
The facility's management has committed to addressing the identified deficiencies, though the scope and systemic nature of the violations suggest significant operational changes will be necessary to ensure resident safety and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diamond Hill Nursing and Rehabilitation Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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