Abbey Road Assisted Living Ulster

A certification complaint, prompted by #CO40814 and #CO40828, was completed on 8/26/25. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to request an updated criminal history and adult protective service record check for a staff member who could pose a risk to the health, safety and welfare of the residents affecting eight current residents. Findings include:The personnel file for Staff #1 revealed she was hired in 2020.Staff #1 worked 16-hour shifts from Sundays through Thursdays, according to the July and August 2025 schedule. During the onsite survey on 8/25/25, an updated background check was requested for Staff #1. The updated background check revealed a criminal felony arrest for driving under the influence (DUI) on 6/9/25.On 8/25/25 at 9:45 a.m., the administrator stated that Staff #1 is currently on an ankle monitor due to DUI charges but did not run background check upon knowledge of the ankle monitor and DUI charges. On a later interview, she stated that based on the investigation she conducted that involved Staff #1, "I never felt there was a deviation of moral character." The administrator said background checks were completed as a part of the initial onboarding process. She added she did not request an updated criminal history upon knowledge of the DUI arrest on 6/9/25 and adult protective service record check for Staff #1. On 8/25/25 at 1:10 p.m., Staff #1 confirmed that the police arrested her for DUI on 6/9/2.. Based on record review and interview, the facility (residence) failed to investigate allegations of neglect in accordance with regulation and written policy, involving two former members (residents) (#1,#2) and eight current residents.Findings include:1. Reference and Residence Policy:a. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted;(F) A requirement that if the alleg..

A licensure complaint, prompted by #CO40815 and #CO40829, was completed on 8/26/25. Deficiencies were cited. Based on interview and record review, the residence failed to request an updated criminal history and adult protective service record check for a staff member who could pose a risk to the health, safety and welfare of the residents affecting eight current residents. (Cross-reference T1410 and T0410).Findings include:The personnel file for Staff #1 revealed she was hired in 2020.Staff #1 worked 16-hour shifts from Sundays through Thursdays, according to the July and August 2025 schedule. During the onsite survey on 8/25/25, an updated background check was requested for Staff #1. The updated background check revealed a criminal felony arrest for driving under the influence (DUI) on 6/9/25.On 8/25/25 at 9:45 a.m., the administrator stated that Staff #1 is currently on an ankle monitor due to DUI charges but did not run background check upon knowledge of the ankle monitor and DUI charges. On a later interview, she stated that based on the investigation she conducted that involved Staff #1, "I never felt there was a deviation of.. Based on record review and interview, the residence failed to investigate allegations of neglect in accordance with regulation and written policy, involving two former residents (#1,#2) and eight current residents. (Cross-reference T0410 and T0620)Findings include:1. Reference and Residence Policy:a. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(C) The process for investigating such allegations;(D) How the assis.. Based on record review and interview, the residence failed to report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement (LE) within 24 hours of observation or discovery, affecting current eight residents. (Cross-reference T1410 and T0620)Findings include:1. References and Policiesa .Chapter VII regulations governing assisted living residences:Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (G) Is blindb. The residence' s Abuse, Neglect, and Exploitation policy, dated 2014 and updated in 2025, read in part:"The residence had a ' zero-tolerance' policy regarding abuse, neglect, and or mistreatment of any residents. Should any resident experience abuse or when abuse is suspected, staff and volunteers are required to immediately provide notification to persons/agencies as described in this policy. c. The residence' s reporting policy, dated 2014 and updated in 2025, re..

A relicensure survey was completed on 11/28/23. No deficiencies were cited.

A recertification survey was completed on 11/28/23. No deficiencies were cited.