Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Van Rensselaer Manor during CMS and state inspections, most recent first.
Surveyors observed that wall corners and baseboards were in disrepair at all active nursing stations and unit dining rooms, and that walls in multiple resident rooms (including rooms in units A and B) were also damaged. These findings showed that the environment, including common and resident areas, was not adequately maintained to be safe, clean, comfortable, and homelike, as required by regulation.
Two residents experienced inadequate investigation and documentation of alleged incidents. One resident with mild cognitive impairment and visual issues was found on the floor with a forehead hematoma; the event was documented as an unwitnessed fall from a wheelchair, but the accident report lacked any resident statement or other explanation supporting that conclusion, despite the resident’s ability to communicate. Another resident with quadriplegia reported a missing bag of clothing after a hospital stay; although staff reported conducting an investigation and determining the items were not logged or labeled and would not be reimbursed, the accident report was closed without any documented investigative outcome.
Surveyors found that food service operations did not comply with professional food safety standards in the main kitchen and all unit nutrition rooms. Facility-made cold sandwiches were stored in multiple dietary and nutrition refrigerators without required expiration dates, and temperature logs for unit dietary refrigerators were incomplete, with no logs available for resident-owned refrigerators. In the walk-in refrigerator, a large pan of beef stew lacked a cooling log and, when checked about two hours after refrigeration, remained at 105°F instead of meeting the required 70°F cooling benchmark, indicating improper cooling and documentation practices.
Surveyors identified multiple failures in documentation and protection of resident information, including incomplete narcotic count records on several units where nurses either omitted required shift-change signatures or signed off in advance of the end of their shifts, sometimes only signing when prompted. A resident with anxiety disorder, macular degeneration, and asthma had nebulizer tubing changes documented on the treatment administration record that did not match the date on the tubing observed at bedside, indicating inaccurate treatment documentation. Additionally, two medication cart laptops were found open, logged in under nursing staff accounts, and left unattended with resident-identifiable information visible, while nursing staff were away from the carts.
The facility failed to post required daily nurse staffing information in a prominent, accessible location. During a surveyor observation, the main lobby lacked the Daily Staff Posting, and no such posting was found elsewhere in the building. When interviewed, the staffing coordinator stated they were not responsible for posting the daily staffing and directed the surveyor to the administrator. The administrator reported that the posting is normally placed in the main lobby but had not been posted due to an oversight after the prior day’s notice was removed, despite being aware that daily staffing and census information must be posted each day.
A resident with Parkinson’s disease, dementia, and anxiety, who was documented as cognitively intact for daily decisions, was involved in an incident where a CNA entered the room without knocking, physically pulled the resident into a wheelchair despite apparent resistance, and nearly caused a fall while reseating the resident. Video showed the CNA pushing the wheelchair while the resident tried to block the wheel, then pulling the chair backwards into the hallway, during which the resident stood and fell to the floor onto their side. The CNA then walked away, leaving the resident on the floor alone for several minutes before briefly returning with a mechanical lift and standing away from the resident, who remained unattended on the floor for at least four minutes until an LPN and the ADON arrived and began assessment. Facility leadership stated that staff are expected to treat residents with dignity, avoid physical redirection, and remain with a resident on the floor while summoning help, and that the CNA’s actions were not acceptable.
Two residents with dementia and other comorbidities were not protected from abuse and neglect when a CNA roughly handled one cognitively intact resident, pulled the resident into a wheelchair despite resistance, and left the resident on the floor unattended for several minutes after a fall, and when another resident with severe cognitive impairment sustained facial bruising after being turned in a way that caused impact with a wall. Multiple residents in this CNA’s assignment had unexplained or roughly handled-related bruises, yet staff initially attributed injuries to resident behaviors, environmental factors, or the need for additional education rather than potential abuse. Nursing leadership and other staff did not promptly recognize, report, or fully investigate these events as possible abuse or neglect until a pattern of injuries and video review later revealed neglectful handling and failure to remain with the fallen resident.
A resident with Parkinson’s disease and dementia, who was cognitively intact for daily decisions, was observed on video standing unsupervised in a room when a CNA entered without knocking and repeatedly pulled the resident into a wheelchair despite visible resistance, nearly causing a fall. The CNA then pulled the wheelchair backwards into the hallway; while moving, the resident stood and fell to the floor. The CNA walked away, leaving the resident on the floor alone for about two minutes before returning with a Hoyer lift but did not remain at the resident’s side. An LPN and the ADON then attended to the resident; the ADON performed only a limited ROM check of the arms and had the resident bend the knees, with no documented full ROM assessment of the legs, and the resident was manually lifted from the floor by the arms into the wheelchair instead of being transferred with the Hoyer lift as required by the facility’s post-fall policy.
A deficiency occurred when the facility’s QAA/QAPI program and Supervised Care process were not implemented as required by facility policy to address repeated care concerns and adverse events involving a CNA. One resident with dementia and other comorbidities developed a nasal bruise after an incident during personal care, and another resident with Parkinson’s disease and dementia was mishandled by the same CNA, as shown on video, resulting in a fall and the resident being left on the floor unattended. Despite a policy requiring clear documentation, staff notification, active supervision, and auditing under Supervised Care, the CNA’s Supervised Care form contained only vague "care concerns," had signature irregularities, and there was no evidence of actual supervision or audits. The DON identified increased bruising, injuries, and falls on the CNA’s shift and discrepancies between the CNA’s reports and other information, yet these issues were not effectively brought through the QAA/QAPI process, and the Administrator reported that the investigation and concerns were not discussed in the QAPI meeting while present, demonstrating a failure to use established quality systems to monitor, investigate, and correct identified deficiencies in care and resident safety.
A resident with severe cognitive impairment and dysphagia was served regular chicken tenders instead of the required minced consistency after a CNA swapped meal plates among three residents, despite warnings from another aide. The resident choked and required immediate intervention. Facility policies and staff interviews confirmed that the CNA failed to follow the care plan and meal ticket instructions, resulting in neglect.
A resident with severe cognitive impairment was found with unexplained bruising near the eye, which was observed and discussed by multiple staff members, including RNs, NPs, and the medical director. Despite facility policy and state regulations requiring immediate reporting of injuries of unknown origin, the incident was not reported to the DON, administrator, or state health department within the mandated timeframe.
Two residents experienced incidents involving improper care—one was fed the wrong food consistency and choked after a CNA swapped meal trays, and another developed a bruise of unknown origin that was not promptly or thoroughly investigated. In both cases, the facility did not follow its own investigation protocols, failed to interview all relevant staff, and did not fully determine the circumstances or rule out abuse or neglect, as confirmed by leadership and staff interviews.
A resident with severe cognitive impairment and total dependence for toileting and bed mobility did not receive the required two-person assistance during incontinence care, as specified in their care plan. A CNA provided care alone, contrary to facility policy and staff expectations, despite clear documentation and staff awareness that two-person assistance was necessary for the resident's safety.
A resident with multidrug-resistant organism (MDRO) in their urine was on Enhanced Barrier Precautions, but staff failed to wear a gown during incontinent care as required. Although signage and PPE were present, staff were unclear about which resident required precautions, and the facility lacked specific written policies for Enhanced Barrier Precautions and other transmission-based precautions, leading to inconsistent infection control practices.
A resident identified as full code was found unresponsive by an LPN, who notified an RN. The RN assessed the resident, determined death, and did not check code status or initiate CPR as required by facility policy. Both staff failed to follow protocols for identifying code status and starting CPR, resulting in a delayed response. Nurse supervisors later initiated CPR, but the attempt was unsuccessful.
A CNA threw a water bottle at a resident with dementia, striking them on the back, while another CNA witnessed the event and intervened. There was a delay in removing the offending CNA from resident care, as staff did not immediately call security or remove the individual, contrary to facility policy. The resident was later assessed and found to have no signs of distress.
Failure to Maintain Walls and Common Areas in Good Repair
Penalty
Summary
Surveyors found that the facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not providing effective maintenance services across all resident units. During facility tours conducted over several days between 9:00 AM and 3:00 PM, wall corners and baseboards were observed to be in a state of disrepair at all seven active nursing stations and all seven unit dining rooms. In addition, walls in specific resident rooms A104, A112, A122, B102, A205, A214, and A213 were identified as being in disrepair. These observations showed that the physical environment, including common areas and resident rooms, was not being adequately maintained. During an interview, the Director of Security stated that the facility had focused on ensuring resident safety when prioritizing repairs and that the facility was undergoing renovations in which almost all identified items would be replaced. The deficiency was cited under 10 New York Codes, Rules, and Regulations 415.14(h), related to maintaining a safe, clean, comfortable, and homelike environment.
Failure to Properly Investigate and Document Injury and Missing Property Incidents
Penalty
Summary
The facility failed to investigate and document alleged violations and incidents according to its own policies and professional standards for two residents. For one resident with anxiety disorder, macular degeneration, and asthma, an unwitnessed incident occurred in which the resident was found lying on the floor with a 3.5 x 3.5 cm purple bump on the left forehead. The accident report described the event as an unwitnessed fall with injury and stated the outcome was that the resident fell asleep and fell forward out of their wheelchair. However, the report contained only two statements describing that the resident was found on the floor and did not include any statement from the resident or any other person explaining how it was determined that a fall from the wheelchair caused the injury. At the time of assessment, the resident’s MDS documented that they could usually be understood, usually understood others, and were mildly cognitively impaired. During observation, the resident was seen in a wheelchair with a dark purple raised area on the left forehead and was unable to report how the injury occurred. A reviewing RN stated they were not present at the time of the injury and, after reviewing the accident report, could not determine how the conclusion of a fall was reached. The DON stated that for an unwitnessed fall with injury, they would expect to see a resident statement or other statement clarifying how the event was determined to be a fall, and confirmed that this resident would have been able to vocalize if they had been abused or had fallen. For another resident with anxiety disorder, quadriplegia, and polyneuropathy, an accident report documented that the resident phoned the social worker to report a missing storage bag containing sweaters and sweatshirts that had been in their room before a hospital transfer and was missing upon readmission. The accident report was closed without any documented outcome of the investigation. The resident later stated they had reported the missing clothing to the social worker and did not believe an investigation was started, and that when they asked the administrator about the missing clothing, they were told there was no justification to reimburse or replace the items. The social worker reported that an investigation had been started but the resident could not list the items and they were not logged or labeled on the belongings list, and the Director of Social Work recalled spending time on the investigation and determining the facility could not replace or reimburse the items, but acknowledged they only thought they had documented the outcome, which was not present in the record.
Failure to Follow Food Storage, Dating, and Cooling Standards in Kitchen and Unit Nutrition Rooms
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in the central kitchen and all seven resident unit nutrition rooms. During inspection of the central kitchen, cold, facility-made sandwiches were found in multiple locations, including the sandwich prep station refrigerator and several unit dietary/nutrition refrigerators, without proper expiration dates. Temperature logs for dietary refrigerators on all units were incomplete, and no unit could provide temperature logs for resident-owned refrigerators. In the walk-in refrigerator, surveyors observed a full-size kitchen pan filled with beef stew without a corresponding cooling log to verify that proper cooling procedures were followed. When the temperature of the stew was checked approximately two hours after being placed in the refrigerator, it measured 105°F, which exceeded the required 70°F threshold specified by food safety requirements for that cooling interval. These findings demonstrated noncompliance with New York State food safety regulations and 10 NYCRR 415.14(h) regarding proper food storage, dating, temperature monitoring, and cooling practices.
Incomplete Narcotic Documentation, Inaccurate Treatment Records, and Unsecured PHI on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to maintain medical records and controlled substance documentation in accordance with accepted professional standards, and to safeguard resident-identifiable information. Surveyors’ review of narcotic count record books on multiple units showed missing signatures for both oncoming and off-going nurses at various shift changes, indicating incomplete controlled substance records. Observations revealed nurses signing the narcotic count books in advance of the end of their shifts, and one nurse delayed providing the narcotic sign-off book to the surveyor until they signed it in the surveyor’s presence, without a clear explanation for why it had not been signed earlier. In interviews, nursing staff acknowledged they had not signed when required, stated they were busy or had forgotten, and some reported they routinely signed in this manner and had not been told not to do so. The facility also failed to ensure accurate treatment documentation and protection of resident-identifiable information. For one resident with anxiety disorder, macular degeneration, and unspecified asthma, the treatment administration record showed nebulizer tubing changes documented as completed on three separate dates in March, but an observation later in the month found the nebulizer tubing still labeled with an earlier date, suggesting the documented changes had not occurred as recorded. Additionally, surveyors observed two separate medication cart laptops left open and unattended, logged in under nursing staff accounts, with readable resident information accessible while the responsible staff were not present at the carts. In one instance, the nurse later stated they usually minimize or close the laptop but had forgotten to do so.
Failure to Post Daily Nurse Staffing Information in Prominent Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift in a prominent place readily accessible to residents and visitors, as required. During an observation of the entrance lobby on 04/01/2026 at 11:30 AM, surveyors noted that the Daily Staff Posting was not present, and they were unable to locate any Daily Staff Posting elsewhere in the building. In an interview at 11:40 AM, the staffing coordinator stated they were not responsible for posting the Daily Staffing and referred questions to the administrator. In a subsequent interview at 11:45 AM, the administrator acknowledged that the Daily Staff Posting, which is normally posted in the main lobby, was not posted due to an oversight after the previous day’s posting had been taken down, and further stated awareness that daily staffing and census information should be posted each day. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the absence of the required daily nurse staffing posting and the staff’s acknowledgment of the oversight and responsibility for posting.
Resident Left on Floor After Fall and Rough Handling by CNA
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity, respect, and care in a manner that promotes quality of life. The facility’s own Resident Handbook states that residents have the right to dignity, respect, a comfortable living environment, quality care without discrimination, freedom of choice, privacy, freedom from abuse and restraints, and the ability to exercise their rights without fear of reprisals. The resident involved had diagnoses including Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. An MDS dated 08/08/2025 documented that this resident could be understood, could understand others, and had intact cognition for decisions of daily living. Care plans directed staff to encourage the resident to ask for assistance, orient the resident to changing surroundings, respect the resident’s right to refuse activities, initiate conversation frequently, maintain preferred independent leisure activities, provide escort or transportation as needed, and, for falls, to investigate the cause of any fall immediately, provide reality orientation, keep the resident in a high-profile area when possible, and report unsafe behavior to nursing. On the date of the incident, an incident report documented that a CNA observed the resident standing in their room, assisted them to their wheelchair, and that when exiting the room the resident grabbed the wall handrail and pulled themselves from the wheelchair. The CNA’s written account stated that while attempting to reseat the resident, the resident needed to be lowered to the floor to prevent a fall, and that the resident’s self-propelled standing from the wheelchair was attributed to gastric distress. However, the facility’s abuse investigation, which included video footage, showed that the CNA entered the resident’s room without knocking, placed hands on the resident’s arms, and pulled the resident into the wheelchair while the resident appeared to resist. The resident stood again and was again pulled into the wheelchair, nearly missing the chair and almost falling. The video further showed the CNA pushing the resident in the wheelchair while the resident attempted to block the front wheel with their foot, then turning the wheelchair to move it backwards into the hallway. As the wheelchair was being pulled backwards, the resident stood up and fell to the floor onto their side. The CNA appeared to throw their hands down at their sides and then walked away, leaving the resident lying on the floor. The resident remained alone on the floor for approximately two minutes before the CNA returned in the camera’s view with a mechanical lift, walked past the resident, spoke briefly, and then stood in a nearby doorway at least five feet away. The resident was left unattended on the floor for a minimum of four minutes between 10:49 a.m. and 10:53 a.m. before nursing staff, including an LPN and the Assistant Director of Nursing, arrived and began interacting with and assessing the resident. Interviews with the RN unit manager, the Assistant Director of Nursing, and the Director of Nursing confirmed that staff were expected to treat residents with respect and dignity, that physical redirection was not acceptable, that a CNA who lowered a resident to the floor should stay with the resident and obtain help via call bell or by calling out, and that it was not appropriate to leave a resident unattended on the floor for multiple minutes. The DON stated that the CNA’s actions were not acceptable and not in line with expectations for kind and dignified treatment.
Failure to Protect Residents From Abuse and Neglect by CNA and Inadequate Investigation of Injuries
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse, neglect, or mistreatment of residents and to adequately investigate and respond to incidents involving a CNA’s handling of residents. The facility’s Abuse & Neglect Policy, updated on 04/03/2025, stated that residents had the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation, and involuntary seclusion. Despite this policy, an abbreviated survey found that two of four residents reviewed for abuse, neglect, or mistreatment were not protected from willful infliction of abuse, neglect, or mistreatment. The facility did not fully investigate an incident on 08/02/2025 in which CNA #1 lowered Resident #1 to the floor, and later-obtained video footage showed abusive handling and the resident being left on the floor unattended for several minutes. Resident #1 had diagnoses including Parkinson’s disease with dyskinesia and fluctuations, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An MDS dated 08/08/2025 documented that this resident could understand and be understood and had intact cognition for decisions of daily living. An incident report dated 08/02/2025 documented CNA #1’s account that the resident stood in their room, was assisted into a wheelchair, and, while being taken from the room, grabbed the wall handrail and lifted themselves up, prompting the CNA to lower the resident to the floor to prevent a fall. However, video footage from 08/02/2025 showed CNA #1 entering the resident’s room without knocking, pulling the resident into the wheelchair despite resistance, repeating the maneuver with a near fall, and then moving the wheelchair backward while the resident attempted to block the wheel with their foot. The footage showed the resident standing and falling to the floor on their side, after which CNA #1 gestured toward the resident, walked away, and left the resident on the floor alone for approximately two minutes before returning briefly with a mechanical lift and then leaving again. The resident remained on the floor for about four minutes total before a nurse arrived, and the review of the video concluded that CNA #1 neglected the resident by walking away after the fall. Resident #3 had diagnoses of unspecified dementia with other behavioral disturbances, hypothyroidism, and major depressive disorder. An MDS documented that this resident was usually able to understand others, was usually understood, and was severely cognitively impaired. The care plan indicated the resident required one-person assistance for bed mobility and ADLs and had a history of hitting and screaming at staff and resisting care, with interventions such as allowing time to de-escalate, reapproaching if refusing care, and placing a soft object in the resident’s hands if combative. An incident report dated 08/01/2025 documented a blue/gray bruise on the resident’s nose, with contributing factors listed as poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and resting their head on a table when fatigued. However, the ADON documented that CNA #1 had previously provided personal care and turned this resident in a way that caused them to hit their face on the wall, causing injury. The facility attributed the injury to environmental and resident factors and did not treat the event as potential abuse, instead viewing CNA #1 as needing more education on bed mobility. The facility’s broader investigation, dated 08/15/2025 through 09/03/2025, showed that CNA #1 was suspended after being possibly responsible for multiple injuries on more than one resident in their care assignments. On 07/19/2025, a bruise and abrasion on Resident #2’s forehead were attributed to rough handling during bed mobility. On 08/01/2025, bruising on the right side of Resident #3’s face and around the eye and nose was attributed to another CNA rolling the resident into the wall and to ill-fitting glasses. On 08/15/2025, bruising on Resident #4’s neck, appearing multiple days old, was attributed to the resident being resistive to care. Interviews with nursing leadership and staff showed that, at the time of the incidents, they did not suspect abuse by CNA #1, did not immediately remove the CNA from resident care, and did not fully investigate the events as potential abuse or neglect until a pattern of injuries and video review prompted further scrutiny. The DON and ADON acknowledged that the actions captured on video were not acceptable and that leaving a resident unattended on the floor for multiple minutes was not appropriate, but these acknowledgments occurred after the events that led to the deficiency. Interviews also revealed gaps in immediate reporting and investigation. CNA #1 stated they gave a verbal statement on the day of Resident #1’s fall but were unable to enter a written statement into the computer and that no written statement was taken from them at that time. LPN #4 reported being told by CNA #1 that the resident had been ambulating when they were not supposed to and did not suspect the explanation was inaccurate, despite the later video evidence. The ADON described that if there had been any indication from Resident #1 of an issue with CNA #1, they would have handled the situation differently, such as interviewing the staff member privately or changing assignments, but this did not occur at the time. The DON and Administrator described that video footage was typically reviewed only for certain types of incidents, such as falls with injuries or resident-to-resident issues, and that no staff raised concerns about CNA #1 until the DON began questioning employees. These actions and inactions contributed to the failure to protect residents from abuse and neglect and to promptly and thoroughly investigate potential mistreatment as required by regulation.
Failure to Perform Complete Post-Fall Assessment and Safe Transfer After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-centered care and to follow its own post-fall policy and professional standards when responding to a fall. The facility’s Post Fall Routine policy required that an RN assess the resident for injury and provide emergency treatment as necessary, that all residents be assisted off the floor with a Hoyer lift (with limited supervisory discretion), and that residents be monitored and assessed for injury, including range of motion, before being moved. For the fall event in question, video footage and interviews showed that these requirements were not followed, and that a complete assessment, including full range of motion, was not performed before the resident was manually lifted from the floor and placed in a wheelchair. The resident involved had Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. The MDS documented that the resident could be understood, could understand others, and had intact cognition for daily decision-making. The resident’s care plans addressed falls, vision, and activity participation, including interventions such as investigating the cause of falls immediately, providing reality orientation, maintaining the resident in high-profile areas when possible, and reporting unsafe behavior to nursing. On the day of the incident, video footage showed the resident standing unsupervised in their room when a CNA entered without knocking, placed hands on the resident’s arms, and pulled the resident into a wheelchair despite apparent resistance. The CNA repeated this action when the resident stood again, nearly causing a fall as the resident almost missed the wheelchair. The video further showed the CNA pushing the resident in the wheelchair, with the resident attempting to block the front wheel with their foot. The CNA then turned the wheelchair and pulled it backwards into the hallway; while the wheelchair was moving, the resident stood up and fell to the floor onto their side. Contrary to the CNA’s written account, there was no video evidence of the resident grabbing a handrail and pulling themselves from the wheelchair. After the fall, the CNA appeared to throw their hands down and walked away, leaving the resident on the floor alone for approximately two minutes before returning with a Hoyer lift, then again standing away from the resident. An LPN arrived to attend to the resident, followed by the Assistant DON, who spoke with the resident and performed only a limited range of motion assessment on the resident’s arms and had the resident bend their knees. Without documented evidence of a full range of motion assessment, particularly of the legs, the Assistant DON and LPN manually lifted the resident from the floor by the arms and placed them in the wheelchair, instead of using the Hoyer lift as required by policy. Interviews with the DON and Assistant DON confirmed that a full assessment, including range of motion and pain assessment, was expected after a fall and that leaving a resident unattended on the floor for multiple minutes and manually lifting them in this manner was inconsistent with facility expectations and policy.
Failure of QAA/QAPI and Supervised Care Processes to Address Staff Care Concerns and Adverse Events
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) program functioned as described in its own policies to identify, analyze, and correct quality problems, including adverse events and staff performance concerns. The facility’s QAPI policy required consistent data collection, monitoring, and analysis of care and services, including adverse event tracking and implementation of action plans to prevent recurrence. Despite this, the facility did not ensure that the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies, and did not implement written policies and procedures for feedback, data collection systems, and monitoring related to performance improvement plans, staff correction, and resident safety. One resident, identified as having unspecified dementia with behavioral disturbances, hypothyroidism, and major depressive disorder, was found on an incident report to have a blue/gray bruise on the nose. The report attributed contributing factors to poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and the resident resting their head on the table when fatigued. The report also documented that a CNA described the resident as difficult during care, stated the resident swung their hands during personal care, and hit their head on the wall while rolling over, though the CNA reported not seeing an injury at that time. This event triggered the use of the facility’s “Supervised Care” process for the CNA, but the documentation and implementation of that process did not follow the facility’s own Supervised Work and Supervised Care policy, which required clear documentation of reasons, staff notification, and ongoing supervision and auditing until the staff member was deemed safe to perform their job. Another resident, with Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, was involved in an incident where the CNA reported that the resident stood from their wheelchair, grabbed a handrail, and had to be lowered to the floor to prevent a fall. However, video footage reviewed during the facility’s abuse investigation showed the CNA entering the resident’s room without knocking, physically pulling the resident into a wheelchair despite apparent resistance, nearly causing a fall, and later pulling the wheelchair backward while the resident stood, resulting in the resident falling to the floor. The CNA then walked away, leaving the resident on the floor for approximately two minutes before returning with a mechanical lift and then leaving again as an LPN began attending to the resident. This sequence of events, combined with prior concerns about bruising, injuries, and falls on the CNA’s shift, demonstrated that the facility’s systems for monitoring adverse events, reconciling staff accounts with objective evidence, and escalating concerns through QAA/QAPI were not effectively implemented. The facility’s Supervised Care policy required that any employee who failed to follow resident care, medication, or treatment policies, or whose care was under review, be placed on Supervised Care with documented job responsibilities, supervisory sign-off each shift, and Department Head review with notification to the Administrator if problems were identified. In this case, the Supervised Care form for the CNA listed only vague “care concerns,” lacked detailed reasons such as bruising or rough care, and had signature discrepancies, including a misspelled version of the CNA’s name that did not match other documents. There was no documented evidence that any actual auditing of the CNA’s care occurred, and the CNA stated they were never informed they were on Supervised Care and were not supervised while working. The DON later stated they did not believe the CNA was truly placed on Supervised Care and that the form may have been retroactively documented or not appropriately implemented. Additionally, the Administrator reported that the last QAPI meeting did not address this investigation while they were present, and the DON acknowledged that video footage was only reviewed reactively after an increase in bruising and incident reports, rather than as part of a systematic monitoring process. These facts show that the facility did not operationalize its QAA/QAPI policies to ensure consistent monitoring, investigation, and corrective action for identified quality and safety concerns involving staff performance and resident adverse events. Interviews further underscored the breakdown in the facility’s quality systems. The DON reported noticing a notable increase in incident reports of bruising, injuries, and falls on the unit and during the CNA’s shift, with discrepancies between the CNA’s accounts and other staff reports or observed injuries, yet there was no evidence that these concerns were effectively brought through the QAA process or resulted in a properly implemented Supervised Care plan. The Assistant DON described Supervised Care in this case as primarily an educational tool without one-to-one supervision, while the DON described Supervised Care as meaning the staff member should not be alone and should receive hands-on instruction and audits. The CNA denied being placed on Supervised Care and alleged the Supervised Care form signature was forged. The Administrator stated they were not aware of the care concerns surrounding the CNA until suspicions of multiple cases of abuse arose and acknowledged that the incident and related concerns were not discussed in the QAPI meeting while they were present. Collectively, these actions and inactions demonstrate that the facility did not follow its own policies for Supervised Care, did not consistently monitor and track adverse events and staff performance issues, and did not ensure that the QAA/QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Neglect Due to Failure to Follow Dietary Consistency Leading to Choking Incident
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide failed to follow a resident's care plan regarding dietary meal consistency, resulting in the resident being served food of the wrong texture. The resident, who had diagnoses including dementia with agitation, chronic obstructive pulmonary disease, and bladder cancer, was assessed as cognitively severely impaired and required a mechanically altered diet with ground meats due to dysphagia and impaired swallowing. The resident's care plan and dietary assessments clearly indicated the need for a mechanical soft diet with minced meats, and the meal ticket on the resident's tray specified this requirement. During a supper meal, the Certified Nurse Aide intentionally swapped meal plates among three residents, providing the resident with regular chicken tenders instead of the required minced consistency. Despite being warned by another aide that the food was not the correct consistency, the aide proceeded to feed the resident the regular chicken. This resulted in the resident choking and requiring immediate intervention, including back thrusts and mouth sweeps, to clear the airway. Staff interviews confirmed that the aide did not read the meal ticket and failed to follow established procedures for obtaining alternative meals, such as contacting the kitchen. Facility policies and staff education materials emphasized the importance of following care plans, meal tickets, and dietary restrictions to prevent neglect and ensure resident safety. The incident was witnessed by multiple staff members, and statements from nursing and medical staff indicated that the aide's actions were negligent and directly led to the resident's choking episode. The failure to adhere to the resident's prescribed diet and established protocols constituted neglect as defined by facility policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin involving a resident was reported to the Administrator and the State Survey Agency within the required timeframe. According to facility policy, all incidents, accidents, and injuries of unknown source must be reported immediately, or no later than two hours after discovery, to the appropriate authorities. In this case, a resident with diagnoses including dementia, hypertension, and peripheral vascular disease was found to have discoloration and bruising below the right eye, which was first documented by a registered nurse as purpura. The resident was cognitively severely impaired and unable to recall how the injury occurred. Despite multiple staff members, including registered nurses, nurse practitioners, and the medical director, being aware of the injury over several days, the incident was not reported to the Director of Nursing, Administrator, or the New York State Department of Health within the mandated timeframe. Progress notes and staff statements indicated that the injury was observed, discussed among staff, and assessed by medical personnel, but the required notifications and reporting were not completed as per facility policy and state regulations. The facility's own documentation and staff interviews confirmed that the injury was of unknown origin and should have triggered immediate reporting. Interviews with facility staff, including the DON, Administrator, and Medical Director, revealed a consensus that the initial nurse who identified the injury should have reported it for further assessment and to the appropriate authorities. The failure to report the injury of unknown origin in a timely manner constituted a violation of both facility policy and state regulations, as all agreed that the incident met the criteria for mandatory reporting within 24 hours.
Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving potential abuse, neglect, or mistreatment, as required by its own policies and federal regulations. In the first incident, a resident with severe cognitive impairment and dysphagia was fed regular consistency chicken tenders instead of the prescribed mechanical soft, minced diet. This error occurred after a certified nurse aide intentionally swapped meal plates among three residents without verifying dietary restrictions, resulting in the resident choking and requiring emergency intervention. The facility's investigation did not determine where the incorrect food originated, nor did it include a review of the dietary plans or meal tickets for the other residents involved in the plate swap. Key staff, including the therapy director, nurse practitioner, and medical director, were unaware of the full extent of the incident, and the director of nursing acknowledged the investigation was incomplete. In the second incident, a resident with dementia and a history of behavioral symptoms was found to have a bruise of unknown origin below the right eye. Documentation showed that the discoloration was first noted as purpura by a registered nurse, but no provider assessment or investigation was initiated at that time. The facility's investigation began several days later, did not review all relevant progress notes, and failed to interview all staff assigned to the resident during the period when the injury could have occurred. Several staff members, including those who provided care during the relevant shifts, confirmed they were not interviewed as part of the investigation. Both the director of nursing and the administrator later acknowledged that the investigation was not thorough and did not follow the facility's established procedures for injuries of unknown origin. In both cases, the facility's failure to conduct comprehensive investigations meant that not all potential causes or responsible parties were identified, and the required steps to rule out abuse or neglect were not completed. The deficiencies were confirmed through staff interviews, record reviews, and direct admissions from facility leadership that the investigations were incomplete and did not meet policy or regulatory standards.
Failure to Provide Two-Person Assist for Dependent Resident's Incontinence and Bed Mobility Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia with agitation, generalized anxiety disorder, and major depressive disorder, who was assessed as cognitively severely impaired and totally dependent for toileting hygiene and bed mobility, did not receive care as outlined in their comprehensive care plan. The care plan, as well as the Certified Nurse Assistant Assignments Summary, specified that the resident required the assistance of two or more staff members for incontinent care and bed mobility due to their total dependence and risk for skin breakdown. However, during an observed episode of incontinence care, a single Certified Nurse Aide provided all care and repositioning without the required second staff member, despite the resident intermittently vocalizing during the process. Interviews with multiple staff members, including the CNA involved, another CNA, an LPN, an RN, the Director of Nursing, and the Administrator, confirmed that the expectation and documented plan of care was for two-person assistance for this resident's incontinent care and bed mobility. The CNA acknowledged not following the care plan and not requesting assistance, while all other staff interviewed stated they would have expected the care plan to be followed for the resident's safety. The facility's policy required comprehensive, person-centered care plans to be implemented as written, but this was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions and Lack of Transmission-Based Precaution Policies
Penalty
Summary
A deficiency was identified when staff failed to implement proper infection prevention and control practices for a resident on Enhanced Barrier Precautions due to the presence of extended-spectrum beta-lactamase-producing bacteria in their urine. During an observation, a Certified Nurse Aide provided incontinent care involving exposure to urine and feces without donning a gown, as required by the posted Enhanced Barrier Precaution signage. The signage clearly indicated that gloves and gowns were to be worn during high-contact resident care activities, such as dressing, hygiene, and changing briefs. The Certified Nurse Aide acknowledged awareness of the signage but was uncertain about which resident required precautions and did not follow the required protocol during care. Interviews with facility staff, including the Certified Nurse Aide, Registered Nurses, the Director of Nursing, the Infection Preventionist, and the Medical Director, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions. However, it was revealed that the facility did not have specific written policies and procedures for Enhanced Barrier Precautions or for other types of transmission-based precautions, such as airborne, droplet, and contact precautions. Staff reported relying on CDC guidelines and posted signage but lacked formalized facility policies to guide their actions. The resident involved had significant cognitive impairment, was frequently incontinent of bowel and bladder, and had a care plan indicating the need for staff to use personal protective equipment per the posted precaution card. Despite these documented needs and the presence of signage and PPE supplies, the lack of clear, facility-specific policies and procedures contributed to inconsistent implementation of infection control measures, as evidenced by the observed failure to use appropriate PPE during high-risk care activities.
Failure to Initiate Timely CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was a full code and found unresponsive. The facility's policies required that residents who had chosen CPR be clearly identified with green wristbands, stickers, and other visual cues, and that staff initiate CPR in accordance with the resident's advance directives and physician orders. Despite these protocols, when the resident was found unresponsive, both the LPN and RN involved did not immediately check the resident's code status or initiate CPR. The LPN discovered the resident unresponsive and notified the RN, who assessed the resident and determined the resident had expired without checking the code status or starting CPR. The RN then began the process of notifying the family and funeral home, and left the unit without calling a code or informing a supervisor or physician. It was only after the RN began charting and realized the resident was a full code that the issue was brought to the attention of nurse supervisors, who then initiated CPR, but the attempt was unsuccessful. Interviews and documentation revealed that both the LPN and RN were aware of the resident's full code status but did not follow facility policy or physician orders to initiate CPR. The delay in identifying the resident's code status and the failure to start CPR in a timely manner resulted in Immediate Jeopardy Past Noncompliance, with the potential for serious harm to the health and safety of all residents. The incident was attributed to staff not following established protocols for identifying code status and responding to unresponsive residents.
Delay in Removal of Staff Following Resident Abuse Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) threw a water bottle at a resident with non-Alzheimer's dementia, osteoarthritis, and age-related debility. The incident took place in a hallway near the nurses' station, where the resident, who had severe cognitive impairment but could communicate, was sitting in a wheelchair. The CNA first threw the bottle, missing the resident, then retrieved it and threw it again, striking the resident on the back and causing water to spray onto them. This act was witnessed by another CNA, who intervened by moving the resident away from the situation. Despite the immediate risk, there was a delay in removing the offending CNA from resident care. The witnessing CNA reported the incident to an LPN, who then attempted to locate a supervisor. During this time, the CNA who committed the abuse remained in the area, and staff did not immediately call security or remove the perpetrator from the unit. The LPN instructed staff to monitor the CNA until a supervisor arrived, at which point the CNA was finally removed from the facility by security. The facility's policy required immediate reporting and removal of staff suspected of abuse, but this protocol was not followed. Interviews with staff confirmed that there was confusion and hesitation in responding to the incident, resulting in a delay in protecting residents from further potential harm. The resident involved was assessed and showed no signs of physical or psychological distress following the event.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Center For Rehabilitation And Nursing | 1 mi | — | 8 | 0 |
| Eddy Heritage House Nursing And Rehabilitation Ctr | 3.2 mi | — | 9 | 2 |
| Eddy Memorial Geriatric Center | 3.3 mi | — | 0 | 0 |
| Rosewood Rehabilitation And Nursing Center | 3.5 mi | — | 55 | 2 |
| Hudson Park Rehabilitation And Nursing Center | 3.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.