Van Rensselaer Manor

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure residents were treated with dignity and respect for one (1) of one (1) resident reviewed (Resident #143) and B1 unit. Specifically, staff failed to maintain discretion regarding resident conditions, used inappropriate and unprofessional language in resident care areas, interacted with a resident in a reprimanding manner during medication administration, and displayed non-dignified signage in a public area. These failures had the potential to cause emotional distress and negatively impact resident dignity and the facility environment.

Inspectors wroteBased on observation and interview conducted during the survey, the facility failed to provide effective maintenance services on seven (7) of seven (7) resident units. Specifically, several walls were in various states of disrepair.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure alleged violations were investigated, prevented, or corrected according to professional standards for two (2) (Resident #31 and #271) of 12 residents reviewed. Specifically, Resident #271 was found on the floor of their room with an injury of unknown origin; an investigation was started and closed without any documented statements from the resident or persons identifying how the injury occurred. Resident #31 reported a missing tote of clothing; an investigation was started and closed without a documented outcome.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure that comprehensive care plans were developed and implemented according to professional standards for three (3) (Residents #94, 132, and 192) of 41 residents reviewed. Specifically, Resident #94 did not have a care plan for Self-Administration of Medication, Resident #132 did not have a care plan for alcohol use, and Resident #192 had a care plan titled Nutrition with an intervention of lab draws yearly that was not implemented.

Inspectors wroteBased on observation record review, and interviews conducted during the survey, the facility failed to ensure that comprehensive care plans were revised according to professional standards for one (1) (Resident #192) of 41 residents reviewed. Specifically, Resident #192 had a care plan titled Nutrition that was reviewed on 3/26/2026 but not revised to reflect the resident's current status.

Inspectors wroteBased on record review and interviews during the survey, the facility failed to ensure that residents were free of unnecessary medications for three (3) (Resident #13, 31, and 231) out of seven (7) residents reviewed. Specifically, Resident #13 and #231 had psychotropic drugs ordered on 03/04/2026 with no end and or renewal date. Resident #13 also had scheduled pain management narcotics ordered two (2) times a day routine and every four (4) hours as needed with no end dates.

Inspectors wroteBased on observation, record review and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in seven (7) of seven (7) resident unit nutrition rooms and the central kitchen. Specifically, several items were found without expiration dates and proper food cooling procedures were not followed.

Inspectors wroteBased on record reviews, observations, and interviews conducted during the survey, the facility failed to ensure medical records were kept in accordance with accepted professional standards and the facility did not ensure that resident identifiable information was not released to the public according to professional standards, complete and accurate for five (5) of five (5) units and one (1) (Resident #271) of one (1) resident. Specifically, a) narcotic count record books for five (5) of five (5) units were incomplete, b) for Resident #271, nebulizer tubing was labeled with date of 03/08/2026 and the treatment administration record was signed weekly for tubing changes through the remainder of 03/2026, and c) two (2) of two (2) laptop computers were left unattended on medication carts with resident identifiable information accessible.

Inspectors wroteBased on observation and interviews during the survey, the facility failed to ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, the facility entrance lobby was observed on 04/01/2026 at 11:30 AM without the Daily Staff Posting. Additionally, there were no Daily Staff Posting elsewhere throughout the building. Finding is:During an observation on 04/01/2026 at 11:30 AM, the lobby was without the Daily Staff Posting. Additionally, there were no Daily Staff Posting elsewhere throughout the building. During an interview on 04/01/2026 at 11:40 AM, Staffing Coordinator #1 stated they were not responsible for posting the Daily Staffing and referred to the Administrator. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure that residents were free of accident or hazards according to professional standards for three (3) (Resident #94, 132, and 231) of eight (8) residents reviewed. Specifically, Resident #94 had an over-the-counter nasal spray on their bedside table, Resident #132 had a can of unopened beer on their personal storage shelf as well as an unopened single shot of liquor on their dresser, and Resident #231 had a clear plastic bag of prescription medication in their chair located next to the doorway in their room.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey, the facility did not ensure each resident was treated with respect and dignity, and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life for one (1) (Resident #1) of four (4) residents reviewed. Specifically, Resident #1 was left alone on the floor after fall for upwards of four (4) minutes after Certified Nurse Aide #1 physically abused them by causing the resident to fall from their wheelchair. This is evidenced by:Cross referenced to F600The facility's undated Resident Handbook, presented as the facility dignity policy, documented 'as a nursing home resident, you have the right to: dignity, respect and a comfortable living environment; quality of care and treatment without discrimination; freedom of choice to make your own, independent decisions; [...]

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (Case #2591142), the facility did not prevent willful infliction of abuse, neglect, or mistreatment for two (2) (Resident # 1, and 3) of four (4) residents reviewed for abuse, neglect, or mistreatment. Specifically, the facility did not fully investigate an incident that occurred on 08/02/2025 when Certified Nurse Aide #1 lowered Resident #1 to the floor. Video footage captured on 08/02/2025 was viewed by facility staff on 08/14/2025 and showed abusive handling of Resident #1 that resulted in the resident falling to the floor and remaining unattended for four (4) minutes. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey, the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one (1) (Resident #1) of four (4) residents reviewed. Specifically, Resident #1 was not assessed for full range of motion before being manually lifted from the floor and placed in their wheelchair after suffering a fall to the floor. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the abbreviated surveys (Case #2591142), the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, the facility did not follow the policies established to provide performance improvement plans, staff correction, and resident safety. This is evidenced by: Cross reference: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Abbreviated survey (Complaint #NY00379718) completed on 6/10/2025, the facility did not ensure the resident's right to be free from abuse, neglect or mistreatment for one (1) (Resident #2) of three (3) residents reviewed for abuse, neglect and mistreatment. Specifically, a Certified Nurse Aide #3 did not follow Resident #2's care plan for dietary meal consistency when they provided Resident #2 with a regular chicken consistency that caused Resident #2 to choke and required back thrusts and mouth sweeps to clear their throat and mouth. This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00378218) completed on 6/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (1) (Resident #5) of three (3) residents reviewed. Specifically Resident #5 was found to have an injury of unknown source to their right eye, and it was not reported within the required timeframe. This is evidenced by: The facility policy and procedure title, Resident Incident / Accident Reporting, date revised 9/2023 documented the following: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00379718 and #NY00378218) completed on 6/10/2025, it was determined the facility did not ensure that all violations of abuse, neglect, mistreatment were thoroughly investigated for two (2) (Resident #2 and #5) of three (3) residents reviewed. Specifically, (1.) An incident involving Resident #2, who was fed regular chicken consistency by Certified Nurse Aide #3, was not thoroughly investigated to determine where the Certified Nurse Aide retrieved the regular consistency meal; and (2.) Resident #5's injury of unknown origin was not investigated thoroughly. Reference F 600 D and F 609 D This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure that all residents comprehensive person-centered care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the resident was not provided with two (2) staff members for incontinent care and bed mobility as care planned. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #1) of one (1) resident reviewed for infection control practices. Specifically, Resident #1 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment while providing incontinent care of urine and feces. [...]

Inspectors wroteBased on record review and interview during an abbreviated complaint survey (Case #NY00357407), the facility did not ensure personnels ability to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring such care prior to the arrival of emergency medical personnel in accordance with the resident's advance directives and subject to related physician orders for one (Resident #1) of three residents reviewed. Specifically, the facility did not ensure Resident #1's advance directive status was known during a significant change in the resident's respiratory condition on [DATE]. The facility failed to initiate cardiopulmonary resuscitation in a timely manner for a resident that was a full code and was in cardiopulmonary arrest (a resident without a pulse or respiration). [...]

Inspectors wroteBased on observation, record review, and staff interviews during an abbreviated survey (Case # NY00358602), the facility did not ensure the resident's right to be free of abuse for 1 (Residents #2) of 3 residents reviewed for abuse and neglect. Specifically on 10/27/2024, Certified Nurse Aide #1 threw a water bottle toward Resident #2, picked the bottle up and again threw it at the resident, striking them on their back without injury. Additionally, the second throw was witnessed by Certified Nurse Aide #2, and there was a delay in removing Certified Nurse Aide #1 from resident care. This is evidenced by: Facility policy titled, Abuse/Neglect, or Mistreatment, updated 11/04/2024, documented it was the policy of the facility that all residents had the right to be free from neglect, verbal, sexual, physical, or mental abuse, corporal punishment, exploitation, and involuntary seclusion. 1. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey dated 4/25/2023 through 5/1/2023, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 3, 43, 91, 120, 219 and 243) of 35 residents reviewed. Specifically, for Resident #3, the facility did not ensure a comprehensive care plan was in place to address care of a suprapubic urinary catheter; for Resident #43, the facility did not ensure comprehensive care plans were developed and implemented for psychotropic medication monitoring, activities of daily living (ADLs) related to the resident's feeding ability, behavior monitoring, and participation in activities; [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (Resident #'s 43, 91, and 219) of 3 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 43, 91 & 219 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: [...]

Inspectors wroteBased on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure the desired staffing levels for Nurses and Certified Nurse's Aides (CNAs) as documented in the Facility Assessment and reported by the Staffing Coordinator, were met 7 of 7 calendar days from 4/24/2023 to 4/30/2023. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure safe and secure storage of all medications for 3 (Unit # A2, A3, and C3 ) of 7 units for medication storage. Specifically, for Units A2, A3, and C3, the facility did not ensure controlled substances were kept in a separately locked, permanently affixed compartment for storage and for Unit A3, the facility did not ensure that the medication cart was locked when unattended. This is evidenced by: Finding 1: Units A2, A3, and C3 During an observation on 04/27/2023 at 10:01 AM, the A2 medication storage room refrigerator was not permanently affixed to the wall or countertop; maintenance was working on securing it to the countertop with a metal wire. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 4/25/2023 through 5/01/2023, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and six (6) of 7 units kitchenettes. Specifically, in the main kitchen, the final rinse on the automatic dishwashing machine was 183 degrees Fahrenheit (F) at 33 pounds per square inch (psi): the information placard on the dishwashing machine requires the final rinse to be between 20 psi and 25 psi; the chemical test kit used to measure the chemical solution used to sanitize food contact equipment did not provide color graduations to indicate if the solution is at the minimum concentration or is too concentrated: [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey from 4/25/2023 to 5/2/2023, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 4 (Resident #'s 43 92, 98, and 174) of 4 residents reviewed for Activities of Daily Living related to sufficient staffing. Specifically, for Resident #92, 98, and 174, the facility did not ensure residents, who were unable to carry out activities of daily living, received their weekly showers to maintain good personal hygiene. Additionally, for Resident #43, the facility did not ensure the resident received staff assistance with eating on 4/27/2023 in accordance with the comprehensive care plan. This is evidenced by: Finding #1: [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey on 4/25/2023 through 5/1/2023, the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 2 (Resident #44 and 244) of 4 residents reviewed for dementia care. Specifically, for Resident #44 and #244, the facility did not ensure the development and implementation of person-centered care plans that included interventions specific to the residents and did not address the residents' customary routines, interests, preferences, or choices to enhance the resident's well-being related to their cognitive status. This is evidenced by: Resident #44: [...]

Inspectors wroteBased on record review and interviews, during a recertification survey, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #59) of 3 residents reviewed for hospitalizations. Specifically, for Resident #59, the facility failed to follow the Nurse Practitioner's readmission plan for the resident to have a Foley catheter (a tube inserted into the bladder to drain urine). The facility failed to notify the physician/nurse practitioner (NP) on multiple occasions for directions based on condition changes related to the resident's Foley catheter and urinary status, and did not obtain a urine specimen timely to determine the presence of an infection. [...]

Inspectors wroteBased on observation and interview during the recertification survey the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions for 4 (Medication Carts A1, A3, B2 and C3) of 8 and 2 (B2 and C2) Medication Rooms of 4 inspected. Specifically, the facility did not ensure medication carts and medication rooms on the nursing units did not contain expired or outdated beyond the date listed on the medication container labels. This is evidenced by the following: Inspections of Medication Carts were as follows: [...]

Inspectors wroteBased on observations, record review and interviews during a recertification survey, the facility did not ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms for 2 (Resident #81 and #203) of 2 resident reviewed for restraints. Specifically, for Resident #81, the facility did not ensure the resident's alarmed clip seat belt was released every 2 hours as documented on the comprehensive care plan, that the physician order identified a medical symptom that necessitated the use of the restraint, and that the resident representative was informed of potential risks and benefits of using an alarmed clip seat belt as a restraint, and for Resident #203, the facility did not ensure the Velcro belt, that was not easily removed by the resident, was assessed as a restraint. [...]

Inspectors wroteBased on interview and record review during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and the resident representative for 3 (Residents #'s 5, 59 and #161) of 3 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and the resident representatives' received written notice of the bed hold policy when the residents' were transferred to the hospital. This was evidenced by: The Administrator stated that the policy and procedure for bed holds was included in the resident admission packet. The resident admission packet provided documented that a written bed hold notification would be provided to residents or their representatives when transferred to the hospital. Resident #5: [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey completed on 4/2/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure staff on B2, a quarantined unit where all residents were on contact and respiratory precautions, consistently wore gowns and changed them between resident encounters, and performed hand hygiene between resident encounters; further, the facility did not ensure residents were socially distanced while dining, and the facility did not ensure reusable equipment was properly sanitized. This is evidenced by: [...]