F-F600: Free from Abuse and Neglect

The facility ' s Policy and Procedure Titled, Abuse Prevention and Reporting, last revised 4/2024, documented, the purpose is to protect all residents and provide a safe environment. Abuse is defined as inappropriate physical, verbal or mental contact which harms or is likely to harm a resident. Upon receiving a report of suspicion of abuse of any kind, mistreatment, neglect or misappropriation of property, supervisory/administrative staff are required to immediately initiate an investigation into the alleged incident.

iv. All abuse investigations will be reviewed by the Administrator, Medical Director and Director of Nursing.

v. Determination of validity of report must be made in the most-timely fashion possible in order to comply with reporting requirements as stated in the most current version of the Incident Reporting Manual (August 2016 as of this writing)

vi. If deemed a reportable incident, reporting of the incident is to be made in accordance with the requirements stated in manual for specific incident. Reference appended table for categories of incidents and reporting time frame requirements.

vii. Notification is to be made to local police authorities as well as the Attorney General ' s Office as appropriate.

Resident #48

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Resident #48 was admitted to the facility with the diagnoses of Diabetes type 2 (when the body cannot use insulin correctly and sugar builds up in the blood); Dementia (loss of the ability to think, remember, and Level of Harm - Minimal harm or reason to levels that affect daily life and activities); and major depressive disorder (a mood disorder that potential for actual harm causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 01/28/2025, documented the resident was able to be understood and was able to understand others Residents Affected - Some with moderate cognitive impairment.

Resident #78

Resident #78 was admitted to the facility with the diagnoses of Aphasia (a disorder that affects how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written) following cerebral infarction (disrupted blood flow to the brain), and apraxia (when a person is unable to perform tasks or movements when asked). The Minimum Data Set (an assessment tool) dated 03/20//2025 documented the resident was able to be understood and was able to understand others with moderate cognitive impairment.

The Comprehensive Care Plan dated 9/23/2024 with focus: Resident #48 has potential to be an aggressor related to mental illness. Interventions include: (1) Administer medications as ordered. (2) Analyze key times, places, circumstances, triggers and what de-escalates behavior. (3) Assess and anticipate resident needs (4) Monitor residents closely when they are around other residents.

The facility Investigative Summary dated 9/22/2024 documented an alleged resident to resident altercation between Resident #s 48 and 78. Specifically that Resident #48 struck Resident #78 in the face while grabbing a personal item from Resident #78. The summary with conclusion was signed by Assistant Director of Nursing Services #2 on 9/22/2024.

There was no documented evidence the facility reported the results of the investigations to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation was verified appropriate corrective action was taken.

During an interview on 04/30/2025 at 10:30 AM, Director of Nursing #1 stated they did not have the Investigative File for review. The previous administrator did not leave the file where it could be located. They would have to recreate the file.

Resident #416

Resident #416 was admitted to the facility with the diagnoses of right hemiplegia (paralysis of one side of the body) following a cerebral infarction (disrupted blood flow to the brain); Parkinson ' s Disease (a movement disorder of the nervous system that worsens over time), and Muscle Weakness (when muscles aren't as strong as they should be). The Minimum Data Set (an assessment tool) dated 5/30/2024, documented the resident was able to be understood and was able to understand others with severe cognitive impairment.

The Comprehensive Care Plan Titled Activities of Daily Living revised 4/16/2024, documented shower transfer - dependent (assist of two (2)) mechanical lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Nursing progress note dated 6/4/2024 documented, upon entering resident ' s room resident was lying on the floor alongside bed. Resident appeared out of their norm, vital signs were blood pressure 84/68, pallor noted, Level of Harm - Minimal harm or Neurological assessment were within normal limits; lower extremities could not be assessed. Resident was potential for actual harm assisted off of floor via Hoyer lift. Family insisted on sending resident to hospital for further evaluation, 911 was called and resident transferred to hospital. Residents Affected - Some

The Nursing Home Facility Incident Report was submitted by Administrator #2 on 6/4/2024 at 10:07 AM to

the State Survey Agency.

There was no documented evidence the facility reported the results of the investigations to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action was taken.

During an interview on 5/08/2025 at 11:30 AM, Assistant Director of Nursing #1 stated the administrator handled the entire investigation and they did not have any part of investigation or reporting.

During an interview on 5/08/2025 at 11:49 AM, Director of Nursing #1 stated they were only in this position for three weeks; they were unaware of what took place regarding the investigation. They stated they believed

a Certified Nurse Aide was terminated due to failure to follow care plan. They further stated that they were aware completed investigations are to be submitted results to the New York State Department of Health agency within five (5) days.

During an interview on 5/08/2025 at 12:23 PM, Administrator #1 stated they had only been serving as administrator at this facility for a short time, that there were two previous administrators at the facility for a short time and some things were not filed as they should have been.

10 New York Codes, Rules, and Regulations 415.4(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48413

Residents Affected - Few Based on record review and interviews conducted during a recertification survey, the facility did not ensure

the facility conducted initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity and completed not less than once every 12 months for two (2) (Resident #s 28 and 415) of 32 residents reviewed for Comprehensive Resident Assessments. Specifically, (a) for Resident # 28, the Comprehensive Resident Assessments were not completed to assess

the patient's edema, and (b) for Resident #415, the Comprehensive Resident Assessments were not completed to assess items from their baseline care plan.

This is evidenced by:

Cross reference to

F-F636: Comprehensive Assessments & Timing

Facility Policy and Procedure titled, Change in a Resident ' s Condition or Status, documented the nurse manager/charge nurse would record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.

The Policy and Procedure titled, Skin Care, Routine Care/Prevention Protocol, reviewed/revised 11/1/2017, documented the purpose of the policy was to maintain skin integrity and prevent tissue breakdown. It documented all residents did not require a physician order unless specialty equipment was required. Procedure included apply named moisturizer to all areas of the skin prone to dryness after bathing. Report reddened areas or skin breakdown to the nurse.

Resident #61:

Resident #61 was admitted to the facility with diagnoses of displaced fracture of greater trochanter of right femur (fracture of upper part of thigh bone), multiple myeloma (cancer that forms in a type of white blood cell), and unspecified heart failure (a condition where the heart is not pumping effectively). The Minimum Data Set, dated dated dated [DATE REDACTED], documented the resident was cognitively intact, was able to make themselves understood and understood others.

Wound Care Note dated 2/13/2025 by Physician Assistant #1, documented the resident had an unmeasurable vascular wound (caused by poor circulation in the arteries or veins) on the left lower extremity.

The wound bed was 20 percent eschar (collection of dry, dead tissue within a wound) and 80 percent epithelial (refers to the epidermis, the outermost layer of skin, as it regenerates and covers a wound ' s surface). There was moderate drainage. The periwound (skin surrounding a wound) was intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Nursing Progress Note dated 2/19/2025 at 11:19 PM, documented that upon examination, the nurse observed that the area in question (left leg) was very red and exhibited pitting edema (occurred when excess Level of Harm - Minimal harm or fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit or indentation potential for actual harm will remain). The resident had decreased sensation in the affected area. Additionally, there were multiple blisters present, one of which was open. The supervisor was promptly notified of the findings. The area was Residents Affected - Some cleaned thoroughly with soap and water, ensuring all debris was removed. The cleaned area was then dried gently to prevent further irritation. The resident did not exhibit any immediate signs of discomfort during the treatment process. The nurse was placing a note in Nurse Practitioner communication book.

Review of the Nurse Practitioner communication book on 5/08/2025, documented an undated handwritten note for Resident #61: left leg open blisters. Treatment plan needs to be modified. Refer to note. Pitting edema.

Nursing Progress Notes dated 2/20/2025 to 3/03/2025, did not document Resident #61 ' s change in condition noted on 2/19/2025, was being monitored by nursing staff.

Review of orders dated February and March 2025 did not document an order for periodic skin checks.

Review of Wound Care Notes dated 2/20/2025 and 2/27/2025, did not document any new wounds on the resident ' s left leg. The skin assessment for the wound on the left lower extremity documented the same details of the wound as was previously documented on 2/13/2025.

Review of Daily Medicare Notes dated 2/21/2025, 2/25/2025, 2/27/2025, and 2/28/2025 by Registered Nurse #2, documented the resident had no wounds.

Nursing Progress Note dated 3/04/2025 at 8:27 AM by Licensed Practical Nurse #2, documented left leg redness. Blisters noted intact at this time. Licensed Practical Nurse #2 would have Nurse Practitioner #1 evaluate today. Resident #61 was encouraged to elevate lower extremity. Would continue to monitor.

Progress Note dated 3/04/2025 at 12:52 PM by Nurse Practitioner #1 documented the following: They were asked to see the resident for drowsiness, increased left lower extremity redness and drainage. Per the nurse manager, the resident had increased drowsiness and lower extremity wounds appeared worse despite treatments. Resident #61 stated, they would be better in a couple days. Vital signs were reviewed and stable. The resident had no complaint of pain. Physical exam of the skin documented bilateral lower extremity chronic skin changes, left lower ankle wound, positive odor, purulent drainage, erythema (redness), edema. Neurological documented positive sensation to extremities. Assessment documented lower extremity cellulitis and intravenous antibiotics were ordered to be given daily for five (5) days.

43805

Resident #28:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Resident #28 was admitted with the diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs resulting in swelling, irritation, and inflammation inside the airways Level of Harm - Minimal harm or that limit airflow into and out of the lungs), chronic ischemic heart disease (a long-term reduction in blood potential for actual harm flow to the heart muscle, often due to coronary artery disease), and cellulitis (a common bacterial skin infection that causes pain, redness, swelling, and warmth in the affected area). The Minimum Data Set, Residents Affected - Some dated dated dated [DATE REDACTED], documented that the resident was usually understood and could sometimes understand others, and required extensive assistance for most activities of daily living.

During an interview on 5/01/2025 at 10:57 AM, Resident #28 was observed sitting on the edge of their bed and had severely edematous legs. Resident #28 was asked what the facility did to help them with their legs, and they stated that the facility did nothing for them. The resident stated that sometimes the legs weep, and that staff would occasionally wrap them, but not very often.

A review of Resident #28's Comprehensive Care Plan had no interventions for the resident's edema or cellulitis.

A review of Resident #28 Medication Administration Record and Treatment Administration Record for May 2025 did not have any documentation addressing the resident's edema or cellulitis.

During an interview on 5/06/2025 at 11:46 AM, Registered Nurse #10 stated that there should have been an assessment and plan for residents' edema and cellulitis, and did not know why there was none. They stated that there should have been interventions listed for these issues in the comprehensive care plan, as well as

the medication administration and treatment administration records.

48413

Resident #6:

Resident #6 was admitted to the facility with diagnoses of congestive heart failure, chronic obstructive pulmonary disease, and muscle weakness. The Minimum Data Set (an assessment tool) dated 3/06/2025 documented the resident was able to be understood, was able to understand others, and was cognitively intact.

During an observation on 4/29/2025 and 4/30/2025, the resident's feet appeared to be dry, scaly, and peeling.

During an interview on 4/29/2025, the resident denied pain.

A review of the Medication Administration Record and Treatment Administration Record for March 2025 and April 2025 documented there were no treatments ordered for the resident's feet.

A review of the resident's care plan titled At Risk for Skin Breakdown did not address care for the resident's feet.

The Medical Provider Order dated 4/28/2025 documented podiatry (foot doctor) consultation as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of the resident's medical record showed there were no podiatry visits documented.

Level of Harm - Minimal harm or During an interview on 05/06/2025 at 10:46 AM, Registered Nurse #1 stated there was no order for lotion or potential for actual harm foot care for the resident. They stated a new podiatrist would be starting at the facility soon.

Residents Affected - Some 10 New York Code of Rules and Regulations 415.12

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 48744 potential for actual harm Based on record reviews and interviews during the recertification and abbreviated survey (Case #s Residents Affected - Few NY00362000 and NY00377938), the facility did not ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident # 413) of two (2) residents reviewed. Specifically, for Resident #413, (a.) treatment for a Stage 2 pressure ulcer was not initiated on 11/04/2024 when an open area was noted on the coccyx until 11/07/2024; (b.) Resident #413 ' s care plan was not updated to include goals, treatments, or interventions related to the discovery of this pressure ulcer; (c.) there was no documented evidence of weekly assessment as recommended on 11/07/2024.

This is evidenced by:

51317

The facility policy and procedure titled, Pressure Ulcer Prevention, dated 3/01/2024, documented it was the policy of the facility to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation included reviewing the resident ' s care plan and identifying risk factors as well as interventions designed to reduce or eliminate those considered modifiable. Inspect the skin daily when performing or assisting with personal care or activities of daily living. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis.

The facility policy and procedure titled, Protocols for Treatment of Pressure Ulcers Pressure Ulcers/Injuries (undated), documented weekly wound rounds, and wound meetings were to occur to evaluate the progress of treatment and change and update treatment if needed. Nursing evaluated daily and documented/notified medical doctor if any signs of deterioration, infection, significant change were present. Team members for wound rounds included the medical director/wound care specialist, wound care nurse or designee, unit manager, Registered Nurse supervisor or designee, rehabilitation staff, dietician, and consultant surgeon, wound medical doctor (whenever necessary). If a pressure ulcer failed to show some evidence of progress towards healing the pressure ulcer and the resident ' s clinical condition should be reassessed. When residents were identified as at risk for pressure ulcer and/or diagnosed with an actual site, a care plan would be implemented. Care plan would reflect each resident ' s identified needs, efforts implemented to promote prevention and/or healing, and continued evaluation. Residents with pressure ulcers would have their care plans updated.

Resident #413 was admitted to the facility with diagnoses of type 2 diabetes (a chronic condition that happens when the body cannot use insulin correctly and sugar levels build up in the blood) dementia, unspecified severity, with other behavioral disturbances (loss of memory) and hypertensive chronic kidney disease (a condition where high blood pressure damages the kidneys, leading to a decline in kidney function). The Minimum Data Set (an assessment tool) dated 9/03/2024, documented the resident had moderate cognitive impairment, could be understood and understand others. The Minimum Data Set Documented Resident #413 was at risk of developing pressure ulcers/injuries, and did not have one or more unhealed pressure ulcers/injuries.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 The Comprehensive Care Plan for Skin Integrity: At Risk for Skin Breakdown, effective 10/24/2024, documented Resident #413 was at risk for skin breakdown. Interventions included: Use pressure reducing Level of Harm - Minimal harm or cushion when in wheelchair. potential for actual harm

Review of Treatment Administration Record for November 2024 documented on 11/01/2024 from 3:00 PM to Residents Affected - Few 11:00 PM through 11/03/2024 11:00 PM to 7:00 AM shift to evaluate and document skin check of identified at-risk skin area each shift. All of these dates/shifts documented either intact skin, no issues, or none. On 11/04/2024 on the 3:00 PM to 11:00 PM shift, the Treatment Administration Record documented an opening

on Resident #413 ' s coccyx (tail bone) that was cleaned and covered.

There was no documented evidence of progress notes or wound assessment on 11/04/2024 that Resident #413 had an opening on the coccyx that was cleaned and covered.

Progress note written by Nurse Practitioner #1 dated 11/05/2025 at 1:27 PM documented staff reported an open area to coccyx discovered this morning. No reported injury. Resident #413 was incontinent of bowel and bladder at times, non-ambulatory, used a wheelchair. Progress notes documented decubitus (pressure injury to the skin and underlying tissues that occurred when prolonged pressure was exerted on the body, particularly over bony areas) ulcer of coccyx, Stage 2. No signs of infection. Treatment included trial Santyl once a day with dry dressing, wound care team consult, offload.

Physician Order dated 11/07/2024 10:28 AM documented Santyl 250 unit/gram topical ointment. Apply one (1) film by topical route once daily and as needed. Cleanse the sacral area with normal saline. Dry well, apply one (1) application of Santyl, and cover with dry dressing.

Nursing Progress Note dated on 11/07/2024 at 10:34 AM written by Registered Nurse #1 documented new orders received for stage 2 pressure ulcer on the sacral area order for Santyl daily and as needed transcribed into electronic medical record. Health care proxy/family member made aware of opening on visit.

Treatment Administration Record for November 2024 documented treatment of Santyl 250 ointment, apply one (1) film by topical route once daily and as needed was administered on the 7:00 AM-3:00 PM shift once daily for the dates of 11/07/2024 through 11/18/2024.

Wound Care note dated 11/07/2024 documented Resident #413 was being seen by the wound care team. Wound #1 was on the sacral area. It was unstageable. measures 7 centimeters length, 3 centimeters width and depth 0.1 centimeters. no tunneling, wound Bed (nothing documented Small amount of drainage, no odor and peri wound intact. Apply Santyl and dry protective dressing. It documented the resident was improving. Continue with positioning. Case discussed with the wound care team. Will reassess in 1 week.

Progress note dated 11/12/2024 documented Resident #413 refused to get out of bed due to pain. They complained of left hip pain and buttock pain where their wound was. The progress note documented to increase tramadol to 50 milligrams every morning, continue Tylenol 1 gram three times a day, and Volteran topical. Left hip x-ray was ordered. Resident #413 had a decubitus ulcer of coccyx, stage 2. Continue Santyl with Dry dressing. Follow up with wound care as scheduled.

Physician order dated 11/14/2024 documented a wound consultation with an in-house wound team as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 There was no documented evidence of weekly wound assessments to monitor the progression of the wound between 11/07/2025 and 11/18/2025. Level of Harm - Minimal harm or potential for actual harm Dietary progress note dated 11/17/2024 documented Resident #413 was being followed on wound rounds for a stage 2 pressure ulcer on their sacrum. Resident #413 was receiving ensure plus three times a day. Residents Affected - Few Progress note dated 11/18/2024 at 2:21 PM written by Assistant Director of Nursing #1 documented they were asked to see Resident #413 due to decline in status. Resident #413 was awake, and minimally responsive Skin was hot and dry. Skin turgor was poor. Tongue furrowed. Resident #413 ' s family member present stated Resident #413 was not like that yesterday when they visited. Nurse Practitioner #1 was called to the unit stat to evaluate the resident. The buttock sacrum wound had declined.

Wound and skin record dated 11/18/2024 documented Resident #413 had a pressure ulcer on the sacral area. Risk factors and causes were incontinence and pressure ulcer. Stage: Unstageable slough or eschar. Measures 7 centimeters length by 3 centimeters width and depth 0.1 centimeters, no tunnelling or undermining. Necrotic; black in color. Small amount of serous drainage of less than 25% to dressing . Apply Santyl and dry protective dressing. Resident experiencing pain related to pressure ulcer and unable to communicate. Response to treatment deteriorated. Culture Sent. Physician and family notified.

Progress note dated 11/18/2024 at 4:30 PM written by Registered Nurse #1 documented the following: A Certified Nurse Aide approached the Registered Nurse #1 for wound treatment for Resident #413. Upon Registered Nurser #1 entering the room to perform the treatment. Family member of Resident #413 was present and assisted. Resident #413 did not respond during the treatment. Upon assessment, they appeared lethargic and exhibited tremors. The wound on the sacral area showed necrotic tissue and foul odor. Nurse Practitioner #1 and administration were informed of Resident #413 ' s changes in health status. Orders were given to administer Narcan 0.4 milligrams intramuscularly as a one-time dose and Invanz, 1 gram intramuscularly immediately, followed by four additional doses. The Administration and Nurse Practitioner #1 evaluated and discussed the changes in Resident #413 ' s medical condition with the family. Additional orders were received and transcribed according to facility protocol.

Nursing progress note on 11/18/2024 documented Resident #413 continued to be unresponsive. Their blood pressure was 154/87. Pulse was 139. Temperature was 102.4. Nurse Practitioner #1 was called and information on their condition was provided. Resident #413 was transported to the hospital.

Progress note dated 11/19/2024 at 9:32 AM written by Assistant Director of Nursing #1 documented Resident #413 was admitted to hospital with the diagnosis of sepsis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview on 5/05/2025 at 11:50 AM and 5/08/2025 at 9:46 AM, Registered Nurse #1 stated weekly skin checks were done by a nurse on days when a resident took a shower. If there was a concern noted Level of Harm - Minimal harm or during the skin check, a more formal skin assessment would be completed. Wounds were followed by the potential for actual harm wound care team weekly. Registered Nurse #1 stated the wound care team was made up of the Assistant Director of Nursing and someone else from an outside team, but they could not recall. The team would Residents Affected - Few monitor the wounds weekly. They further stated they like to see all wounds and how they are healing. They received a list from Assistant Director of Nursing #1 of residents that have wounds. When asked about Resident #413, Registered Nurse #1 recalled the resident was transferred to the hospital because of a wound on the buttock and a family member reported the resident would not return to the facility due to concerns regarding this pressure ulcer. They stated interventions on Resident #413 ' s skin integrity care plan included to use a pressure reducing cushion on the resident ' s wheelchair. There were no other interventions related to the Pressure Ulcer on it. Registered Nurse #1 state this occurred around the time the facility switched over from using Vendor #2 electronic medical record system to Vendor #1 electronic medical

record system and resident ' s care plans needed to be entered manually. Registered Nurse #1 did not know why the skin integrity care plan for Resident #413 was not updated when the Pressure ulcer was discovered. Registered Nurse #1 stated Resident# 413 ' s turning and positioning schedule was not tracked as it was not

a task for the Certified Nursing Aides to document when the Resident was turned and positioned. At the time of the switch over to Vendor #1 ' s electronic medical record system, they stated updates made to the care plan were not automatically linked to the care cards followed by the Certified Nursing Aides. They stated they found out a month ago that they needed to update care cards manually when a care plan change was initiated and they have been working every day on having the care plans match the care cards.

During an interview on 5/05/2025 at 12:16 PM, Nurse Practitioner #1 stated they could not recall Resident #413. Nurse Practitioner #1 stated wounds were managed by the wound care team and the facility used an outside consulting service for a member on the wound care team. The outside provider participated with facility providers and residents were assessed weekly. Recommendations regarding treatment were made based on the findings of the assessment. Nurse Practitioner #1 stated they reviewed the findings from the wound care rounds and may agree or disagree with recommendations and they would proceed from there. Nurse Practitioner #1 stated skin checks should be done on a weekly basis, but they were not sure which nurse completed the skin checks. They stated based on the results from the skin check, they may make recommendations for the resident to be seen by the wound team. They stated if they were made aware of a skin concern, they would write a progress note about it. If the wound was unstageable, they would implement

the appropriate treatment and refer the resident to be seen by the wound care team.

During an interview on 5/05/2025 at 12:03 PM, Assistant Director of Nursing #1 stated every resident had an order for a weekly skin check to be done when they have their shower. The skin check was completed by the Certified Nurse Aide and the Licensed Practical Nurse. The Licensed Practical Nurse assessed the skin and identified anything that would need to be addressed by the Registered Nurse. They stated wound assessments were done weekly by themselves and Physician Assistant #1, an outside consultant who was

the facility wound specialist. They stated they expected to know of a new concern or wound within 24 hours of an abnormal finding. They stated the first time they saw the wound for Resident #413 was when the resident was sent to the hospital on 11/18/2024. They stated they had Nurse Practitioner #1 see Resident #413 on that day as it was a rough day for the resident and the resident was not doing well. Assistant Director of Nursing #1 stated they were not sure what the treatment for the wound was prior to them seeing

the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a phone interview on 5/06/2025 at 11:09 AM, Physician Assistant #1 stated wound rounds were done once a week with themself, Assistant Director of Nursing #1 and the unit manager. They stated they Level of Harm - Minimal harm or document their findings on a note in the resident ' s electronic medical record. If a Licensed Practical Nurse potential for actual harm discovered an area of concern on a skin check, they would expect for them to put the resident down to be evaluated during wound rounds and they would expect a notification so treatment could be initiated for the Residents Affected - Few wound. They could not recall the specifics regarding the pressure ulcer Resident #413 developed and they were not able to access their records during the time of the interview. They stated the most important thing was to identify the wound and start the treatment. Ideally, treatment should have started the day the wound was identified or the next day. Physician Assistant #1 stated there was a delay in treatment for Resident #413 ' pressure ulcer developed on 11/04/2024. Physician Assistant #1 stated Resident #413 should have been reassessed seven (7) or eight (8) days after their first assessment by the wound care team on 11/07/2024 as the recommendation was to reassess this resident in one week. They could not recall if Resident #413 was reassessed during this timeframe.

During an interview on 5/06/2025 at 12:15 PM and 5/08/25 at 10:23 AM, Director of Nursing #1 stated the interdisciplinary wound care team that met weekly was comprised of the Assistant Director of Nursing, dietary, therapy, and the nurse manager. The facility had a Physician Assistant that consulted with the facility for wound treatment and the Physician Assistant sent their notes to the facility to be uploaded into the resident ' s chart. If there was a concern noted during a skin check, the Licensed Practical Nurse should notify their supervisor or nurse manager or the provider. If the skin was compromised, an incident and accident report should be initiated. When the Director of Nursing was shown Resident #413 ' s Treatment Administration Record for November 2024 and the entry for 11/04/2024 documenting there was an open area to Resident #413 ' s coccyx, they stated the provider and supervisor should have been notified and an email regarding the open area should have been sent to the Assistant Director of Nursing and an incident and accident report should have been initiated. They noted none of this was done, and a progress note on 11/04/2024 regarding the open area to Resident # 413 ' s coccyx was not written. They stated the staff missed a step. They stated Nurse Practitioner#1 was notified on 11/05/2024 based on the progress note they wrote and the order for the Santyl treatment to the pressure ulcer was initiated on 11/07/2025. Director of Nursing #1 stated the treatment for the pressure ulcer should have been started on 11/05/2024. They stated Resident #413 was not seen weekly for a reassessment of the pressure ulcer as recommended. Director of Nursing #1 stated care plans are a fluid tool and as the resident changes, their care plan should be updated to reflect the change. Comprehensive care plans included every diagnosis and medication a resident had, and it should be personalized as much as possible. Director of Nursing #1 stated the care plan for skin integrity for Resident #413 was not updated when the pressure ulcer was discovered. The only goal on the care plan was for use of the pressure reducing cushion. They would expect to see goals with appropriate interventions such as turning and positioning, offloading, and wound care, but it was not listed on Resident #413 ' s care plan.

10 New York Codes Rules and Regulations 415.12(c)(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34630

Residents Affected - Many Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case # ' s NY00371796, NY00358669, NY00357360, NY00363370, NY00371256, NY00353853, NY00347329 and NY00378103), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents stated they were not assisted with care when requested; staff stated they were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed; and an analysis of the actual staffing schedule showed that on multiple occasions from 3/01/2025 to 4/28/2025, the facility did not ensure minimum staffing levels were met based on the facility assessment.

This is evidenced by:

Cross reference to

F-F656: Develop/implement Comprehensive Care Plan

A facility's undated policy and procedure titled Comprehensive Care Plans documented that the assessment must accurately reflect the resident's status and be reflective of the resident's state at the time of assessment. A comprehensive care plan will be developed within seven (7) days after completion of the comprehensive assessment and address specific care areas (focuses) as identified therein, as well as those deemed appropriate through resident interview or other data sources.

Resident #28

Resident #28 was admitted with the diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs resulting in swelling, irritation, and inflammation inside the airways that limit airflow into and out of the lungs), chronic ischemic heart disease (a long-term reduction in blood flow to the heart muscle, often due to coronary artery disease), and cellulitis (a common bacterial skin infection that causes pain, redness, swelling, and warmth in the affected area). The Minimum Data Set, dated dated dated [DATE REDACTED], documented that the resident was usually understood and could sometimes understand others and required extensive assistance for most activities of daily living.

A review of Resident #28 Minimum Data Set conducted on 4/11/2025 did not indicate that the resident had edema as described in their baseline care plan.

A review of Resident #28 Medication Administration Record and Treatment Administration Record for May 2025 did not have any documentation addressing the resident's edema or cellulitis.

A review of Resident #28's Comprehensive Care Plan had no interventions for the resident's edema or cellulitis.

During an interview on 5/01/2025 at 10:57 AM, Resident #28 was observed sitting on the edge of their bed and had severely edematous legs. Resident #28 was asked what the facility did to help them with their legs, and they stated that the facility did nothing for them. The resident stated that sometimes the legs weep, and that staff would occasionally wrap them, but not very often.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 During an interview on 5/6/2025 at 11:46 AM, Registered Nurse #3 stated that there should have been an assessment and plan for residents' edema and cellulitis, and did not know why there was none. They stated Level of Harm - Minimal harm or that there should have been interventions listed for these issues in the comprehensive care plan, as well as potential for actual harm the medication administration and treatment administration records.

Residents Affected - Few Resident #415

Resident #415 was admitted to the facility with the diagnoses of dementia (a generative neurological disease which causes memory issues), type 2 diabetes mellitus (an endocrine dysfunction causing unregulated blood glucose levels), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool), dated 3/11/2025, documented that the resident was able to be understood and understood others, with severe cognitive impairment.

The baseline care plan, dated 1/24/2025, documented the following:

Resident is at risk for/has skin impairment due to: .

Resident ' s significant medical diagnoses include:.

Resident is admitted on antibiotics for continued treatment of:.

Resident has intravenous/dialysis/chemotherapy port present at {site} on admission.

Resident ' s significant mental health diagnoses include:.

Resident need Total/Ext/Limited/Supervision support of [3 ] staff to complete activities of daily living.

Resident has history of constipation/obstruction:.

Resident is on special diet of:.

Resident is at risk for pain/is on pain management due to:.

Resident is at risk for elopement as evidenced by:.

Resident has expressed significant religious/cultural preferences:.

Resident has an ostomy.

There were no documented responses to any of the above prompts in the baseline comprehensive care plan. There was no documented evidence that Resident #415 had an ostomy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 The comprehensive care plan for skin integrity dated 1/24/2025 documented that the resident had a rash on their buttock to be treated with {insert medication} for {duration}. The goal documented that the rash would Level of Harm - Minimal harm or not worsen and show signs of improvement. The interventions documented to apply local treatment, monitor potential for actual harm for infection, report worsening condition, use an air cushion when in the [NAME] lounger, and float the resident ' s heels. There was no documentation that the resident was at risk for developing pressure sores. Residents Affected - Few

The comprehensive care plan for psychosocial well-being, dated 1/24/2025, documented the resident would be provided emotional support, assistance with activities of daily living, nutrition, and hydration. There was no documentation regarding an ostomy.

The comprehensive care plan for nutritional status dated 1/24/2025 documented that the resident was to tolerate their diet and maintain weight with 75 percent of their intake. There was no documentation regarding

an ostomy.

During an interview on 5/08/2025 at 10:38 AM, Registered Nurse #1 stated they worked on the care plans but were severely in need of help. Registered Nurse #1 stated that they were told they would receive an assistant last year, but it had not happened. Registered Nurse #1 stated that they worked passing medications, acted as an aide, and spent most of their time working to provide resident care on the unit.

10 New York Code of Rules and Regulations 415.11(a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or 43805 potential for actual harm Based on a record review and staff interviews conducted during a recertification survey, the facility did not Residents Affected - Few ensure that Preadmission Screening was complete for two (2) (Resident #s 31 and 103) of the 32 residents reviewed. Specifically, an accurate Preadmission, Screening and Resident Review (PASARR) was not completed or corrected.

This is evidenced by:

The Policy and Procedure for Admission Screening and Approval Process for Long Term Care (New York State) documented the admission process to the facility from a hospital or other health facility. A qualified Registered Professional Nurse assessor must complete a Patient Review Instrument, and the Preadmission Screening must be completed and signed by a qualified assessor.

Resident #31

Resident #31 was admitted to the facility with the diagnoses of bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of mania or hypomania to periods of depression), chronic obstructive pulmonary disease (term for certain types of irreversible lung and airway damage that obstruct your airways and make it hard to breathe), and hyperlipidemia (a condition characterized by elevated levels of lipids, or fats, in the blood). The Minimum Data Set (an assessment tool) dated 4/29/2025 documented that the resident could be understood, understand others, and was cognitively intact.

The review of the Preadmission Screening and Resident Review Assessment documented that the assessment was completed on 11/19/2024 and signed by a Registered Nurse performing the evaluation. The assessment documented that Resident #31 had dementia.

There was no documented evidence of a serious mental illness.

A review of Resident #31's medical records conducted on 5/01/2025 at 9:39 AM documented that the resident did not have a diagnosis of dementia but did have a diagnosis of bipolar disorder.

During an interview on 5/06/2025 at 11:39 AM, Corporate Social Worker #1 stated that admissions did the initial review of the screening assessment before the resident was sent to the facility, and Social Workers were the second level of review. They stated that serious mental illnesses included the diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, panic disorder, and major depressive disorder.

They further stated that any serious mental disorder consisted of any that would impair the daily function of

the resident. Corporate Social Worker #1 stated that nursing would ensure that the resident's diagnoses were correct and review with the hospital for accuracy before admittance. Corporate Social Worker #1 stated that admissions would review the resident's diagnoses for accuracy, review a list of residents with mental health diagnoses, and make appropriate Level II PASARR referrals.

48413

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 Resident #103

Level of Harm - Minimal harm or Resident #103 was admitted to the facility with the diagnoses of schizophrenia (a chronic and severe mental potential for actual harm disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), type 2 diabetes mellitus (a chronic condition where the body either doesn't produce Residents Affected - Few enough insulin or can't effectively use the insulin it produces), and dysphagia (medical term for difficulty swallowing that can be a painful condition and in some cases impossible). The Minimum Data Set) dated 3/5/2025 documented that the resident was able to be understood, was able to understand others, and was cognitively intact.

The Preadmission Screening and Resident Review assessment was completed on 2/04/2025. There was no documented evidence of a serious mental illness or a referral for Level II services.

The Progress notes dated 2/10/2025 documented the resident resided in a group home overseen by the New York State Office of Mental Health.

The Progress notes dated 3/20/2025 documented that the resident ' s discharge goal was to return to their mental health housing.

The Progress notes dated 3/29/2025 documented that a conference was held with the resident ' s community mental health team, including the housing manager and a case manager from Community Treatment.

During an interview on 5/06/2025 at 10:36 AM, Social Worker #1 stated they, themselves, were not licensed to complete the screen form, so they did not have much to do with it. They stated they would consider the diagnosis of schizophrenia as a serious mental illness. They stated they were surprised there was no Level II referral for Resident #103. They stated they had been working with their community housing and mental health team toward a discharge back to the community.

During an interview on 05/06/2025 at 11:39 AM, Corporate Social Worker #1 stated that a Level II referral should have been completed after the resident was no longer considered short stay (30 days or less). They stated that a diagnosis of schizophrenia should have triggered the request for a Level II evaluation. They further stated that a list of residents with mental health diagnoses had been compiled, and the appropriate Level II referrals would be made.

10 New York Code of Rules and Regulations 415.11(e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33538

Residents Affected - Many 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. Specifically, (a.) Resident #6 ' s, care plan did not address foot care; (b.) Resident #13 ' s care plan did not include person centered interventions for behavior and diabetes mellitus management; (c) Resident #28 ' s, pain care plan was not implemented for monitoring for effectiveness of administered pain medication; (d) Resident #52 ' s at risk for malnutrition care plan lacked person centered interventions: (e) Resident #61 did not have a care plan to address vascular wounds; (f) Resident #70 ' s care plans for dementia and mood lacked person centered interventions; (g) Resident #72 ' s, care plan was not implemented to prevent the resident from falling; (h) Resident #86 ' s care plans for behaviors lacked person centered interventions; (i) Resident #103 ' s, care plan for abuse prevention lacked interventions; (j) Resident #107, did not have a care plan in place for infections; (k) Resident #262 did not have a care plan to address an abscess; (l) Resident #10, did not have a care plan to address conjunctivitis; (m) Resident #413, did not have a care plan to address the treatment of a pressure ulcer; (n) Resident #415 did not have a care plan to address denture care, or at risk for pressure ulcers, (o) Resident #37 ' s comprehensive care plan was not implemented to reflect the resident's safety concerns regarding other residents entering their room at times, and this issue needed to be addressed by staff, (p) Resident #31 ' s care plan did not include person centered interventions and specific goals for oxygen administration.

This is evidenced by:

An undated facility policy titled Comprehensive Resident Centered Care Plans documented the care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident ' s strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. A resident ' s care plan should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in resident care.

Resident #103

Resident #103 was admitted to the facility with the diagnoses of atrial fibrillation (abnormal heart rhythm), type 2 diabetes, and dysphagia (swallowing disorder). The Minimum Data Set (an assessment tool) dated 3/05/2025 documented the resident could be understood, could understand others, and was cognitively intact.

The comprehensive care plan titled Risk for Abuse, initiated 4/26/2025, had no interventions for the focus (Risk for Abuse).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 5/0/2025 at 10:46 AM, Registered Nurse #1 stated they were responsible for initiating and updating care plans, though other registered nurses could as well, like off shift supervisors. They did not Level of Harm - Minimal harm or know why there were no interventions listed for this comprehensive care plan. potential for actual harm Resident #72 Residents Affected - Many Resident #72 was admitted with the diagnoses of hypertension (high blood pressure), depression (a mood disorder characterized by persistent sadness and loss of interest or pleasure in daily activities), and gastroesophageal reflux disease (when stomach acid flows back up into the esophagus and causes heartburn). The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident could be understood, could understand others, and was severely cognitively impaired.

34630

The comprehensive care plan titled Risk for Falls documented the following interventions to be put in place to prevent falls and injury:

-bedside mats to floor when in bed

-low bed

43805

The Incident and Accident forms dated 3/12/2025 and 3/25/2025 documented the resident fell from bed and

the floor mat was not in place. The Incident and Accident form dated 3/18/2025 documented the resident fell from their bed that was left in the high position, rather than the low position as directed by the comprehensive care plan.

48413

The comprehensive care plan titled Behavior Problem: disruptive/dangerous/inappropriate last revised on 4/0/2025 did not include person-centered recommendations to help mitigate or prevent behaviors that could lead to injury.

48744

During an interview on 5/0/2025 at 10:46 AM, Registered Nurse #1 stated they were responsible for initiating and updating care plans, though other registered nurses could as well, like off shift supervisors. They agreed comprehensive care plans should be resident centered. They stated that they had not been aware that interventions on the comprehensive care plan were not flowing automatically to the certified nursing assistant Kardex. They did not know why the resident ' s interventions were not in place, resulting in falls. They stated

the low bed for the resident had been ordered and was on back order.

51317

Resident #415

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Resident #415 was admitted to the facility with the diagnoses of dementia (a generative neurological disease which causes memory issues), type 2 diabetes mellitus (an endocrine dysfunction causing unregulated blood Level of Harm - Minimal harm or glucose levels), and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE REDACTED], potential for actual harm documented the resident could be understood, could understood others, and was severely cognitively impaired. Residents Affected - Many

The comprehensive care plan for skin integrity dated 1/24/2025 documented the resident had a rash on their buttock, to be treated with {insert medication} for {duration}. The goal documented the rash would not worsen and show signs of improvement. The interventions documented to apply local treatment, monitor for infection, report worsening condition, use air cushion when in the [NAME] lounger, and to float the resident ' s heels. There was no documentation that the resident was at risk for developing pressure sores.

The comprehensive care plan for nutritional status dated 1/24/2025 documented the resident was to tolerate their diet and maintain weight with 75 percent of their intake.

The comprehensive care plan for dental care, dated 1/24/2025, did not document the resident had dentures.

A nursing note dated 3/06/2025 at 4:04 PM documented Resident #415 had developed a moisture-related redness, and maceration to their buttocks, the area was cleaned and dressed; the family was made aware and a consult with wound care had been placed. There was no update to the care plan to reflect the change

in skin condition.

A wound care note date created 3/07/2025 and last updated 5/08/2025, documented Resident #415 had a stage 2 pressure sore with no drainage noted on 3/07/2025. The same pressure sore had increased in size and progressed to a stage 3 with moderate drainage by 3/21/2025. On 3/27/2025, the pressure sore was noted to be unstageable, and had decreased slightly in length, but the depth remained the same. There was no documented update to the care plan after each skin assessment.

During an interview on 5/8/2025 at 10:08 AM, Licensed Practical Nurse #5 stated if a new pressure area developed, they would immediately call a supervisor for measurements and directives, and the nurse practitioner was there every day and would be told.

During an interview on 5/08/2025 at 10:38 AM, Registered Nurse #1 stated they worked on the care plans but were severely in need of help. Registered Nurse #1 stated that they were told they would receive an assistant last year, but it had not happened. Registered Nurse #1 stated that they worked passing medications, acted as an aide, and spent most of their time working to provide resident care on the unit.

10 New York Codes, Rules, and Regulations 415.11 (c)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43805

Residents Affected - Some Based on observations, record reviews, and interviews conducted during a recertification and abbreviated survey (Case #NY00377938), the facility did not ensure that Comprehensive Care Plans were reviewed after each assessment and revised based on the changing goals, preferences, and needs of the resident and in response to current interventions for four (4) (Residents # ' s 13, 37, 97, and 415) of 32 residents reviewed. Specifically, (a) for Resident #13, the resident ' s allergy care plan was not updated to reflect the resident ' s current medication allergies; (b) for Resident #37, the resident ' s comprehensive care plan was not updated to reflect the resident's safety concerns regarding other residents entering their room; (c) for Resident #97, there was no care plan meeting held to review and revise the comprehensive care plan with the resident/resident ' s representative; and (d) for Resident #415, the resident ' s comprehensive care plan was not updated to reflect the resident's pressure ulcers.

This is evidenced by:

Resident #13

Resident #13 was admitted with the diagnoses of fracture of the right femur (a break in the long bone of the leg), end-stage renal disease (a condition where the kidneys can no longer effectively filter waste and excess fluid from the blood), and type 2 diabetes mellitus (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set (an assessment tool) dated 3/25/2025 documented that the resident was able to be understood, able to understand others, and was cognitively intact.

The Comprehensive Care Plan, titled 'Allergy,' last updated on 4/16/2025, listed cholecalciferol as a medication allergy.

The Physician's Order, dated 4/15/2025, documented cholecalciferol 125 micrograms in a capsule to be administered orally once daily.

A review of the Medication Administration Record for April 2025 and May 2025 documented that the resident had received this medication.

During an interview on 5/06/2025, at 10:46 AM, Registered Nurse #1 stated that they were responsible for initiating and updating care plans. They indicated that they were not aware of the conflicting allergy care plan.

Resident #97

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Resident #97 was admitted to the facility with the diagnoses of chronic respiratory failure (a condition where

the lungs cannot adequately exchange oxygen and carbon dioxide), chronic obstructive pulmonary disease Level of Harm - Minimal harm or (a group of lung diseases that block airflow and make it difficult to breathe), and congestive heart failure ((a potential for actual harm weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). The Minimum Data Set, dated dated dated [DATE REDACTED] documented that the resident was understood, could understand others, Residents Affected - Some and was cognitively intact.

A review of the medical record revealed that no care plan meetings had been held since the admission care plan meeting on 11/13/2024.

During an interview on 4/03/2025, at 8:37 AM, Resident #97 stated that they had not been invited to a care conference but would like to attend one.

During an interview on 5/06/2025 at 10:36 AM, Social Worker #1 stated care plan meetings were held after admission, quarterly, annually, and as needed. They stated the care plans were reviewed and updated as required by the interdisciplinary team.

During an interview on 5/08/2025 at 1:15 PM, Social Worker #1 stated they weren ' t aware Resident #97 hadn ' t had a care meeting but would investigate it.

48744

Resident #415

Resident #415 was admitted to the facility with diagnoses of dementia (a generative neurological disease which causes memory issues), type 2 diabetes mellitus, and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE REDACTED], documented that the resident was able to be understood and understand others, with severe cognitive impairment.

The Comprehensive Care Plan for Skin Integrity dated 1/24/2025 documented that the resident had a rash

on their buttock to be treated with '{insert medication} for {duration}. ' The goal documented was the rash would not worsen and show signs of improvement. The interventions documented to apply local treatment, monitor for infection, report worsening condition, use an air cushion when in the [NAME] lounger, and to float

the resident ' s heels.

There was no documented evidence that the resident was at risk for developing pressure sores.

A nursing note dated 3/06/2025 at 4:04 PM documented that Resident #415 had developed a moisture-related redness and maceration to their buttocks, that the area was cleaned and dressed; the family was made aware, and a consult with wound care had been placed.

There was no documented evidence of an update made to the care plan to reflect the change in skin condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 A wound care note dated 3/07/2025 and last updated 5/08/2025, documented that Resident #415 had a stage two (2) pressure sore with no drainage noted on 3/07/2025. The same pressure sore had increased in Level of Harm - Minimal harm or size and progressed to a stage 3 with moderate drainage by 3/21/2025. On 3/27/2025, the pressure sore potential for actual harm was noted to be unstageable and had decreased slightly in length, but the depth remained the same.

Residents Affected - Some There was no documented evidence of an update to the care plan after each skin assessment.

During an interview on 5/08/2025 at 10:38 AM, Registered Nurse #1 stated they worked on the care plans but were severely in need of help. Registered Nurse #1 stated that they were told they would receive an assistant last year, but it hadn ' t happened. Registered Nurse #1 stated that they worked the carts, acted as

an aide, and spent most of their time working the unit.

10 New York Code of Rules and Regulations 483.21 (b)(2)(iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34630 potential for actual harm Based on record review and interview during a recertification and abbreviated survey (Case # ' s Residents Affected - Some NY00348580; NY00355929; NY00348873; NY00351874 and NY00347329), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #s 6, 28, 61, and 262) of 32 residents reviewed. Specifically, (a.) Resident #61 was noted by nursing staff on 2/19/2025 to have signs and symptoms of cellulitis (bacterial skin infection) on the left leg.

The facility did not have evidence of monitoring of the resident ' s condition from 2/20/2025 to 3/3/2025; there was no order for periodic skin checks. The resident was not seen by the provider until 3/04/2025 and was diagnosed and treated for cellulitis of the left leg. (b.) Resident #28 was observed with severely edematous (swelling caused by excess accumulation of fluid) legs and the resident reported the facility was not doing anything to treat the condition. (c.) Resident #6 ' s feet were dry, scaly, and peeling, with no documented treatment. (d.) The facility did not administer Resident #262 ' s ace wraps as ordered by the provider.

This is evidenced by:

Cross-referenced to

Upon entrance to the facility on [DATE REDACTED], 108 residents resided on two floors. Upon observing and reviewing

the Facility Staffing Sheet, six (6) Licensed Nurses and ten (10) Certified Nurse Aides were on duty.

During an interview on 4/30/2025 at 12:59 PM, the facility Ombudsman stated that there had been a high facility administration turnover. They stated that a lack of consistent staff associated with the leadership turnover had been an ongoing issue. They stated that residents were not getting the care due to low staffing levels, and showers had been an ongoing issue because of staffing, where the staff would tell the residents

they were too short-staffed to provide resident showers.

During a surveyor-led group resident meeting on 5/01/2025 at 9:32 AM, five residents who attended the meeting reported insufficient staffing to meet their needs. They stated that they often had to wait an extended period to get care and were yelled at by staff, or staff were rude and disrespectful. They stated that many times they have been left unattended for extremely long times, and the Certified Nurse Aides would say they would come back but never did.

During an interview on 5/01/2025 at 9:32 AM, Resident #22 stated when they put their call light on, some Certified Nurse Aides would come into the room and tell them in that they were not their aide, then turn the call light off, leave the room and not come back. They stated it could take one (1) to three (3) hours for someone to finally come in and help them. Resident #22 stated they needed help with using the bathroom and said they had laid in their bed soaking wet after having an accident because Certified Nurse Aides did not respond to the call. Resident #22 stated they felt degraded when Certified Nurse Aides refused to help them. Resident #22 further stated Certified Nurse Aides would argue and fight about their assignments in front of them and other residents, and Certified Nurse Aides and would look directly at them and say that

they were not assigned to care for them.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

During an interview on 5/05/2025 at 1:08 PM, Certified Nursing Aide #1 stated staff were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed. Certified Nurse Aide #1 stated staff regularly reported the inability to provide care and services to the residents due to staffing issues with administration.

During an interview on 5/08/2025 at 10:38 AM, Registered Nurse #1 stated they worked on the care plans but were severely in need of help. Registered Nurse #1 stated that they were told they would receive an assistant last year, but it had not happened. Registered Nurse #1 stated that they worked passing medications, acted as an aide, and spent most of their time working to provide resident care on the unit.

The Facility Assessment, last reviewed on 9/10/2024, documented that the facility's bed capacity was 120.

The section titled, Staffing Plan, documented the following: - Licensed Nurses providing administrative direction, supervision, and direct care: - Director of Nursing: 1 Registered Nurse full-time Days - Assistant Director of Nursing: 1 Full-Time Employee - Registered Nurse Manager - 2 Full-Time Employees - Registered Nurse Supervisors: Evening and Weekends: 3 Full-time Employees - Licensed Practical Medication Nurses: 5 for days, 5 for evenings, and 3 for nights. - Direct Care Staff: - Certified Nurse Aides: 11 for days, 11 for evenings, 6 for nights.

A review of staffing sheets provided by the facility from 3/01/2025 through 4/8/2025 documented that they did not meet their assessed minimum staffing on most shifts for the following: - On 3/02/2025, the nursing schedule had 6 nursing staff during the day shift, 3 for the evening shift, and 2 for the night shift. The Certified Nurse Aide schedule had 8 aides during the day shift, 7 for the evening shift, and 5 for the night shift. - On 3/09/2025, the nursing schedule had 6 nursing staff during the day shift, and 5 for the evening shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 6 for the evening shift, and 2 for the night shift. - On 3/16/2025, the nursing schedule had 6 nursing staff during the day shift, 4 for the evening shift, and 2 for the night shift. The Certified Nurse Aide schedule had 5 aides during the day shift, 6 for the evening shift, and 4 for the night shift. - On 3/25/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 10 for the evening shift, and 5 for the night shift.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many - On 4/01/2025, the nursing schedule had 5 for the evening shift and 3 for the night shift. The Certified Nurse Aide schedule had 9 for the evening shift and 3 for the night shift. - On 4/13/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 5 aides during the day shift, 5 for the evening shift, and 5 for the night shift. - On 4/20/2025, the nursing schedule had 5 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 10 for the evening shift, and 5 for the night shift. - On 4/25/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 5 for the evening shift, and 4 for the night shift.

During an interview on 5/6/2025 at 2:30 PM, Staffing Coordinator #1 stated they determined the staffing levels per the census; it was discussed at the morning meeting what the goal for the staffing levels should be for the next day. They stated that a minimum of three (3) Certified Nurse Aides should be on the first floor and six (6) Certified Nurse Aides should be on the second floor. They stated that if they are short-staffed,

they will attempt to fill the spots by offering bonuses or other incentives to get staffing at appropriate levels.

During an Interview on 5/06/2025 at 2:55 PM, Assistant Director of Nursing #1, who is also the Nurse educator, described the competency levels for staff. They stated that they perform all competencies during

the hiring process and then yearly or when needed if the issue arises. They stated that Certified Nurse Aides had monthly in-services for all areas, including neglect and abuse training.

During an interview on 5/06/2025 at 3:08 PM, Director of Nursing #1 stated that they have tried to meet the regulations every day. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on record review and interview during a recertification survey, the facility did not ensure it established

a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) the facility did not document receipt of Oxycodone (narcotic pain medication) by the pharmacy for Resident #82, and (b.) did not document nursing unit narcotics as having been counted by two licensed staff members and signed as appropriate on the facility-provided narcotic record sheets for two (2) of two (2) nursing units.

This is evidenced by:

The Policy and Procedure titled, Medications - Controlled Substances, effective 3/13/2024, documented it was the facility ' s policy to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Handling Controlled Substances documented controlled substances were counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals signed the designated controlled substance record. If the count was correct, an individual resident-controlled substance record was made for each resident who would be receiving a controlled substance. The record included the quantity received, date and time received, and signature of person receiving medication.

Dispensing and Reconciling Controlled Substances documented, controlled substance inventory was monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection/follow-up. Nursing staff count controlled medication in inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing Services.

Resident #82: Resident #82 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke) affecting one side of the body, unspecified pain, and anxiety disorder. The Minimum Data Set (an assessment tool) dated 4/28/2025, documented the resident was cognitively intact, was able to make themselves understood, and understood others.

Physician Order dated 4/29/2025, documented Oxycodone 10 milligram tablet, give one (1) tablet (10 milligrams) by oral route every four (4) hours as needed for unspecified pain. Maximum daily dose: six (6) tablets.

Individual Patient Controlled Substance Administration Record dated 4/29/2025, documented Oxycodone 10 milligram tablet, one (1) tablet every four (4) hours as needed. Maximum daily dose: six (6) tablets.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

The record did not document the signature of the person and title receiving the drug, the date received, and

the amount received.

Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, Team #s 1 and 2, dated April 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, 4/13/2025, 4/26/2025, and 4/30/2025 7AM - 3PM did not document a signature for the off-going and oncoming nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, Team #s 1 and 2, dated May 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, 5/1/2025 and 5/5/2025 7AM - 3PM did not document a signature for the off-going nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the second-floor nursing unit, Team East; West; and North, dated April 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, North team on 4/7/2025 11PM - 7AM did not document a signature for the off-going and oncoming nurse. 4/8/2025 3PM - 11PM did not document a signature for the off-going and oncoming nurse. 4/16/2025 7AM - 3PM, 3PM - 11PM, and 11PM - 7AM did not document a signature for the off-going and oncoming nurse. [NAME] team on 4/2/2025 3PM - 11PM, did not document a signature for the off-going nurse and 11PM - 7AM did not document a signature for the oncoming nurse. 4/6/2025 7AM - 3PM and 3PM - 11PM did not document a signature for the off-going nurse. East team on 4/1/2025 3PM - 11PM did not document a signature for the oncoming nurse and the 11PM to 7AM did not document a signature for

the off-going nurse. 4/25/2025 7AM - 3PM did not document a signature for the off-going and oncoming nurse and 3PM - 11PM did not document a signature for the off-going nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the second-floor nursing unit, Team West, dated May 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, on 5/1/2025 7AM - 3PM did not document a signature for the off-going nurse. 5/06/2025 7AM - 3PM did not document a signature for off-going nurse and 11PM - 7AM did not document a signature for the oncoming nurse.

During an interview on 5/07/2025 at 11:05 AM, Licensed Practical Nurse #3 stated they always counted the narcotics but did not always sign the paper that the count was done.

During an interview on 5/07/2025 at 3:13 PM, Licensed Practical Nurse #2 stated they learned about the narcotic issue that day (5/07/2025) and completed an actual count with the nurse. They stated they just reviewed the process of narcotic counting with staff. They stated ultimately, the licensed nurse was responsible for counting the narcotics, because they were licensed professionals and were accountable for everything they did.

During an interview on 5/08/2025 10:39 AM, Licensed Practical Nurse #2 stated the supervisor was responsible for receiving narcotics from the pharmacy and was to count them, sign for them, and document

the date medication was received.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 5/8/2025 at 12:55 PM, Director of Nursing #1 stated they would expect the narcotics to be counted and narcotic count sheets to be signed by the off-going and oncoming nurse. They further stated the controlled substance records should have been signed by two (2) nurses when the narcotics were received from the pharmacy. They stated they expected narcotics would be counted at time of receipt. 10 New York Code Rules and Regulations 415.18(a) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Based on record review and interview conducted during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, timeframes for the different steps in the process. Additionally, the drug regimen of each resident was not reviewed at least once a month by a licensed pharmacist. Specifically, the facility policy titled, Medication Regimen Review, did not identify time frames for steps in the medication review process.

Additionally, there was no documented evidence of a pharmacist's review of the medication regimens for January, February, and March of 2025, affecting all residents.

This is evidenced by:

The facility policy titled, Medication Regimen Review, created 7/19/2019 with no updates or revisions, documented the Consultant Pharmacist should review the medication regimen of each resident at least monthly. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. If the situation was serious enough to represent a risk to a person ' s life, health, or safety, the Consultant Pharmacist would contact the Physician directly to report the information to the Physician and would document such contacts. The Consultant Pharmacist would provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions.

The facility policy did not address the time frames for steps in the Medication Regimen Review process.

During an interview on 5/05/2025 at 2:59 PM the Director of Nursing confirmed that as far as they know, the pharmacy did not provide medication regimen reviews for January, February, and March 2025. They were not the Director of Nursing at this facility for those months. They stated that they were not aware the policy did not have the required time frames. 10 New York Code Rules and Regulations 415.18(c)(2) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure medication error rates are not 5 percent or greater.

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5 percent for one (1) (Resident # 6) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 36 percent.

This is evidenced by:

The facility ' s Policy and Procedure titled, Administering medications, effective 3/13/2024, documented medications are administered in accordance with prescriber orders, including any required time frame.

Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Resident #6 Resident #6 was admitted to the facility with the diagnoses of congestive heart failure (when the heart can't pump blood well enough to give the body a normal supply), chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs resulting in swelling and irritation), and depression (a constant feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 3/06//2025 documented the resident was able to be understood and was able to understand others with intact cognition.

The Medication Administration Record dated April 2025 for Resident #6 documented the following medications were to be administered at 9:00 AM: Albuterol sulfate 2.5 milligram/3 milliliter (0.083 percent) solution for nebulization. Inhale 3 milliliters (2.5 milligram) by nebulization route every 6 hours as needed Cardizem CD 240 milligram capsule, extended release. Give 1 capsule (240 milligram) by oral route once daily.

Eliquis 5 milligram. Give 1 tablet (5 milligram) by oral route 2 times per day.

Lasix 40 milligram. Give 1 tablet (40 milligram) by oral route once daily Magnesium oxide 400 milligram (241.3 milligram magnesium). Give 1 tablet by oral route once daily Olanzapine 2.5 milligram. Give 1 tablet (2.5 milligram) by oral route once daily.

Trelegy Ellipta 200 microgram-62.5 microgram-25 microgram powder for inhalation. Inhale 1 puff by inhalation route once daily.

Venlafaxine ER 150 milligram capsule. Give 1 capsule (150 milligram) by oral route once daily.

Enteric Coated Aspirin 81 milligram. Give 1 tablet (81 milligram) by oral route once daily.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

During the medication administration observation on 04/30/2025 at 10:40 AM, Licensed Practical Nurse #7 administered the above medications to resident #6 at approximately 10:45 AM. Licensed Practical Nurse #7 stated they were always this late with their morning medication pass because they had 28 residents with a lot of medications. They were unable to administer them on time. They further stated Human Resources spoke with them regarding the late medications, and they explained the medications pass was too heavy for one person. They also stated the nurse manager was aware, and they were not given any assistance.

During an interview on 04/30/2025 at 10:47 AM, Registered Nurse #1 stated Human Resources spoke with Licensed Practical Nurse #7. Registered Nurse #1 stated no assistance was provided because other nurses were completing the same medication pass on time. They stated they plan to do an audit on Licensed Practical Nurse #7 sometime in the future. Registered Nurse #1 stated the nurse performing the medication pass was responsible for notifying the nurse practitioner when medications are late.

During an interview on 04/30/2025 at 10:55 AM, Nurse Practitioner #1 stated nursing staff should have notified them when medications are late either by phone or in person when they are in the building. They had not been notified of any late medications on this day. They further stated that on the previous day (4/29/2025), there was an entry made by Licenses Practical Nurse #7, in the Nurse Practitioner communication book that medications were late.

During an interview on 05/08/2025 at 11:49 AM, Director of Nursing #1 stated there had been problems with Licensed Practical Nurse #7 administering medications on time. The expectation for all nurses was to adhere to the policy of administering medications one hour before or after ordered time. When a nurse finds themselves late in giving medications, they should immediately notify the physician and or nurse practitioner of the late medication(s) via telephone or in person, then notify their supervisor or manager, who can provide help. At no time should notification of any late medication be placed in the Nurse Practitioner/Physician communication book. All Registered Nurses and Licensed Practical Nurses received training on medication administration upon hire and with annual competencies. 10 New York Codes, Rules, and Regulations 415.12 (m)(1) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that residents are free from significant medication errors. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33538 Based on observations, record review, and interviews conducted during a recertification and abbreviated survey (Case #'s NY00344251, NY00348580, NY355929, NY00347329 and NY00371796), the facility failed to ensure residents were free of significant medication errors for six (6) (Resident #s 10, 70, 82, 86, 107 and 416) of six (6) residents reviewed for medication administration. Specifically, (a.) Residents #s 10 and 70 had orders for antibiotic eye ointment that were not administered as ordered. (b.) Resident #82 had an order for narcotic pain medication that was not administered as ordered. (c.) Residents #s 86 and 107 had orders for antibiotics that were not administered as ordered. (d) Resident #416 was given medication that was not ordered for them.

This is evidenced by:

The facility policy titled, Medication Administration, created 4/2013 and last revised 12/2019, documented medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document as such in designated format (hard copy or electronic) space provided for that drug and dose.

There was no documented evidence that the policy addressed notification of the medical provider when medications were not administered as ordered.

Resident #10 Resident #10 was admitted to the facility with a diagnosis of type (two) 2 diabetes, chronic obstructive pulmonary disease (narrowing of airways) and chronic atrial fibrillation (an irregular heart rate). The Minimum Data Set (an assessment tool) dated 2/06/2025 documented the resident could be understood, could understand others, and was cognitively intact.

A Physician ' s Order dated 1/25/2025, documented the resident was to receive Tobradex ophthalmic 0.1/0.3 percent eye ointment to the right eye, (two) 2 drops to the right eye (four) 4 times per day for (seven) 7 days for conjunctivitis.

Review of the Medication Administration Record for January 2025 documented TobraDex eye ointment was to be administered at 9 AM, 1 PM, 5 PM, and 9 PM.

This medication was not administered on the following dates and times: 1/26/2025 at 9 AM and 1 PM. Reason was due to clinical monitoring. 1/26/2025 at 5 PM. Reason was due to within normal range. 1/26/2025 at 9 PM. Reason was due to clinical monitoring. 1/27/2025 at 9 AM, 1 PM, 5 PM and 9 PM. Reason was due to clinical monitoring.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1/28/2025 at 5 PM and 9 PM. Reason was below normal parameters. 1/30/2025 at 9 AM and 9 PM due to clinical monitoring.

Nursing progress note dated 2/01/2025 documented Resident #10 completed TobraDex.

There was no documentation in Resident #10 ' s electronic medical record progress note section that indicated Resident #10 was not administered TobraDex eye ointment on the above dates/times.

During an interview on 5/08/2025 at 9:46 AM, Registered Nurse #1 stated if medications were not administered, the Licensed Practical Nurse should have notified the Nurse Practitioner on call. Registered Nurse #1 looked at the Medication Administration record for Resident #10 for the month of January 2025 and stated TobraDex eye ointment was not administered each day as ordered.

During an interview on 5/08/2025 at 12:30 PM, Nurse Practitioner #1 stated they had been notified in the past when residents did not receive their medications. They assumed nursing staff would notify them if there was a missed dose of a medication because they may have been able to offer an alternative depending on

the circumstance (such as if a medication was not available, they could offer an alternative medication in the meantime). Nurse Practitioner #1 stated that they could not recall receiving notifications that Resident #10 did not receive the TobraDex eye ointment as ordered.

During an interview on 5/08/2025 at 10:23 AM, Director of Nursing #1 stated when a provider ordered a medication or treatment for a resident, it was documented on the medication administration record and/or treatment administration record. Director of Nursing #1 was shown the Medication Administration Record for January 2025 for Resident #10. They stated TobraDex was initiated for this resident in January 2025, but there were missed doses of the medication. They stated that they were not aware why clinical monitoring would be documented for a reason as to why administration of TobraDex did not occur. They stated there were no progress notes that documented why the medication was not administered to Resident #10.

Resident #107 Resident #107 was admitted to the facility with the diagnoses of type (two) 2 diabetes, atrial fibrillation (an irregular heart rate), and cellulitis (bacterial infection of the skin). The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident could be understood, could understand others, and was severely cognitively impaired.

The Physician's Order dated 4/22/2025 documented Rocephin (one) 1 gram solution for injection, give (one) 1 gram intramuscular route once daily for (five) 5 days.

The Medication Administration Record for April 2025 documented (four) 4 doses were given over (four) 4 days. The antibiotic was not administered on 4/24/2025, the reason documented was, there was no lidocaine (a pain-relieving medication that can be mixed with other medications to help prevent pain at an injection site).

A review of the progress notes for 4/22/2025-4/30/2025 had no documentation a physician being informed and dosages changed due to receiving less than the prescribed dosages.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

During an interview on 5/08/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that the medical provider should be informed of any missed doses of an antibiotic so the schedule can be extended or adjusted to ensure the resident received each ordered dose. They stated conversations with the medical provider should always be documented in the progress notes.

During an interview on 5/08/2025 at 1:11 PM, Licensed Practical Nurse #2 stated the doctor should have been called for any missing dose. They stated that lidocaine is always available, and they were never made aware of any shortage. They stated the nurse that did not administer the ordered dose was no longer employed at the facility.

Resident #416 Resident #416 was admitted to the facility with the diagnoses of right hemiplegia (paralysis of one side of the body) following a cerebral infarction (disrupted blood flow to the brain); Parkinson ' s Disease (a movement disorder of the nervous system that worsens over time), and Muscle Weakness (when muscles aren't as strong as they should be). The Minimum Data Set, dated dated dated [DATE REDACTED], documented the resident could be understood and could understand others with severe cognitive impairment.

The hospital progress note dated 6/07/2024 documented, Per medical records, resident unintentionally received 40 units of Lantus Sunday prior to admission. Resident was brought to Hospital on 6/03/2024 and was admitted .

Nursing progress note dated 6/03/2024 at 6:43 AM documented, reported by roommate that resident was given their PM dose of insulin. Resident ' s blood glucose this morning was 88. Resident was noted to be more sluggish than usual this morning and was given ensure to bring blood sugar up. Supervisor notified and, repeat check of blood sugar was 108.

Resident #416 ' s Medication Administration Record dated June 2024, did not include an order for Lantus or any other insulin medication.

The Medication Error Report dated 6/03/3024, documented Resident #416 received Lantus 40 units without

a physician order.

During an interview on 5/08/2025 at 11:49 AM, Director of Nursing #1 stated Licensed Practical Nurses and Registered Nurses receive medication administration training upon hire as well as completed annual competencies. Nurses follow the six (6) rights for medication administration that include verifying (1) right patient (2) right drug (3) right dose (4) right time (5) right route (6) right documentation. 10 New York Codes Rules and Regulations 415.12(m)(2) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48615 Regulation S483.45(h)(2): The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) Medication Rooms (2nd floor); and for two (2) of three (3) medication carts (first floor unit 100 and second floor unit 300) reviewed. Specifically, (a.) two (2) open bottles of lidocaine injectable solution had no open and or expiration dates (b.) seven (7) insulin kwik pens had no expiration dates (c.) one (1) inhaler had no open and or expiration date, and four (4) other inhalers had no expiration dates. Additionally, (d.) for the second-floor medication room narcotic box 1 West, both inside and outside locks were broken. The first-floor medication room narcotic boxes had no keys and were inaccessible to staff. Narcotics were observed to be stored on medication carts.

This is evidenced by:

The facility ' s Policy and Procedure titled, Administering medications, with effective date of [DATE REDACTED] documented the following: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 13. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure. 15. Insulin pens are clearly labeled with the resident ' s name or other identifying information. 16. All multidose injectable medications will be labeled with the date opened and expiration date. 30. Each nurses ' station has a current medication reference, as well as a copy of the surveyor guidance for F,d+[DATE REDACTED] (Pharmacy Services) available. Manufacturer ' s instructions or user ' s manuals related to any medication administration devices are kept with the devices or at the nurses ' station.

During an observation on [DATE REDACTED] at 10:59 AM, the second floor medication cart [NAME] Unit 300 contained two (2) opened lidocaine bottles with no open and or expiration date; four (4) opened insulin pens (1 Humalog, 2 Lantus and 1 Lispro) with no expiration dates; and three (3) opened inhalers (fluticasone; budesonide and incruse ellipta) with no expiration dates.

During an observation on [DATE REDACTED] at 11:15 AM, the second-floor medication room contained a narcotic box.

The inside lock had been removed leaving an open hole where lock should had been. The outside lock could not be fully secured and was partially opened.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

During an interview on [DATE REDACTED] at 11:20 AM, Licensed Practical Nurse #5 stated the narcotic box lock had been broken for several weeks and that their maintenance department had previously tried to repair locks.

Registered Nurse #1 stated maintenance was aware locks still were in need of repair and it was on their to do list.

During an observation on [DATE REDACTED] at 11:40 AM, the first floor medication cart East Unit 100 contained one (1) albuterol inhaler with no name, no open or expiration date; one (1) incruse ellipta inhaler with no expiration date; three (3) opened insulin pens (2 Lantus and 1Toujeo) with no expiration dates.

During an interview on [DATE REDACTED] at 11:45 AM, Registered Nurse #2 stated they were not aware of medications with shortened expiration dates and were unable to verbalize when insulins and or inhalers expired after opening. Registered Nurse #2 stated they did not utilize the narcotic lock box in the medication room and that narcotics were instead kept on the medication cart.

During an interview on [DATE REDACTED] at 11:48 AM, Assistant Director of Nursing #1 stated the first floor did not use

the narcotic box in the mediation room due to a disagreement that occurred when the medication room was moved to a different location several months ago. They further stated that since that time, narcotics had been stored in the medication cart.

During an interview on [DATE REDACTED] at 11:49 AM, Director of Nursing #1 stated the medication nurse was responsible to ensure their cart was clean and orderly. They stated that upon opening, medications should have been labeled with open and expiration dates; their pharmacy vendor should also have conducted medication cart audits. Director of Nursing #1 stated narcotic box locks on the second floor were immediately repaired on [DATE REDACTED], and new keys were made for the narcotic box on the first floor and was now in use. 10 New York Codes, Rules, and Regulations 415.18(d) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33538 Based on observations and interviews during a recertification survey the facility did not ensure food and drink were palatable and attractive for two of two units test trays and one (1) (Resident #61) of one (1) resident reviewed for palatable and appealing food and drink. Specifically, (a) resident #61 complained that the food was usually inedible, often unidentifiable, and not what was on the meal ticket. (b) Test trays on two (2) of two (2) units were identified by surveyors as unpalatable.

This is evidenced by:

The Minimum Data Set, dated dated dated [DATE REDACTED], documented the Resident #61 was cognitively intact, was able to make themselves understood and understood others.

During an interview on 4/30/2025 at 12:28 PM, Resident #61 stated the quality of the food was not good.

They stated they were served a mystery meat patty covered with gravy and vegetables are overcooked.

Alternate was a sandwich on stale bread. Resident #61 further stated sometimes they were supposed to have coleslaw but receive macaroni salad instead. They further stated that they had not received fresh fruit

in a long time, and do not get a choice, ' you eat what they give you. '

During an observation on 4/30/2025 at 12:28 PM, Resident #61 ' s meal ticket dated 4/30/2025 documented oven fried chicken, braised red cabbage, cream of corn, canned fruit. The meal tray contained chicken covered with gravy, green beans, an unidentifiable reddish-brown substance, cream of corn, and fruit. All of which was uneaten.

During a test tray on 5/08/2025 at 11:59 AM on Unit 1, the meal ticket documented roast pork, baked sweet potatoes, and cauliflower. The roast pork was covered with salty gravy. The baked sweet potato appeared to be boiled, was mushy and waterlogged. The cauliflower was overcooked and easily mashed when pressed down with a fork. None of the food items were palatable.

During a test tray on 5/08/2025 at 12:13 PM on Unit 2, the food served was overcooked and determined to be of poor quality. The roast pork was overcooked and dry with salty gravy. The baked sweet potato appeared to have been boiled with skin on and had no flavor. The cauliflower was overcooked and mushy.

None of the food items were palatable. 10 New York Code of Rules and Regulations 415.14(d)(1)(2) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards.

Based on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) (First Floor Unit and Second Floor Unit) of two (2) kitchenettes.

Specifically, the dishwashing machine final rinse water pressure was too low, equipment was not in good repair, and surfaces were not clean.

This is evidenced by:

During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM:

The water pressure during the final rinse of the automatic dishwashing machine was zero pounds per square inch; the dishwashing machine data plate stated that the water pressure was to be between 15 and 25 pounds per square inch.

The steamtable sink faucet leaked, the cold-water faucet did not work, and the faucet fixture was loose.

The handwashing sink paper towel dispenser was empty.

The metal finish was torn off on two 6-inch sections on the exterior bottom of the walk-in freezer and one 6-inch section of the walk-in refrigerator. 12 ceramic wall tiles were missing.

Seven floor tiles adjacent to the exit doors in the dietary suite corridor were broken and cracked.

Water was puddled on the floor of dishwashing machine room.

In the Second Floor Unit kitchenette, the bottom interior of the sink cabinet was heavily warped, cracked, and had multiple exposed sections of exposed unsealed particleboard.

During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM,

the following areas soiled with food particles and/or dirt: Spice rack tray.

Handwashing sink.

Ceiling and ceiling lights.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Kitchen windows.

Kitchen office floor.

Emergency food stock room floor.

Dietary suite corridor floor.

Janitor closet floor.

Second Floor Unit kitchenette floor.

During an interview on 4/29/2025 at 7:22 PM, Food Service Director #1 stated that the pressure gauge, missing wall tiles, puddling water, loose faucet, exterior of the walk-in freezer and refrigerator, broken floor tiles, and kitchenette sink will be reported for repair to the maintenance department. The paper towel dispenser would be refilled, and the cleaning items would be immediately addressed. They further stated that

the kitchenette floors would be reported for cleaning to the housekeeping department. 10 New York Codes, Rules, and Regulations 415.14(h) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dispose of garbage and refuse properly.

Based on observation and interviews conducted during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was not closed, and garbage littered the area.

This is evidenced by:

During observations on 4/29/2025 at 7:03 PM, the side door of the garbage dumpster was not closed, and garbage littered the area around the dumpster and side of the parking lot.

During an interview on 4/29/2025 at 7:30 PM, Food Service Director #1 stated that they would re-educate staff to keep the dumpster doors closed and would speak with the maintenance and housekeeping departments regarding picking up the litter. 10 New York Codes, Rules, and Regulations 415.14(h) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Based on observation and interview conducted during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. Specifically, carbon monoxide detection was not installed in main kitchen by gas fuel fired equipment (e.g., stove).

This is evidenced by:

During observations in the main kitchen on 4/29/2025 at 6:26 PM, a carbon monoxide detector was found on

the shelf below the steamtable and not installed as required in the stove area.

During an interview on 5/07/2025 at 3:14 PM, Director of Maintenance #1 stated that they would consult with corporate maintenance and reinstall the carbon monoxide detector. 10 New York Codes, Rules, and Regulations 400.2 2015 International Fire Code, Section 915 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51317 Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure resident medical records contained an accurate representation of the actual experiences of

the resident and included enough information to provide a picture of the resident ' s progress, including their response to treatments and services, and changes on their condition, plan of care, objectives, and/or interventions. Specifically, (a.) for Resident #61, the facility did not ensure Daily Medicare Notes accurately documented the resident ' s wounds and, (b.) for Resident #s 70 and 86, the facility did not ensure documentation of the residents ' condition that required antibiotic treatment.

This is evidenced by: Resident #61: Resident #61 was admitted to the facility with diagnoses of displaced fracture of greater trochanter of right femur (fracture of upper part of thigh bone), multiple myeloma (cancer that forms in a type of white blood cell), and unspecified heart failure (a condition where the heart is not pumping effectively) . The Minimum Data Set (an assessment tool) dated 5/01/2025, documented the resident was cognitively intact, was able to make themselves understood and understood others.

Wound Care Note dated 2/27/2025 by Physician Assistant #1 documented the resident had wounds on the right lower extremity, left lower extremity, left medial calf, bilateral feet, and bilateral buttocks. Treatments were documents for all wounds.

Daily Medicare Note dated 2/27/2025 and 2/28/2025 by Registered Nurse #2 documented the resident had no wounds.

Resident #70: Resident #70 was admitted to the facility with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning)major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and acute atopic conjunctivitis. (a chronic, allergic eye condition primarily affecting adults with a history of atopic dermatitis characterized by inflammation of the clear membrane covering the whites of the eyes and inner surfaces of the eyelid), The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident could rarely be understood, could rarely understand others, and was severely cognitively impaired.

Medical Provider Note dated 4/08/2025 documented a staff report of increased redness to right eye.

Conjunctivitis, trial ofloxacin ophthalmic 0.3 percent, two (2) drops both eyes four (4) times daily for seven (7) days.

Review of Nursing Progress Notes revealed no documentation of the resident ' s condition related to the need for antibiotic treatment prior to, during, or after the treatment was completed.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident# 86: Resident #86 was admitted to the facility with diagnosis including chronic obstructive pulmonary disease (lung and airway diseases that restricts breathing), polyneuropathy (damage affecting nerves), and pleural effusion (accumulation of fluid surrounding the lungs). The Minimum Data Set, dated dated dated [DATE REDACTED], documented the resident could be understood, could understand others, and was cognitively intact.

A Medical Provider Note dated 4/29/2025 documented the resident was seen for staff reports of chest congestion. Chest x-ray, DuoNeb, and Mucinex ordered. A trial of Invanz (a broad spectrum antibiotic effective against a wide range of bacteria) 1 gram was to be given one time.T

A Medical Provider Note dated 5/01/2025 documented the resident was seen for continued cough. Chest x-ray reveals mild left basilar infiltrate with small left pleural effusio(a buildup of fluid between the tissues that lined the lungs and the chest) and mild right infrahilar infiltrate (a collection of abnormal substances like pus, blood, or protein in the lung tissue below where the lungs connected to the airway and blood vessels). Start Levaquin 500 milligrams daily for seven (7) days.

Review of Nursing Progress Notes revealed no documentation of the resident ' s condition related to the need for antibiotic treatment prior to, during, or after the treatment was completed.

Interviews:

During an interview on 5/07/2025 at 3:13 PM, Licensed Practical Nurse #2 stated Resident #61 was originally treated for edema and vascular issues. They stated the edema in their legs turned into blisters and open wounds. They stated the Resident #61 was being seen on wound round by Physician Assistant #1.

They stated that according to Physician Assistant ' s written notes on 2/27/2025, Resident #61 had wounds

on their left and right inner calf, toes, and buttocks.

During an interview on 5/08/2025 at 11:17 AM, Licensed Practical Nurse #2 stated they did not understand why Registered Nurse #2 was documenting in the Daily Medicare Notes that Resident #61had no wounds.

They stated the Resident #61 had wounds and Registered Nurse #2 was providing wound care to the resident daily.

During an interview on 5/08/2025 at 2:54 PM, Licensed Practical Nurse #8 stated if a resident was on antibiotics, there should have been notes about their condition and progress.

During an interview on 5/08/2025 at 1:05 PM Licensed Practical Nurse #2 stated there should have been progress notes describing the resident's condition and progress during antibiotic treatment. 10 New York Codes Rules and Regulations 415.22(a)(1-4) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43805 Based on observations, record reviews, and interviews conducted during a recertification survey, the facility did not ensure an infection control program was implemented to prevent the transmission of communicable diseases to residents. Specifically, (a.) for Resident #64, enhanced barrier precautions were not implemented for the resident who had an indwelling catheter; (b.) for Resident #97, the resident's nebulizer equipment was not stored to prevent contamination of the equipment.

This is evidenced by: Resident #64 Resident #64 was admitted to the facility with the diagnoses of polyneuropathy (peripheral nervous system disorders that impact nerve function), chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 2/24/2025 documented the resident understood, could understand others, had moderately impaired cognition, and had an indwelling urinary catheter.

The policy and procedure titled, Enhanced Barrier Precautions and last reviewed 2/19/2025, documented enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a multi drug resistant organism.

During multiple observations on 4/29/2025, 4/30/2025, 5/02/2025, and 5/05/2025, there was no signage for enhanced barrier precautions and no personal protective equipment cart near the resident's room.

A Physician's Order dated 11/04/2024 documented enhanced barrier precautions for Resident #64 related to indwelling catheter and wounds.

During an interview on 5/06/2025 at 10:46 AM, Registered Nurse #1 could not say why Resident #64 was not

on enhanced barrier precautions. They stated they were aware that the resident had an indwelling urinary catheter.

Resident #97 Resident #97 was admitted to the facility with the diagnoses of chronic respiratory failure (when lungs cannot properly exchange gases), chronic obstructive pulmonary disease, and congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs). The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident was understood, could understand others, and was cognitively intact.

The policy and procedure titled, Administration of Nebulizer Medication last reviewed 8/2024 documented once treatment is complete to rinse, dry, and store nebulizer per facility policy.

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

During multiple observations on 4/29/2025, 4/30/2025, 5/02/2025, 5/05/2025, and 5/06/2025, the nebulizer equipment was on the resident's bedside table with the nebulizer mask laying uncovered on the nebulizer machine.

A review of current Physician Orders did not document an order for rinsing/cleaning the nebulizer equipment

after use.

During an interview on 5/06/2025 at 10:43 AM, Licensed Practical Nurse #1 stated the nebulizer mask or pipe should be rinsed, dried, and stored in a plastic bag after each use.

During an interview on 5/06/2025 at 10:46 AM, Registered Nurse #1 stated the nebulizer mask should be stored in a bag if one is available, otherwise the mask can be placed on a paper towel.

In an e-mail received 5/07/2025 at 2:02 PM, Director of Nursing #1 clarified that the facility policy for storing nebulizer equipment was to store in a bag at the bedside.

During an interview on 5/08/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that nebulizers should be rinsed, dried, and stored in a plastic bag. They stated that laying a nebulizer on a paper towel or on top of

the nebulizer machine would not be correct.

During an interview on 5/8/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that any nurse could contact the medical provider for the order to initiate transmission-based precautions including enhanced barrier precautions. They stated that unit managers should be rounding their units daily to ensure transmission-based precautions were in place as ordered.

New York Codes, Rules, and Regulations 415.19(a)(1-3) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that a working call system is available in each resident's bathroom and bathing area. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21414 Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case #NY00354621), the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on two (2) of two (2) units. Specifically, the facility nurse call system did not function in resident room #s 203 and 320.

This is evidenced by:

During observations on 4/29/2025 at 8:03 PM, the call bell device in the resident room [ROOM NUMBER] bathroom was missing from the mounting hardware and the wires were hanging out of the mounting hardware.

During an observation on 05/06/2025 at 1:02 PM, the call bell device was hanging by wires and not mounted to wall in resident room [ROOM NUMBER].

Workorders dated 10/29/2024 through 4/15/2025 documented 10 instances of call bell disrepair.

There was no documented evidence that workorders were submitted to repair the call bells in room #s 203 and 320.

During an interview on 5/07/2025 at 3:05 PM, Director of Maintenance #1 stated that they would repair the call bells in room #s 203 and 320. 10 New York Codes, Rules and Regulations 713-1.3(b) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Based on observation and interviews conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building, and grounds were not clean and maintained.

This is evidenced by:

During observations on 5/05/2025 from 12:04 PM through 12:31 PM: Sections of the lower portion of the building facade was covered with moss and algae.

Piles of old construction materials and accumulations of leaves and litter were found on the grounds along

the building.

The garbage dumpsters were not seated in the designated fenced area; vegetation was encroaching on the fencing.

During an interview on 5/07/2025 at 3:09 PM, Director of Maintenance #1 stated that they would have the construction debris and litter picked up, the vegetation cut back and direct the vendor to place the dumpster

in the designated area. 10 New York Codes, Rules, and Regulations 415.5(h)(4) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have enough outside ventilation via a window or mechanical ventilation, or both.

Based on observation and interviews conducted during the recertification, the facility did not ensure adequate ventilation of one (1) (second floor) of (2) resident units. Specifically, the Second Floor Unit Soiled Holding Room and shower room were not adequately ventilated.

This is evidenced by:

During observations on 4/29/2025 at 8:47 PM, unpleasant odors were found in the Second Floor Unit Soiled Holding Room and a heavy must odor was found in the Second Floor Unit shower room.

During an interview on 5/07/2025 at 3:10 PM, Director of Maintenance #1 stated that the motors servicing the ventilation system for the Second Floor Unit Soiled Holding Room and the Second Floor Unit shower room were not powerful enough to remove the odors and required replacement. 10 New York Codes, Rules and Regulations 483.90(i)(2) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Put firmly secured handrails on each side of hallways.

Based on observation and interviews conducted during a Recertification Survey, handrails were not maintained on two (2) of two (2) resident units. Specifically, handrails had broken plastic and missing pieces exposing sharp edges.

This is evidenced by:

During observations on 04/29/2025 at 7:51 PM through 8:58 PM:

The Second Floor Unit south corridor handrail had a six (6)-inch section of broken plastic with sharp edges.

The Second Floor Unit Elevator one (1) corner guard had broken plastic with sharp edges.

The First Floor Unit handrail had six (6) areas where the edge turn pieces missing exposing sharp edges.

During an interview on 5/07/2025 at 3:03 PM, Director of Maintenance #1 stated that they would repair the broken plastic and install the missing pieces on the handrails. 10 New York Codes, Rules, and Regulations 713-1.8(a) 08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/09/2025 Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21414 Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00354621, NY00355929, NY00356190, and NY00357360), the facility did not maintain

a pest-free environment and an effective pest control program on two (2) of two (2) resident units.

Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas.

This is evidenced by:

During observations on 4/29/2025 at 8:45 PM, a resident was heard yelling, ' There is a bee in my room, ' and a wasp was found flying in resident room [ROOM NUMBER]. Director of Maintenance #1 immediately found and killed the wasp.

During observations on 5/05/2025 at 1:55 PM, gnat-like flies were found in the conference room.

During observations on 5/06/2025 from 10:17 AM through 1:49 PM, gnat-like flies or ants were found in resident room [ROOM NUMBER] and the employee break room.

During observations on 5/07/2025 at 11:12 AM, gnat-like flies were found in the main kitchen dishwashing area.

The document titled [vendor] Pest Management, the facility pest-sighting logbook, documented that fruit flies were found in room #s 207 and 226 during 9/2024.

The document titled [vendor] Pest Management documented that the facility was treated for ants during 4/2025 and for small flies in the dishwasher area of the kitchen periodically from 5/2024.

There was no documented evidence that the facility was treated for wasps.

There was no documented evidence that the facility was treated for small flies and ants in resident room [ROOM NUMBER] or for small flies the conference room or the employee break room since 5/2024.

During an interview on 5/07/2025 at 3:12 PM, Director of Maintenance #1 stated that they contacted the vendor to treat for small flies resident room [ROOM NUMBER], the conference room, and the employee break room. 10 New York Codes, Rules and Regulations 415.29(j)(5) 08/27/2025

F-F925.

Upon entrance to the facility on [DATE REDACTED], 108 residents resided on two floors. Upon observing and reviewing

the Facility Staffing Sheet, six (6) Licensed Nurses and ten (10) Certified Nurse Aides were on duty.

During an interview on 4/30/2025 at 12:59 PM, the facility Ombudsman stated that there had been a high facility administration turnover. They stated that a lack of consistent staff associated with the leadership turnover had been an ongoing issue. They stated that residents were not getting the care due to low staffing levels, and showers had been an ongoing issue because of staffing, where the staff would tell the residents

they were too short-staffed to provide resident showers.

During a surveyor-led group resident meeting on 5/01/2025 at 9:32 AM, five residents who attended the meeting reported insufficient staffing to meet their needs. They stated that they often had to wait an extended period to get care and were yelled at by staff, or staff were rude and disrespectful. They stated that many times they have been left unattended for extremely long times, and the Certified Nurse Aides would say they would come back but never did.

During an interview on 5/01/2025 at 9:32 AM, Resident #22 stated when they put their call light on, some Certified Nurse Aides would come into the room and tell them in that they were not their aide, then turn the call light off, leave the room and not come back. They stated it could take one (1) to three (3) hours for someone to finally come in and help them. Resident #22 stated they needed help with using the bathroom and said they had laid in their bed soaking wet after having an accident because Certified Nurse Aides did not respond to the call. Resident #22 stated they felt degraded when Certified Nurse Aides refused to help them. Resident #22 further stated Certified Nurse Aides would argue and fight about their assignments in front of them and other residents, and Certified Nurse Aides and would look directly at them and say that

they were not assigned to care for them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 5/05/2025 at 1:08 PM, Certified Nursing Aide #1 stated staff were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed. Certified Nurse Level of Harm - Minimal harm or Aide #1 stated staff regularly reported the inability to provide care and services to the residents due to potential for actual harm staffing issues with administration.

Residents Affected - Many During an interview on 5/08/2025 at 10:38 AM, Registered Nurse #1 stated they worked on the care plans but were severely in need of help. Registered Nurse #1 stated that they were told they would receive an assistant last year, but it had not happened. Registered Nurse #1 stated that they worked passing medications, acted as an aide, and spent most of their time working to provide resident care on the unit.

The Facility Assessment, last reviewed on 9/10/2024, documented that the facility's bed capacity was 120.

The section titled, Staffing Plan, documented the following:

- Licensed Nurses providing administrative direction, supervision, and direct care:

- Director of Nursing: 1 Registered Nurse full-time Days

- Assistant Director of Nursing: 1 Full-Time Employee

- Registered Nurse Manager - 2 Full-Time Employees

- Registered Nurse Supervisors: Evening and Weekends: 3 Full-time Employees

- Licensed Practical Medication Nurses: 5 for days, 5 for evenings, and 3 for nights.

- Direct Care Staff:

- Certified Nurse Aides: 11 for days, 11 for evenings, 6 for nights.

A review of staffing sheets provided by the facility from 3/01/2025 through 4/8/2025 documented that they did not meet their assessed minimum staffing on most shifts for the following:

- On 3/02/2025, the nursing schedule had 6 nursing staff during the day shift, 3 for the evening shift, and 2 for the night shift. The Certified Nurse Aide schedule had 8 aides during the day shift, 7 for the evening shift, and 5 for the night shift.

- On 3/09/2025, the nursing schedule had 6 nursing staff during the day shift, and 5 for the evening shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 6 for the evening shift, and 2 for the night shift.

- On 3/16/2025, the nursing schedule had 6 nursing staff during the day shift, 4 for the evening shift, and 2 for the night shift. The Certified Nurse Aide schedule had 5 aides during the day shift, 6 for the evening shift, and 4 for the night shift.

- On 3/25/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 10 for the evening shift, and 5 for the night shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 - On 4/01/2025, the nursing schedule had 5 for the evening shift and 3 for the night shift. The Certified Nurse Aide schedule had 9 for the evening shift and 3 for the night shift. Level of Harm - Minimal harm or potential for actual harm - On 4/13/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 5 aides during the day shift, 5 for the evening shift, Residents Affected - Many and 5 for the night shift.

- On 4/20/2025, the nursing schedule had 5 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 10 for the evening shift, and 5 for the night shift.

- On 4/25/2025, the nursing schedule had 6 nursing staff during the day shift, 5 for the evening shift, and 3 for the night shift. The Certified Nurse Aide schedule had 7 aides during the day shift, 5 for the evening shift, and 4 for the night shift.

During an interview on 5/6/2025 at 2:30 PM, Staffing Coordinator #1 stated they determined the staffing levels per the census; it was discussed at the morning meeting what the goal for the staffing levels should be for the next day. They stated that a minimum of three (3) Certified Nurse Aides should be on the first floor and six (6) Certified Nurse Aides should be on the second floor. They stated that if they are short-staffed,

they will attempt to fill the spots by offering bonuses or other incentives to get staffing at appropriate levels.

During an Interview on 5/06/2025 at 2:55 PM, Assistant Director of Nursing #1, who is also the Nurse educator, described the competency levels for staff. They stated that they perform all competencies during

the hiring process and then yearly or when needed if the issue arises. They stated that Certified Nurse Aides had monthly in-services for all areas, including neglect and abuse training.

48413

During an interview on 5/06/2025 at 3:08 PM, Director of Nursing #1 stated that they have tried to meet the regulations every day.

10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 34630

Residents Affected - Some Based on record review and interview during a recertification survey, the facility did not ensure it established

a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) the facility did not document receipt of Oxycodone (narcotic pain medication) by the pharmacy for Resident #82, and (b.) did not document nursing unit narcotics as having been counted by two licensed staff members and signed as appropriate on the facility-provided narcotic record sheets for two (2) of two (2) nursing units.

This is evidenced by:

The Policy and Procedure titled, Medications - Controlled Substances, effective 3/13/2024, documented it was the facility ' s policy to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Handling Controlled Substances documented controlled substances were counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals signed the designated controlled substance record. If the count was correct, an individual resident-controlled substance record was made for each resident who would be receiving a controlled substance. The record included the quantity received, date and time received, and signature of person receiving medication. Dispensing and Reconciling Controlled Substances documented, controlled substance inventory was monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detection/follow-up. Nursing staff count controlled medication in inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing Services.

Resident #82:

Resident #82 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke) affecting one side of the body, unspecified pain, and anxiety disorder. The Minimum Data Set (an assessment tool) dated 4/28/2025, documented the resident was cognitively intact, was able to make themselves understood, and understood others.

Physician Order dated 4/29/2025, documented Oxycodone 10 milligram tablet, give one (1) tablet (10 milligrams) by oral route every four (4) hours as needed for unspecified pain. Maximum daily dose: six (6) tablets.

Individual Patient Controlled Substance Administration Record dated 4/29/2025, documented Oxycodone 10 milligram tablet, one (1) tablet every four (4) hours as needed. Maximum daily dose: six (6) tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 The record did not document the signature of the person and title receiving the drug, the date received, and

the amount received. Level of Harm - Minimal harm or potential for actual harm Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, Team #s 1 and 2, dated April 2025, did not consistently document signatures by the off-going and oncoming nurse. For Residents Affected - Some instance, 4/13/2025, 4/26/2025, and 4/30/2025 7AM - 3PM did not document a signature for the off-going and oncoming nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the first-floor nursing unit, Team #s 1 and 2, dated May 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, 5/1/2025 and 5/5/2025 7AM - 3PM did not document a signature for the off-going nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the second-floor nursing unit, Team East; West; and North, dated April 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, North team on 4/7/2025 11PM - 7AM did not document a signature for the off-going and oncoming nurse. 4/8/2025 3PM - 11PM did not document a signature for the off-going and oncoming nurse. 4/16/2025 7AM - 3PM, 3PM - 11PM, and 11PM - 7AM did not document a signature for the off-going and oncoming nurse. [NAME] team on 4/2/2025 3PM - 11PM, did not document a signature for the off-going nurse and 11PM - 7AM did not document a signature for the oncoming nurse. 4/6/2025 7AM - 3PM and 3PM - 11PM did not document a signature for the off-going nurse. East team on 4/1/2025 3PM - 11PM did not document a signature for the oncoming nurse and the 11PM to 7AM did not document a signature for

the off-going nurse. 4/25/2025 7AM - 3PM did not document a signature for the off-going and oncoming nurse and 3PM - 11PM did not document a signature for the off-going nurse.

Review of Narcotic and Controlled Substance Shift Count Sheet for the second-floor nursing unit, Team West, dated May 2025, did not consistently document signatures by the off-going and oncoming nurse. For instance, on 5/1/2025 7AM - 3PM did not document a signature for the off-going nurse. 5/06/2025 7AM - 3PM did not document a signature for off-going nurse and 11PM - 7AM did not document a signature for the oncoming nurse.

During an interview on 5/07/2025 at 11:05 AM, Licensed Practical Nurse #3 stated they always counted the narcotics but did not always sign the paper that the count was done.

During an interview on 5/07/2025 at 3:13 PM, Licensed Practical Nurse #2 stated they learned about the narcotic issue that day (5/07/2025) and completed an actual count with the nurse. They stated they just reviewed the process of narcotic counting with staff. They stated ultimately, the licensed nurse was responsible for counting the narcotics, because they were licensed professionals and were accountable for everything they did.

During an interview on 5/08/2025 10:39 AM, Licensed Practical Nurse #2 stated the supervisor was responsible for receiving narcotics from the pharmacy and was to count them, sign for them, and document

the date medication was received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview on 5/8/2025 at 12:55 PM, Director of Nursing #1 stated they would expect the narcotics to be counted and narcotic count sheets to be signed by the off-going and oncoming nurse. They further Level of Harm - Minimal harm or stated the controlled substance records should have been signed by two (2) nurses when the narcotics were potential for actual harm received from the pharmacy. They stated they expected narcotics would be counted at time of receipt.

Residents Affected - Some 10 New York Code Rules and Regulations 415.18(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 33538

Residents Affected - Many Based on record review and interview conducted during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, timeframes for the different steps in the process. Additionally, the drug regimen of each resident was not reviewed at least once a month by a licensed pharmacist. Specifically, the facility policy titled, Medication Regimen Review, did not identify time frames for steps in the medication review process. Additionally, there was no documented evidence of a pharmacist's review of the medication regimens for January, February, and March of 2025, affecting all residents.

This is evidenced by:

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The facility policy titled, Medication Regimen Review, created 7/19/2019 with no updates or revisions, documented the Consultant Pharmacist should review the medication regimen of each resident at least monthly. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. If the situation was serious enough to represent a risk to a person ' s life, health, or safety, the Consultant Pharmacist would contact the Physician directly to report the information to the Physician and would document such contacts. The Consultant Pharmacist would provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions.

48413

The facility policy did not address the time frames for steps in the Medication Regimen Review process.

During an interview on 5/05/2025 at 2:59 PM the Director of Nursing confirmed that as far as they know, the pharmacy did not provide medication regimen reviews for January, February, and March 2025. They were not the Director of Nursing at this facility for those months. They stated that they were not aware the policy did not have the required time frames.

10 New York Code Rules and Regulations 415.18(c)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 48615 potential for actual harm Based on observation, record review, and interviews conducted during a recertification survey, the facility did Residents Affected - Many not ensure that its medication error rate did not exceed 5 percent for one (1) (Resident # 6) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 36 percent.

This is evidenced by:

The facility ' s Policy and Procedure titled, Administering medications, effective 3/13/2024, documented medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Resident #6

Resident #6 was admitted to the facility with the diagnoses of congestive heart failure (when the heart can't pump blood well enough to give the body a normal supply), chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs resulting in swelling and irritation), and depression (a constant feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 3/06//2025 documented the resident was able to be understood and was able to understand others with intact cognition.

The Medication Administration Record dated April 2025 for Resident #6 documented the following medications were to be administered at 9:00 AM:

Albuterol sulfate 2.5 milligram/3 milliliter (0.083 percent) solution for nebulization. Inhale 3 milliliters (2.5 milligram) by nebulization route every 6 hours as needed

Cardizem CD 240 milligram capsule, extended release. Give 1 capsule (240 milligram) by oral route once daily.

Eliquis 5 milligram. Give 1 tablet (5 milligram) by oral route 2 times per day.

Lasix 40 milligram. Give 1 tablet (40 milligram) by oral route once daily

Magnesium oxide 400 milligram (241.3 milligram magnesium). Give 1 tablet by oral route once daily

Olanzapine 2.5 milligram. Give 1 tablet (2.5 milligram) by oral route once daily.

Trelegy Ellipta 200 microgram-62.5 microgram-25 microgram powder for inhalation. Inhale 1 puff by inhalation route once daily.

Venlafaxine ER 150 milligram capsule. Give 1 capsule (150 milligram) by oral route once daily.

Enteric Coated Aspirin 81 milligram. Give 1 tablet (81 milligram) by oral route once daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During the medication administration observation on 04/30/2025 at 10:40 AM, Licensed Practical Nurse #7 administered the above medications to resident #6 at approximately 10:45 AM. Licensed Practical Nurse #7 Level of Harm - Minimal harm or stated they were always this late with their morning medication pass because they had 28 residents with a lot potential for actual harm of medications. They were unable to administer them on time. They further stated Human Resources spoke with them regarding the late medications, and they explained the medications pass was too heavy for one Residents Affected - Many person. They also stated the nurse manager was aware, and they were not given any assistance.

During an interview on 04/30/2025 at 10:47 AM, Registered Nurse #1 stated Human Resources spoke with Licensed Practical Nurse #7. Registered Nurse #1 stated no assistance was provided because other nurses were completing the same medication pass on time. They stated they plan to do an audit on Licensed Practical Nurse #7 sometime in the future. Registered Nurse #1 stated the nurse performing the medication pass was responsible for notifying the nurse practitioner when medications are late.

During an interview on 04/30/2025 at 10:55 AM, Nurse Practitioner #1 stated nursing staff should have notified them when medications are late either by phone or in person when they are in the building. They had not been notified of any late medications on this day. They further stated that on the previous day (4/29/2025), there was an entry made by Licenses Practical Nurse #7, in the Nurse Practitioner communication book that medications were late.

During an interview on 05/08/2025 at 11:49 AM, Director of Nursing #1 stated there had been problems with Licensed Practical Nurse #7 administering medications on time. The expectation for all nurses was to adhere to the policy of administering medications one hour before or after ordered time. When a nurse finds themselves late in giving medications, they should immediately notify the physician and or nurse practitioner of the late medication(s) via telephone or in person, then notify their supervisor or manager, who can provide help. At no time should notification of any late medication be placed in the Nurse Practitioner/Physician communication book. All Registered Nurses and Licensed Practical Nurses received training on medication administration upon hire and with annual competencies.

10 New York Codes, Rules, and Regulations 415.12 (m)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33538 potential for actual harm Based on observations, record review, and interviews conducted during a recertification and abbreviated Residents Affected - Many survey (Case #'s NY00344251, NY00348580, NY355929, NY00347329 and NY00371796), the facility failed to ensure residents were free of significant medication errors for six (6) (Resident #s 10, 70, 82, 86, 107 and 416) of six (6) residents reviewed for medication administration. Specifically, (a.) Residents #s 10 and 70 had orders for antibiotic eye ointment that were not administered as ordered. (b.) Resident #82 had an order for narcotic pain medication that was not administered as ordered. (c.) Residents #s 86 and 107 had orders for antibiotics that were not administered as ordered. (d) Resident #416 was given medication that was not ordered for them.

This is evidenced by:

The facility policy titled, Medication Administration, created 4/2013 and last revised 12/2019, documented medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document as such in designated format (hard copy or electronic) space provided for that drug and dose.

There was no documented evidence that the policy addressed notification of the medical provider when medications were not administered as ordered.

Resident #10

Resident #10 was admitted to the facility with a diagnosis of type (two) 2 diabetes, chronic obstructive pulmonary disease (narrowing of airways) and chronic atrial fibrillation (an irregular heart rate). The Minimum Data Set (an assessment tool) dated 2/06/2025 documented the resident could be understood, could understand others, and was cognitively intact.

A Physician ' s Order dated 1/25/2025, documented the resident was to receive Tobradex ophthalmic 0.1/0.3 percent eye ointment to the right eye, (two) 2 drops to the right eye (four) 4 times per day for (seven) 7 days for conjunctivitis.

Review of the Medication Administration Record for January 2025 documented TobraDex eye ointment was to be administered at 9 AM, 1 PM, 5 PM, and 9 PM.

This medication was not administered on the following dates and times:

1/26/2025 at 9 AM and 1 PM. Reason was due to clinical monitoring.

1/26/2025 at 5 PM. Reason was due to within normal range.

1/26/2025 at 9 PM. Reason was due to clinical monitoring.

1/27/2025 at 9 AM, 1 PM, 5 PM and 9 PM. Reason was due to clinical monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 1/28/2025 at 5 PM and 9 PM. Reason was below normal parameters.

Level of Harm - Minimal harm or 1/30/2025 at 9 AM and 9 PM due to clinical monitoring. potential for actual harm Nursing progress note dated 2/01/2025 documented Resident #10 completed TobraDex. Residents Affected - Many There was no documentation in Resident #10 ' s electronic medical record progress note section that indicated Resident #10 was not administered TobraDex eye ointment on the above dates/times.

During an interview on 5/08/2025 at 9:46 AM, Registered Nurse #1 stated if medications were not administered, the Licensed Practical Nurse should have notified the Nurse Practitioner on call. Registered Nurse #1 looked at the Medication Administration record for Resident #10 for the month of January 2025 and stated TobraDex eye ointment was not administered each day as ordered.

During an interview on 5/08/2025 at 12:30 PM, Nurse Practitioner #1 stated they had been notified in the past when residents did not receive their medications. They assumed nursing staff would notify them if there was a missed dose of a medication because they may have been able to offer an alternative depending on

the circumstance (such as if a medication was not available, they could offer an alternative medication in the meantime). Nurse Practitioner #1 stated that they could not recall receiving notifications that Resident #10 did not receive the TobraDex eye ointment as ordered.

During an interview on 5/08/2025 at 10:23 AM, Director of Nursing #1 stated when a provider ordered a medication or treatment for a resident, it was documented on the medication administration record and/or treatment administration record. Director of Nursing #1 was shown the Medication Administration Record for January 2025 for Resident #10. They stated TobraDex was initiated for this resident in January 2025, but there were missed doses of the medication. They stated that they were not aware why clinical monitoring would be documented for a reason as to why administration of TobraDex did not occur. They stated there were no progress notes that documented why the medication was not administered to Resident #10.

Resident #107

Resident #107 was admitted to the facility with the diagnoses of type (two) 2 diabetes, atrial fibrillation (an irregular heart rate), and cellulitis (bacterial infection of the skin). The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident could be understood, could understand others, and was severely cognitively impaired.

The Physician's Order dated 4/22/2025 documented Rocephin (one) 1 gram solution for injection, give (one) 1 gram intramuscular route once daily for (five) 5 days.

The Medication Administration Record for April 2025 documented (four) 4 doses were given over (four) 4 days. The antibiotic was not administered on 4/24/2025, the reason documented was, there was no lidocaine (a pain-relieving medication that can be mixed with other medications to help prevent pain at an injection site).

A review of the progress notes for 4/22/2025-4/30/2025 had no documentation a physician being informed and dosages changed due to receiving less than the prescribed dosages.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 5/08/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that the medical provider should be informed of any missed doses of an antibiotic so the schedule can be extended or Level of Harm - Minimal harm or adjusted to ensure the resident received each ordered dose. They stated conversations with the medical potential for actual harm provider should always be documented in the progress notes.

Residents Affected - Many During an interview on 5/08/2025 at 1:11 PM, Licensed Practical Nurse #2 stated the doctor should have been called for any missing dose. They stated that lidocaine is always available, and they were never made aware of any shortage. They stated the nurse that did not administer the ordered dose was no longer employed at the facility.

34630

Resident #416

Resident #416 was admitted to the facility with the diagnoses of right hemiplegia (paralysis of one side of the body) following a cerebral infarction (disrupted blood flow to the brain); Parkinson ' s Disease (a movement disorder of the nervous system that worsens over time), and Muscle Weakness (when muscles aren't as strong as they should be). The Minimum Data Set, dated dated dated [DATE REDACTED], documented the resident could be understood and could understand others with severe cognitive impairment.

The hospital progress note dated 6/07/2024 documented, Per medical records, resident unintentionally received 40 units of Lantus Sunday prior to admission. Resident was brought to Hospital on 6/03/2024 and was admitted .

Nursing progress note dated 6/03/2024 at 6:43 AM documented, reported by roommate that resident was given their PM dose of insulin. Resident ' s blood glucose this morning was 88. Resident was noted to be more sluggish than usual this morning and was given ensure to bring blood sugar up. Supervisor notified and, repeat check of blood sugar was 108.

Resident #416 ' s Medication Administration Record dated June 2024, did not include an order for Lantus or any other insulin medication.

The Medication Error Report dated 6/03/3024, documented Resident #416 received Lantus 40 units without

a physician order.

During an interview on 5/08/2025 at 11:49 AM, Director of Nursing #1 stated Licensed Practical Nurses and Registered Nurses receive medication administration training upon hire as well as completed annual competencies. Nurses follow the six (6) rights for medication administration that include verifying (1) right patient (2) right drug (3) right dose (4) right time (5) right route (6) right documentation.

10 New York Codes Rules and Regulations 415.12(m)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48615 Residents Affected - Many Regulation S483.45(h)(2): The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) Medication Rooms (2nd floor); and for two (2) of three (3) medication carts (first floor unit 100 and second floor unit 300) reviewed. Specifically, (a.) two (2) open bottles of lidocaine injectable solution had no open and or expiration dates (b.) seven (7) insulin kwik pens had no expiration dates (c.) one (1) inhaler had no open and or expiration date, and four (4) other inhalers had no expiration dates. Additionally, (d.) for the second-floor medication room narcotic box 1 West, both inside and outside locks were broken. The first-floor medication room narcotic boxes had no keys and were inaccessible to staff. Narcotics were observed to be stored on medication carts.

This is evidenced by:

The facility ' s Policy and Procedure titled, Administering medications, with effective date of [DATE REDACTED] documented the following: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 13. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure. 15. Insulin pens are clearly labeled with the resident ' s name or other identifying information. 16. All multidose injectable medications will be labeled with the date opened and expiration date. 30. Each nurses ' station has a current medication reference, as well as a copy of the surveyor guidance for F,d+[DATE REDACTED] (Pharmacy Services) available. Manufacturer ' s instructions or user ' s manuals related to any medication administration devices are kept with the devices or at the nurses ' station.

During an observation on [DATE REDACTED] at 10:59 AM, the second floor medication cart [NAME] Unit 300 contained two (2) opened lidocaine bottles with no open and or expiration date; four (4) opened insulin pens (1 Humalog, 2 Lantus and 1 Lispro) with no expiration dates; and three (3) opened inhalers (fluticasone; budesonide and incruse ellipta) with no expiration dates.

During an observation on [DATE REDACTED] at 11:15 AM, the second-floor medication room contained a narcotic box.

The inside lock had been removed leaving an open hole where lock should had been. The outside lock could not be fully secured and was partially opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on [DATE REDACTED] at 11:20 AM, Licensed Practical Nurse #5 stated the narcotic box lock had been broken for several weeks and that their maintenance department had previously tried to repair locks. Level of Harm - Minimal harm or Registered Nurse #1 stated maintenance was aware locks still were in need of repair and it was on their to potential for actual harm do list.

Residents Affected - Many During an observation on [DATE REDACTED] at 11:40 AM, the first floor medication cart East Unit 100 contained one (1) albuterol inhaler with no name, no open or expiration date; one (1) incruse ellipta inhaler with no expiration date; three (3) opened insulin pens (2 Lantus and 1Toujeo) with no expiration dates.

During an interview on [DATE REDACTED] at 11:45 AM, Registered Nurse #2 stated they were not aware of medications with shortened expiration dates and were unable to verbalize when insulins and or inhalers expired after opening. Registered Nurse #2 stated they did not utilize the narcotic lock box in the medication room and that narcotics were instead kept on the medication cart.

During an interview on [DATE REDACTED] at 11:48 AM, Assistant Director of Nursing #1 stated the first floor did not use

the narcotic box in the mediation room due to a disagreement that occurred when the medication room was moved to a different location several months ago. They further stated that since that time, narcotics had been stored in the medication cart.

During an interview on [DATE REDACTED] at 11:49 AM, Director of Nursing #1 stated the medication nurse was responsible to ensure their cart was clean and orderly. They stated that upon opening, medications should have been labeled with open and expiration dates; their pharmacy vendor should also have conducted medication cart audits. Director of Nursing #1 stated narcotic box locks on the second floor were immediately repaired on [DATE REDACTED], and new keys were made for the narcotic box on the first floor and was now in use.

10 New York Codes, Rules, and Regulations 415.18(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33538 potential for actual harm Based on observations and interviews during a recertification survey the facility did not ensure food and drink Residents Affected - Few were palatable and attractive for two of two units test trays and one (1) (Resident #61) of one (1) resident reviewed for palatable and appealing food and drink. Specifically, (a) resident #61 complained that the food was usually inedible, often unidentifiable, and not what was on the meal ticket. (b) Test trays on two (2) of two (2) units were identified by surveyors as unpalatable.

This is evidenced by:

The Minimum Data Set, dated dated dated [DATE REDACTED], documented the Resident #61 was cognitively intact, was able to make themselves understood and understood others.

During an interview on 4/30/2025 at 12:28 PM, Resident #61 stated the quality of the food was not good.

They stated they were served a mystery meat patty covered with gravy and vegetables are overcooked. Alternate was a sandwich on stale bread. Resident #61 further stated sometimes they were supposed to have coleslaw but receive macaroni salad instead. They further stated that they had not received fresh fruit

in a long time, and do not get a choice, ' you eat what they give you. '

During an observation on 4/30/2025 at 12:28 PM, Resident #61 ' s meal ticket dated 4/30/2025 documented oven fried chicken, braised red cabbage, cream of corn, canned fruit. The meal tray contained chicken covered with gravy, green beans, an unidentifiable reddish-brown substance, cream of corn, and fruit. All of which was uneaten.

34630

During a test tray on 5/08/2025 at 11:59 AM on Unit 1, the meal ticket documented roast pork, baked sweet potatoes, and cauliflower. The roast pork was covered with salty gravy. The baked sweet potato appeared to be boiled, was mushy and waterlogged. The cauliflower was overcooked and easily mashed when pressed down with a fork. None of the food items were palatable.

During a test tray on 5/08/2025 at 12:13 PM on Unit 2, the food served was overcooked and determined to be of poor quality. The roast pork was overcooked and dry with salty gravy. The baked sweet potato appeared to have been boiled with skin on and had no flavor. The cauliflower was overcooked and mushy. None of the food items were palatable.

10 New York Code of Rules and Regulations 415.14(d)(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 21414

Residents Affected - Some Based on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) (First Floor Unit and Second Floor Unit) of two (2) kitchenettes. Specifically, the dishwashing machine final rinse water pressure was too low, equipment was not in good repair, and surfaces were not clean.

This is evidenced by:

During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM:

The water pressure during the final rinse of the automatic dishwashing machine was zero pounds per square inch; the dishwashing machine data plate stated that the water pressure was to be between 15 and 25 pounds per square inch.

The steamtable sink faucet leaked, the cold-water faucet did not work, and the faucet fixture was loose.

The handwashing sink paper towel dispenser was empty.

The metal finish was torn off on two 6-inch sections on the exterior bottom of the walk-in freezer and one 6-inch section of the walk-in refrigerator.

12 ceramic wall tiles were missing.

Seven floor tiles adjacent to the exit doors in the dietary suite corridor were broken and cracked.

Water was puddled on the floor of dishwashing machine room.

In the Second Floor Unit kitchenette, the bottom interior of the sink cabinet was heavily warped, cracked, and had multiple exposed sections of exposed unsealed particleboard.

During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM,

the following areas soiled with food particles and/or dirt:

Spice rack tray.

Handwashing sink.

Fire extinguishers.

Ceiling and ceiling lights.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Kitchen windows.

Level of Harm - Minimal harm or Floor in corners and next to walls. potential for actual harm Kitchen office floor. Residents Affected - Some Emergency food stock room floor.

Dietary suite corridor floor.

Janitor closet floor.

First Floor Unit kitchenette floor.

Second Floor Unit kitchenette floor.

During an interview on 4/29/2025 at 7:22 PM, Food Service Director #1 stated that the pressure gauge, missing wall tiles, puddling water, loose faucet, exterior of the walk-in freezer and refrigerator, broken floor tiles, and kitchenette sink will be reported for repair to the maintenance department. The paper towel dispenser would be refilled, and the cleaning items would be immediately addressed. They further stated that

the kitchenette floors would be reported for cleaning to the housekeeping department.

10 New York Codes, Rules, and Regulations 415.14(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 21414 potential for actual harm Based on observation and interviews conducted during the recertification survey, the facility did not ensure Residents Affected - Few garbage and refuse was disposed properly. Specifically, the garbage dumpster was not closed, and garbage littered the area.

This is evidenced by:

During observations on 4/29/2025 at 7:03 PM, the side door of the garbage dumpster was not closed, and garbage littered the area around the dumpster and side of the parking lot.

During an interview on 4/29/2025 at 7:30 PM, Food Service Director #1 stated that they would re-educate staff to keep the dumpster doors closed and would speak with the maintenance and housekeeping departments regarding picking up the litter.

10 New York Codes, Rules, and Regulations 415.14(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm 21414 Residents Affected - Few Based on observation and interview conducted during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. Specifically, carbon monoxide detection was not installed in main kitchen by gas fuel fired equipment (e.g., stove).

This is evidenced by:

During observations in the main kitchen on 4/29/2025 at 6:26 PM, a carbon monoxide detector was found on

the shelf below the steamtable and not installed as required in the stove area.

During an interview on 5/07/2025 at 3:14 PM, Director of Maintenance #1 stated that they would consult with corporate maintenance and reinstall the carbon monoxide detector.

10 New York Codes, Rules, and Regulations 400.2

2015 International Fire Code, Section 915

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51317

Residents Affected - Few Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure resident medical records contained an accurate representation of the actual experiences of

the resident and included enough information to provide a picture of the resident ' s progress, including their response to treatments and services, and changes on their condition, plan of care, objectives, and/or interventions. Specifically, (a.) for Resident #61, the facility did not ensure Daily Medicare Notes accurately documented the resident ' s wounds and, (b.) for Resident #s 70 and 86, the facility did not ensure documentation of the residents ' condition that required antibiotic treatment.

This is evidenced by:

Resident #61:

Resident #61 was admitted to the facility with diagnoses of displaced fracture of greater trochanter of right femur (fracture of upper part of thigh bone), multiple myeloma (cancer that forms in a type of white blood cell), and unspecified heart failure (a condition where the heart is not pumping effectively) . The Minimum Data Set (an assessment tool) dated 5/01/2025, documented the resident was cognitively intact, was able to make themselves understood and understood others.

Wound Care Note dated 2/27/2025 by Physician Assistant #1 documented the resident had wounds on the right lower extremity, left lower extremity, left medial calf, bilateral feet, and bilateral buttocks. Treatments were documents for all wounds.

Daily Medicare Note dated 2/27/2025 and 2/28/2025 by Registered Nurse #2 documented the resident had no wounds.

Resident #70:

Resident #70 was admitted to the facility with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning)major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and acute atopic conjunctivitis. (a chronic, allergic eye condition primarily affecting adults with a history of atopic dermatitis characterized by inflammation of the clear membrane covering the whites of the eyes and inner surfaces of the eyelid), The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident could rarely be understood, could rarely understand others, and was severely cognitively impaired.

Medical Provider Note dated 4/08/2025 documented a staff report of increased redness to right eye. Conjunctivitis, trial ofloxacin ophthalmic 0.3 percent, two (2) drops both eyes four (4) times daily for seven (7) days.

Review of Nursing Progress Notes revealed no documentation of the resident ' s condition related to the need for antibiotic treatment prior to, during, or after the treatment was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Resident# 86:

Level of Harm - Minimal harm or Resident #86 was admitted to the facility with diagnosis including chronic obstructive pulmonary disease potential for actual harm (lung and airway diseases that restricts breathing), polyneuropathy (damage affecting nerves), and pleural effusion (accumulation of fluid surrounding the lungs). The Minimum Data Set, dated dated dated [DATE REDACTED], Residents Affected - Few documented the resident could be understood, could understand others, and was cognitively intact.

A Medical Provider Note dated 4/29/2025 documented the resident was seen for staff reports of chest congestion. Chest x-ray, DuoNeb, and Mucinex ordered. A trial of Invanz (a broad spectrum antibiotic effective against a wide range of bacteria) 1 gram was to be given one time.T

A Medical Provider Note dated 5/01/2025 documented the resident was seen for continued cough. Chest x-ray reveals mild left basilar infiltrate with small left pleural effusio(a buildup of fluid between the tissues that lined the lungs and the chest) and mild right infrahilar infiltrate (a collection of abnormal substances like pus, blood, or protein in the lung tissue below where the lungs connected to the airway and blood vessels). Start Levaquin 500 milligrams daily for seven (7) days.

Review of Nursing Progress Notes revealed no documentation of the resident ' s condition related to the need for antibiotic treatment prior to, during, or after the treatment was completed.

Interviews:

During an interview on 5/07/2025 at 3:13 PM, Licensed Practical Nurse #2 stated Resident #61 was originally treated for edema and vascular issues. They stated the edema in their legs turned into blisters and open wounds. They stated the Resident #61 was being seen on wound round by Physician Assistant #1.

They stated that according to Physician Assistant ' s written notes on 2/27/2025, Resident #61 had wounds

on their left and right inner calf, toes, and buttocks.

During an interview on 5/08/2025 at 11:17 AM, Licensed Practical Nurse #2 stated they did not understand why Registered Nurse #2 was documenting in the Daily Medicare Notes that Resident #61had no wounds.

They stated the Resident #61 had wounds and Registered Nurse #2 was providing wound care to the resident daily.

During an interview on 5/08/2025 at 2:54 PM, Licensed Practical Nurse #8 stated if a resident was on antibiotics, there should have been notes about their condition and progress.

During an interview on 5/08/2025 at 1:05 PM Licensed Practical Nurse #2 stated there should have been progress notes describing the resident's condition and progress during antibiotic treatment.

10 New York Codes Rules and Regulations 415.22(a)(1-4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43805 potential for actual harm Based on observations, record reviews, and interviews conducted during a recertification survey, the facility Residents Affected - Few did not ensure an infection control program was implemented to prevent the transmission of communicable diseases to residents. Specifically, (a.) for Resident #64, enhanced barrier precautions were not implemented for the resident who had an indwelling catheter; (b.) for Resident #97, the resident's nebulizer equipment was not stored to prevent contamination of the equipment.

This is evidenced by:

Resident #64

Resident #64 was admitted to the facility with the diagnoses of polyneuropathy (peripheral nervous system disorders that impact nerve function), chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 2/24/2025 documented the resident understood, could understand others, had moderately impaired cognition, and had an indwelling urinary catheter.

The policy and procedure titled, Enhanced Barrier Precautions and last reviewed 2/19/2025, documented enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a multi drug resistant organism.

During multiple observations on 4/29/2025, 4/30/2025, 5/02/2025, and 5/05/2025, there was no signage for enhanced barrier precautions and no personal protective equipment cart near the resident's room.

A Physician's Order dated 11/04/2024 documented enhanced barrier precautions for Resident #64 related to indwelling catheter and wounds.

During an interview on 5/06/2025 at 10:46 AM, Registered Nurse #1 could not say why Resident #64 was not

on enhanced barrier precautions. They stated they were aware that the resident had an indwelling urinary catheter.

Resident #97

Resident #97 was admitted to the facility with the diagnoses of chronic respiratory failure (when lungs cannot properly exchange gases), chronic obstructive pulmonary disease, and congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs). The Minimum Data Set, dated dated dated [DATE REDACTED] documented the resident was understood, could understand others, and was cognitively intact.

The policy and procedure titled, Administration of Nebulizer Medication last reviewed 8/2024 documented once treatment is complete to rinse, dry, and store nebulizer per facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During multiple observations on 4/29/2025, 4/30/2025, 5/02/2025, 5/05/2025, and 5/06/2025, the nebulizer equipment was on the resident's bedside table with the nebulizer mask laying uncovered on the nebulizer Level of Harm - Minimal harm or machine. potential for actual harm

A review of current Physician Orders did not document an order for rinsing/cleaning the nebulizer equipment Residents Affected - Few after use.

During an interview on 5/06/2025 at 10:43 AM, Licensed Practical Nurse #1 stated the nebulizer mask or pipe should be rinsed, dried, and stored in a plastic bag after each use.

During an interview on 5/06/2025 at 10:46 AM, Registered Nurse #1 stated the nebulizer mask should be stored in a bag if one is available, otherwise the mask can be placed on a paper towel.

In an e-mail received 5/07/2025 at 2:02 PM, Director of Nursing #1 clarified that the facility policy for storing nebulizer equipment was to store in a bag at the bedside.

During an interview on 5/08/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that nebulizers should be rinsed, dried, and stored in a plastic bag. They stated that laying a nebulizer on a paper towel or on top of

the nebulizer machine would not be correct.

During an interview on 5/8/2025 at 10:16 AM, Assistant Director of Nursing #1 stated that any nurse could contact the medical provider for the order to initiate transmission-based precautions including enhanced barrier precautions. They stated that unit managers should be rounding their units daily to ensure transmission-based precautions were in place as ordered.

New York Codes, Rules, and Regulations 415.19(a)(1-3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21414 potential for actual harm Based on observation, record review, and interviews conducted during the recertification and abbreviated Residents Affected - Few survey (Case #NY00354621), the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on two (2) of two (2) units. Specifically, the facility nurse call system did not function in resident room #s 203 and 320.

This is evidenced by:

During observations on 4/29/2025 at 8:03 PM, the call bell device in the resident room [ROOM NUMBER] bathroom was missing from the mounting hardware and the wires were hanging out of the mounting hardware.

During an observation on 05/06/2025 at 1:02 PM, the call bell device was hanging by wires and not mounted to wall in resident room [ROOM NUMBER].

Workorders dated 10/29/2024 through 4/15/2025 documented 10 instances of call bell disrepair.

There was no documented evidence that workorders were submitted to repair the call bells in room #s 203 and 320.

During an interview on 5/07/2025 at 3:05 PM, Director of Maintenance #1 stated that they would repair the call bells in room #s 203 and 320.

10 New York Codes, Rules and Regulations 713-1.3(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 21414

Residents Affected - Few Based on observation and interviews conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building, and grounds were not clean and maintained.

This is evidenced by:

During observations on 5/05/2025 from 12:04 PM through 12:31 PM:

Sections of the lower portion of the building facade was covered with moss and algae.

Piles of old construction materials and accumulations of leaves and litter were found on the grounds along

the building.

The garbage dumpsters were not seated in the designated fenced area; vegetation was encroaching on the fencing.

During an interview on 5/07/2025 at 3:09 PM, Director of Maintenance #1 stated that they would have the construction debris and litter picked up, the vegetation cut back and direct the vendor to place the dumpster

in the designated area.

10 New York Codes, Rules, and Regulations 415.5(h)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0923 Have enough outside ventilation via a window or mechanical ventilation, or both.

Level of Harm - Minimal harm or 21414 potential for actual harm Based on observation and interviews conducted during the recertification, the facility did not ensure Residents Affected - Few adequate ventilation of one (1) (second floor) of (2) resident units. Specifically, the Second Floor Unit Soiled Holding Room and shower room were not adequately ventilated.

This is evidenced by:

During observations on 4/29/2025 at 8:47 PM, unpleasant odors were found in the Second Floor Unit Soiled Holding Room and a heavy must odor was found in the Second Floor Unit shower room.

During an interview on 5/07/2025 at 3:10 PM, Director of Maintenance #1 stated that the motors servicing the ventilation system for the Second Floor Unit Soiled Holding Room and the Second Floor Unit shower room were not powerful enough to remove the odors and required replacement.

10 New York Codes, Rules and Regulations 483.90(i)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0924 Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or 21414 potential for actual harm Based on observation and interviews conducted during a Recertification Survey, handrails were not Residents Affected - Some maintained on two (2) of two (2) resident units. Specifically, handrails had broken plastic and missing pieces exposing sharp edges.

This is evidenced by:

During observations on 04/29/2025 at 7:51 PM through 8:58 PM:

The Second Floor Unit south corridor handrail had a six (6)-inch section of broken plastic with sharp edges.

The Second Floor Unit Elevator one (1) corner guard had broken plastic with sharp edges.

The First Floor Unit handrail had six (6) areas where the edge turn pieces missing exposing sharp edges.

During an interview on 5/07/2025 at 3:03 PM, Director of Maintenance #1 stated that they would repair the broken plastic and install the missing pieces on the handrails.

10 New York Codes, Rules, and Regulations 713-1.8(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 64 335377 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335377 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Troy Victorian Rehabilitation & Nursing Care Cntr 100 New Turnpike Road Troy, NY 12182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21414 potential for actual harm Based on observation, record review, and interviews conducted during the recertification and abbreviated Residents Affected - Some surveys (Case #s NY00354621, NY00355929, NY00356190, and NY00357360), the facility did not maintain

a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas.

This is evidenced by:

During observations on 4/29/2025 at 8:45 PM, a resident was heard yelling, ' There is a bee in my room, ' and a wasp was found flying in resident room [ROOM NUMBER]. Director of Maintenance #1 immediately found and killed the wasp.

During observations on 5/05/2025 at 1:55 PM, gnat-like flies were found in the conference room.

During observations on 5/06/2025 from 10:17 AM through 1:49 PM, gnat-like flies or ants were found in resident room [ROOM NUMBER] and the employee break room.

During observations on 5/07/2025 at 11:12 AM, gnat-like flies were found in the main kitchen dishwashing area.

The document titled [vendor] Pest Management, the facility pest-sighting logbook, documented that fruit flies were found in room #s 207 and 226 during 9/2024.

The document titled [vendor] Pest Management documented that the facility was treated for ants during 4/2025 and for small flies in the dishwasher area of the kitchen periodically from 5/2024.

There was no documented evidence that the facility was treated for wasps.

There was no documented evidence that the facility was treated for small flies and ants in resident room [ROOM NUMBER] or for small flies the conference room or the employee break room since 5/2024.

During an interview on 5/07/2025 at 3:12 PM, Director of Maintenance #1 stated that they contacted the vendor to treat for small flies resident room [ROOM NUMBER], the conference room, and the employee break room.

10 New York Codes, Rules and Regulations 415.29(j)(5)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 64 335377