Rosewood Rehabilitation And Nursing Center
ROSEWOOD REHABILITATION AND NURSING CENTER in RENSSELAER, NY — inspection on February 25, 2026.
Found 16 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 02/24/2026 at 2:35 PM, Licensed Practical Nurse #4 stated when entering a resident room, that they would knock and introduce themselves. If they needed to go through a resident's belongings, they would need to ask for permission from the resident. If they heard inappropriate conversation in hallway by staff, they would notify nurse manager.
During an interview on 02/24/2026 at 2:47 PM, Licensed Practical Nurse #7 stated when entering a resident room they would knock, introduce themselves, and then address issues that brought them to the room. If they needed to go through a resident room or belongings they would need to ask permission from resident prior.
They stated if they heard inappropriate conversation in hallway, they would pull staff into their office and give them a verbal warning. If the behavior continued, they would bring the staff member to the director of nursing for further interventions.
During an interview on 02/24/2026 at 2:14 PM, Certified Nursing Aide #9 stated they always ask permission if they needed to search a resident's room.
They always knocked before entering a resident's room and introduced themselves.
They stated cursing in front of residents or other staff was not okay, and they would address staff if they overheard it.
During an interview on 02/24/2026 at 2:42 PM Licensed Practical Nurse #8 stated they would ask permission from the resident before searching a resident's belongings/drawers.
During an interview on 02/24/2026 at 4:21 PM, Licensed Practical Nurse #2 stated they would talk to staff or correct them if they heard any foul language/cursing.
They have witnessed staff arguing in front of the residents, and staff talking on their personal phones using foul language in front of residents.
They stated both situations were dignity issues. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)
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by the facility management team to ensure that residents had physician orders for code statue and/or
jeopardy to resident health or Sustaining Treatment had advanced directives discussed with them or their representee by nursing safety staff.Corresponding Medical Order for Life Sustaining Treatment forms and physician's orders for advanced directives were entered into the electronic medical record by the unit manager and
reviewed the facility policy and Advanced Directives, and no revisions were made.On 02/05/2026, the facility initiated mandatory education to the Nurse Practitioner, all registered nurses, and a licensed practical nurse on the facility policy relating to educating all residents/representees on admission of their right to formulate advanced directives and ensuring a corresponding physician's order or code status and/or a Medical Order for Life sustaining Treatment form are entered into the resident's medical record.Education would be conducted verbally, either in person or by telephone, by the Nursing Supervisor and/or designee.
Education was started on 02/05/2026 and 90% of facility staff would be educated by 02/05/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.As of 02/06/2026, 95% of facility staff were educated. As of 02/06/2026, all current residents (77) had a corresponding physician's order or code status and/or a Medical Order for Life sustaining Treatment form entered into their medical record. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)
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health record, and the family would be notified.
Ideally, it would be reviewed in morning report.
that there were issues surrounding documentation and that staff needed to be educated on the
after things happened.
New York Code of Rules and Regulations 415.4(b)(1)(i)
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During an interview on 2/24/2026 at 11:29 AM, Family Member #7 stated they were made aware of Resident #90's falls on 1/01/2026 and agreed that that resident be sent to the hospital.
After Resident #90's hospital trip on 1/01/2026, they started acting like they had dementia.
They were more confused.
They further stated that when they went to visit, Resident #90 would not stand after their falls on 1/01/2026 and the resident complained that their leg hurt, and they massaged it.
The resident did not indicate that they had pain in their hip.
They stated the family felt bad that they did not pick up on it sooner, but Resident #90 was so confused.
Family Member #7 stated they did not think that any kind of abuse or neglect occurred.
During an interview on 2/25/2026 at 9:29 AM, Medical Director #1 stated they were made aware of falls, skin tears, etc. through Incident and Accident Reports. It was their responsibility to sign off on them.
They stated falls were one of the biggest issues that they faced in long-term care.
They stated they would expect the facility to complete an investigation for an injury of unknown origin, and it should be reported to the Department of Health.
During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated an injury of unknown origin should be reported within two (2) hours to the Department of Health, and the Director of Nursing or Administrator was responsible for reporting.
They stated they would then complete an investigation for an injury of unknown origin.
During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated they reported anything in the regulations that needed to be reported to the Department of Health.
They stated it was a team effort on what should be reported.
They stated some things such as abuse should be reported to the
of unknown origin to the Department of Health. 10 New York Code of Rules and Regulations 415.4(b)(2)
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During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated the Director of Nursing was responsible for making sure Incident and Accident Reports were completed for injuries of unknown origin.
They stated they had to follow the regulations. 10 New York Code of Rules and Regulations 415.4(b)(3)
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During an interview on 2/19/2026 at 11:51 AM, Licensed Practical Nurse #2 stated they implemented a stop sign across Resident #75's door after they were made aware of the grievance.
There was no documented evidence that a care plan for abuse or at risk for abuse was developed and implemented with interventions after Resident #75 was identified as the victim of a resident-to-resident altercation that occurred in June 2025.During an interview on 2/24/2026 at 9:51 AM, Licensed Practical Nurse #8 stated if they noticed that something needed to be added to a resident's care plan, such as fall risk they would notify the unit manager.
During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated care planning was a significant issue at the facility.
They stated they did not have many Registered Nurses to assist with care planning but were interviewing for an Assistant Director of Nursing.
They further stated care planning would be part of their education plan and followed with audits.During an interview on 2/25/2026 at 12:25 PM, Administrator #1 stated care plans should be individualized.
They further stated care plans assured residents were safe and cared for accordingly. 10 New York Code of Rules and Regulations 415.11(c)(1)
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Codes, Rules, and Regulations 415.12
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process.
During an interview on 02/03/2026 at 11:40 AM, Assistant Administrator #1 stated education
jeopardy to resident health or staff are educated.
Assistant Administrator #1 stated staff rounds occurred during care delivery, safety activities, therapy, and routine safety checks multiple times a day.
Staff education was ongoing, including a full-house in-service, to reinforce medication safety, admission procedures, and
Administrator #1 stated they notified Administrator #1 regarding the prescription medications left at Resident #2's bedside.
Nurse Practitioner #1 was notified and determined that the medication was brought into the facility by the resident's family following a hospital discharge.On 01/29/2026, a facility-wide audit of each resident room, including drawers and cabinets, was conducted by the facility management team to ensure that no other residents had medications in their rooms.
There were no findings of any medications in resident rooms during the audit.A second facility-wide audit of each resident room, including drawers and cabinets, was initiated on 02/06/2026 at 2:58 PM and completed on 02/06/2026 at approximately 4:00 PM.
There were no findings of any medications in resident rooms during this audit.On 01/30/2026, Administrator #1 and Assistant Administrator #1 reviewed the facility policy, Administering Medications, and no revisions were made.On 02/03/2026, medications from Resident #2's room were given back to Family Member #3 to take home and destroy.On 02/03/2026, the facility initiated mandatory education to all staff and re-educated that residents were not to have medications in their room and if any medications were found they were to immediately be given to a nurse.Education would be conducted verbally, either in person or over the telephone by the Nursing Supervisor and/or designee.Education was started on 02/03/2026 and 90% of facility staff would be educated by 02/06/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.On 02/03/2026, Director of Maintenance #1 replaced the cover on the baseboard heater in Resident #3's bathroom.On 02/03/2026, Director of Maintenance #1 conducted an audit of the electric baseboard heaters in the facility, ensuring they had covers in place.On 02/06/2026, Assistant Administrator #1 and Director of Maintenance #1 reviewed the facility Work Request Policy, and no revisions were made.On 02/06/2026, the facility initiated mandatory education to all staff regarding the process for reporting damaged, broken and/or malfunctioning equipment.Education would be conducted verbally, either in person or by telephone by the Nursing Supervisor and/or designee.
Education was started on 02/06/2026 and 90% of facility staff would be educated by 02/06/2026 at 11:00 PM.Facility staff that had not been reached by telephone would not be permitted to work until they received the education.As of 02/09/2026, 93% of facility staff were educated. 10 New York Codes, Rules and Regulations 415.12(h)(1)
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more staff specifically on weekends, with typically only one to two (1-2) cooks and four to six (4-6)
talked to Administrator #1 about referral bonuses.
Director of Nursing #1 stated that the facility was
on 2/25/2026 at 10:10 AM, Administrator #1 stated that they would like to avoid staff turnover, but they let go of people that were not helping to move the facility forward.
Administrator #1 stated they had openings on employment websites, offered sign on bonuses, and had booths at job fairs.
Administrator #1 stated that they would schedule interviews, and the people would not show up, or the people would get through orientation and then not show up for their shifts.
Administrator #1 stated that they had tried to work with local colleges but had not been very successful and was discussing offering referral bonuses for staff that would bring in other staff.
Administrator #1 stated they believed that residents were being cared for, and that education and poor documentation were the main issues that needed to be addressed. 10 New York Codes, Rules and Regulation 415.13(a)(1)(i-iii)
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hired.
The online education system tracked the aides' required hours of education and had gone into
cheat sheets for the things staff needed to know.
Dementia training was part of resident rights.
415.26(c)(1)(iv)
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During a meal tray sampling on 02/17/2026 at 7:46 AM, Resident #67's breakfast tray was tested, and a replacement tray was provided.
The breakfast tray was tested for taste and temperature, and the results were as follows: water for tea 144.1 degrees Fahrenheit, whole milk 53.2 degrees Fahrenheit, orange juice 56.1 degrees Fahrenheit, hot cereal 136.9 degrees Fahrenheit, sausage patty 102.0 degrees Fahrenheit, toasted bagel 85.6 degrees Fahrenheit, and two (2) cream cheese packets 41.1 and 41.5 degrees Fahrenheit.During a meal tray sampling on 02/17/2026 at 1:06 PM, Resident #8's lunch tray was tested, and a replacement tray was provided.
The lunch tray was tested for taste and temperature, and the results were as follows: water for tea 140.7 degrees Fahrenheit (tea bag was missing from tray), apple juice 64.9 degrees Fahrenheit, cranberry juice 64.2 degrees Fahrenheit, Philly steak on bun with peppers, onions, and cheese sauce casserole 128.5 degrees Fahrenheit, mixed vegetables 124.9 degrees Fahrenheit, bow tie noodles 110 degrees Fahrenheit (noted to be underprepared with no sauce), cottage cheese 49 degrees Fahrenheit, and Assorted fruit 64.2 degrees Fahrenheit (canned oranges) which were sour to taste.
Interviews:During an interview on 02/11/2026 at 11:00 AM, Resident #72 stated that food was horrible and delivered cold most of the time; sometimes it was warm.
During an interview on 02/12/2026 at 10:03 AM, Family member #6 stated they thought the food in the facilty was gross.
During an interview on 02/12/2026 at 12:44 PM, Resident #8 stated meals were always cold.
They stated they were the last one on the list for food delivery.
During an interview on 02/17/2026 at10:36 AM, Dietary Aide #1 stated their responsibilities included setting up trays (placing silverware, ensuring items match the meal ticket, and cleaning dishes).
They stated each resident received a meal ticket, and as of recently, requested substitutions were being highlighted.
Replacement meals normally take 3-4 minutes to make and get delivered to residents.
Staffing was usually limited. On weekdays, there were typically one (1)-2 cooks and 4-6 dietary aides. In addition, they stated, the cook tested the temperature of food before it was delivered to the residents.
During an interview on 02/20/2026 at 12:53 PM, Certified Nurse Aide #5 stated lunch was usually brought to the unit around 12:30 PM.
They stated residents always complained about the food not matching the meal tickets.
They stated that that morning a resident was missing oatmeal off their tray.
They stated if a resident was missing or did not get an item on their tray they would call the kitchen or walk down there and grab it.
Lunch was still not delivered to the unit at 12:55 PM.
During an interview on 02/25/2026 at 12:25 PM, Administrator #1 stated they checked that the food arrived to the residents, and temperatures were taken randomly. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)ˆˆ
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serve food in accordance with professional standards.
ensure that storage and preparation of food was maintained according to professional standards.
thermometers, and improperly stored food were identified throughout the kitchen.This is evidenced by: During the initial kitchen tour on 2/11/2026 from 10:24 AM to 11:00 AM and the follow-up visits on 2/19/2026 between 11:00 AM and 2:30 PM, the following observations were made:One (1) of four (4) thermometers tested for accurate calibration was outside of acceptable range.
When tested in ice water bath, the thermometer displayed 37 degrees Fahrenheit.Improper storage of food was identified in the following areas:In the walk-in refrigerator open bags of peperoni and hot dogs were found undated.In the walk-in freezer open bags of chicken, green beans, sausage patties and egg patties were found undated.In dry storage room eight (8) bags of English muffins were observed on the shelves.
Product label stated they were to be stored frozen.
All bags were undated.
Four (4) bags had identified mold on the English muffins within the bags.In second floor kitchenettes two (2) bowls of dry cereal were identified stored in the cabinets without dates or times labeled.In second floor kitchenettes five (5) bowls of dry cereal were identified stored in the cabinets without dates or times labeled.Potential for contamination of food products was identified as follows:Two (2) of five (5) kitchen staff were identified to not have required hair protection while working in the food preparation area.One bottle of drain cleaner was identified improperly stored in the food service area.Clean/dry rags were stored at floor level in an overfilled small garbage can.The undated facilities Food Receiving and Storage policy states that all food stored in refrigerator or freezer will be covered labeled and dated.During interview, on 2/11/2026 at 10:46 AM, Food Service Director #1 stated they were aware that the unlabeled food in the walk-in refrigerator and freezer as well as in the unit kitchenettes were supposed to be dated and was unaware of why they were not at that time.During interview on 2/19/2026 at 2:15 PM, Food Service Director #1 stated they were unaware the English muffins were supposed to remain frozen, that someone else must have unpacked them since they usually did, and made sure they were dated.
When the mold was pointed out all products were disposed of immediately.
Food Service Director #1 also stated they were unaware as to why the drain cleaner was not in a properly secured area, and they were trying to move away from the dry rags to wipe down surfaces to single use disposable wipes.
Food Service Director #1 stated they would keep a closer eye on the calibration of the thermometers and ensure that those in use were properly calibrated. 10 New York Codes, Rules, and Regulations 415.14(h)
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tried to address issues that were brought to them as soon as they could.
They were not aware of
discussed in morning meeting and afternoon wrap up.
Administrator #1 stated that department heads
things they did not know the regulations on. 10 New York Code of Rules and Regulations 415.26(b)(3)(1)
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Specifically, the self-closing device on the Walk-in freezer was not functioning as intended.This is
freezer, the self-closing mechanism on the main entry door was inoperable and not pulling the door closed to ensure a tight seal.
During an interview on 2/17/2026 at 2:00 PM, Food Service Director #1 stated that the company was just there several days ago and left several items in disrepair and they would contact them and have it addressed. 10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)
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Rosewood Rehabilitation and Nursing Center 284 Troy Road Rensselaer, NY 12144
During an interview on 2/19/2026 at 9:23 AM Licensed Practical Nurse #3 stated online
2/19/2026 at 9:35 AM, Assistant Administrator #1stated that the Assistant Director of Nursing
education.
Ideally, online teaching would be set up monthly to piggyback on in-house education and would be due by specific date.
With the change of staff, education stopped for a little while.
The previous Assistant Director of Nursing, who became the Director of Nursing, was doing education.
Ideally, they would have kept a binder with the education information, but when they left, Assistant Administrator #1 was not able to find any of the information.
During an interview on 2/24/2026 at 10:18 AM, Licensed Practical Nurse #4 stated that education was done on the computer, and staff came around and did in- service talks.
Licensed Practical Nurse #4 stated that they did not know how to get education on the computer.
During an interview on 2/24/2025 at 10:25 AM, Licensed Practical Nurse #3 stated that they knew they had some electronic education that was overdue.
They knew they had done handwashing and infection control in the last year.
During an interview on 2/24/26 at 11:52 AM, Acting Director of Nursing #1 stated they did not do education.
There were monthly online teachings.
Before the previous Assistant Director of Nursing left, they would post reminders about education, but there was no electronic triggering reminders set up through the electronic system.
During an interview on 2/25/2026 at 10:10 AM, Administrator #1 stated that the changeover in management staff may be part of the problem.
They needed better procedures, education and logging of information.
During an interview on 2/25/2026 at 11:04 AM, Director of Nursing #1 stated the education process needed structure.
Education would go on the Assistant Director of Nursing's role.
Director of Nursing #1 stated that they were aware that Certified Nurse Aides needed to maintain education hours each year and thought that it was 20 hours a year.
During an interview on 2/25/2025 at 12:25 PM, Administrator #1 stated that they would work with Director of Nursing #1 as a team.
The annual education that needed completion would be done by Assistant Director of Nursing when they were hired.
The electronic education system tracked the aides' required hours of education, but they did not think that it alerted staff to what was due.
Administrator #1 stated that they had cheat sheets of codes, phone trees, emergency processes and other things staff needed to know.
Administrator #1 stated that they knew that there were certain mandatory educations that needed to be done yearly and named abuse training and resident rights.
Administrator #1 believed that dementia training was part of the resident rights teaching.
During an interview on 2/25/26 at 6:03 PM, Assistant Administrator #1 stated that the last formal nurse educator in the building was the Assistant Director of Nursing who left at the end of August 2025. 10 New York Codes, Rules and Regulations 415.26(c)(1)(iv)