Cycle 1
Health 2023-05-01 · Fire 2023-05-01
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Troy, NY
Van Rensselaer Manor
1-star overall rating with 1-star inspections with abuse icon flag with $21,645 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
85 Bloomingrove Drive, Troy, NY
(518) 283-2000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
362
Certified beds
Average residents
271
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,438
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9929
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.62
Baseline 19.93% · Performance 19.29% · Measure score 4.62 · Achievement 4.62 · Improvement 1.69
Healthcare-associated infections
5.44
Baseline 8.69% · Performance 6.49% · Measure score 5.44 · Achievement 4.49 · Improvement 5.44
Total nurse turnover
3.07
Baseline 43.75% · Performance 51.13% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Adjusted total nurse staffing
2.85
Baseline 3.51 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 1.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.8% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 6.69% |
| Discharge to community | 34.57% |
50.57%
16 pts worse
|
Worse than the National Rate · Eligible stays 45 · Observed rate 22.22% · Lower 95% interval 22.83% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 17.02% |
53.69%
36.7 pts worse
|
Numerator 8 · Denominator 47 |
| Discharge mobility score | 44.68% |
50.94%
6.3 pts worse
|
Numerator 21 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 3 · Denominator 54 · Adjusted rate 4.57% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 2.87% |
| Staff COVID-19 vaccination coverage | 4.76% |
8.2%
3.4 pts worse
|
Numerator 22 · Denominator 462 |
| Staff flu vaccination coverage | 62.06% |
42%
20.1 pts better
|
Numerator 301 · Denominator 485 |
| Discharge function score | 40.43% |
56.45%
16 pts worse
|
Numerator 19 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 68.57% |
25.2%
43.4 pts better
|
Numerator 24 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
91.2%
8.7 pts better
|
93.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.0%
1.9 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.1% · Q3 4.9% · Q4 5.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
18.5%
15.2 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.7% · Q3 2.6% · Q4 5.7% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.1%
0.1 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.9% · Q3 7.1% · Q4 5.6% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
13.5%
1.8 pts worse
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 15.3% · Q3 14.7% · Q4 13.9% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.5% |
14.8%
13.7 pts worse
|
16.7%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 27.2% · Q3 30.2% · Q4 27.7% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.8% |
15.1%
4.3 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 9.9% · Q3 8.4% · Q4 14.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.5%
1.9 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.6% · Q3 14.0% · Q4 12.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.6%
0.4 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.3% · Q3 1.5% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.4%
1.7 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.6% · Q3 4.2% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
20.8%
1.5 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 20.9% · Q3 25.0% · Q4 22.7% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
6.9%
0.1 pts better
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.8% · Q3 8.1% · Q4 6.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
76.7%
18.5 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.3% · Q3 98.4% · Q4 85.5% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
9.7%
3.3 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 13.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
78.8%
17.3 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
20.6%
5.2 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 24.1% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-02 · Fire 2021-04-02
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-09-30 · Fire 2020-09-30
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-05-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-26
F · Potential for more than minimal harm
2023-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-06
E · Potential for more than minimal harm
2023-05-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-05-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-30
E · Potential for more than minimal harm
2021-04-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-06-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-06-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-06-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-02
D · Potential for more than minimal harm
2025-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-02
J · Immediate jeopardy
2025-01-31
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-10-25
D · Potential for more than minimal harm
2025-01-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-04
E · Potential for more than minimal harm
2023-05-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-28
E · Potential for more than minimal harm
2023-05-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-01
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-04-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-01
G · Actual harm
2021-04-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-14
E · Potential for more than minimal harm
2021-04-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-02
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-05-14
D · Potential for more than minimal harm
2021-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-14
F · Potential for more than minimal harm
2020-09-30
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2020-10-20
Penalties and ownership
What sits behind the stars
$21,645
2025-01-31
Fine
Fine · fine $21,645
Fine
Ownership
Rensselaer County Bureau Of Finance
5% Or Greater Direct Ownership Interest · Organization
Daley, Dana
Operational/Managerial Control · Individual
Rensselaer County Bureau Of Finance
5% Or Greater Security Interest · Organization
Rensselaer County Bureau Of Finance
5% Or Greater Mortgage Interest · Organization
Wasielewski, John
W-2 Managing Employee · Individual
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#3
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