Renaissance Rehabilitation And Nursing Care Center

Review of the chart and the incident report revealed that the Nurse Supervisor on the day of the incident called a phone number to report the incident.

However, it is indicated in iQIES that the phone number called was to the Justice Center, and the Nurse Supervisor left a message but did not leave a return phone number.

The review also revealed that the facility never called local law enforcement, and that local law enforcements' arrival at the facility on the day following the incident was because the Resident #1's representative had called them. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

335404 05/26/2026

Renaissance Rehabilitation and Nursing Care Center 4975 Albany Post Road Staatsburg, NY 12580

01/25/2026 documented that at approximately 3:15 PM, Resident #1 was receiving care from Certified

Certified Nurse Assistant #1 used ice cold water to provide hygienic care. At the time of the

Supervisor #1 reported to the scene and Certified Nurse Assistant #1 was removed from the environment immediately and care was provided by other staff.

Certified Nurse Assistant #1 left the facility and was subsequently notified that they would be suspended pending the outcome of the investigation. A Registered Nurse assessment yielded data supporting emotional upset and anger; there was no indication of physical injury.

The Medical Director was made aware of the incident and followed up with no new orders. A follow up skin check three days later yields no new injury, bruising, discoloration, report of pain or other negative psychical manifestation of the event.

Statements collected from staff on duty support the allegation as stated by Resident #1 regarding being handled roughly and being subjected to loud, disruptive and agitated vocalizations.

The allegation of abuse is substantiated.

During an interview on 05/01/2026 at 3:45pm with the current Director of Nursing they stated they know that the Social Worker met with Resident #1.

The Director of Nursing stated that they would consider that meeting to be a mental health evaluation not a psychiatric evaluation.

The Director of Nursing stated that they do not recall if there were any changes made to the care plan at that time.

The Director of Nursing stated that the social worker would be the staff to update the care plan in the system.

The Director of Nursing also stated that the social worker may have put a care plan in place requiring that two certified nurse assistants provide care to Resident #1. 10NYCRR 415.11(c)(2)(i-iii)

335404 05/26/2026

Renaissance Rehabilitation and Nursing Care Center 4975 Albany Post Road Staatsburg, NY 12580

to the wheelchair or staff can walk with them.

Licensed Practical Nurse #2 stated they did not know

Licensed Practical Nurse #2 stated they were in the hallway, Resident #8 did not walk past them.

Resident #8 on the floor.An interview on 05/20/2026 at 11:39 AM with the Director of Rehabilitation, they revealed that before Resident #8 fell, they were getting Occupational Therapy and Physical Therapy.

They stated that Resident #8's function prior to the fall, was indicated to be contact guard handheld assist, they were very confused, and they would try to self-transfer.

The Director of Rehabilitation stated that Resident #8 should not have been walking around by themself.

The Director of Rehabilitation stated that to communicate the details of the abilities and limitations of the residents to the units, they fill out a rehabilitation recommendation form that is given to the Director of Nursing and this would be linked to the certified nurse assistant documentation, so they can see what residents can do and cannot do.

The Director of Rehabilitation stated that at the time of the incident, the rehabilitation recommendation was given to the Director of Nursing, and they would record the residents' ability levels.

The Director of Rehabilitation stated that they have no way of making sure that nursing is following their recommendations and recording the residents' ability levels.

The Director of Rehabilitation stated that residents with dementia or advanced dementia would not use a walker appropriately.

The Director of Rehabilitation stated that when Resident #8 was in the dining room and stood up, someone should have redirected them, and if they felt like walking someone should have held their hand and walked with them, they should not have walked alone.

The Director of Rehabilitation stated that they have seen a decline in Resident #8's abilities.

During an interview on 05/20/2026 at 12:03 PM with Certified Nurse Assistant #5, they stated they did not know Resident #8 well prior to the fall.

They stated that Resident #8 needs a lot of assistance with everything, such as feeding and getting dressed, and once on their feet, they are very unsteady and can only walk short distances.

Certified Nurse Assistant #5 stated when Resident #8 wanders around they know that they need to be with them, so they ask someone to get Resident #8's wheelchair.

Certified Nurse Assistant #5 stated there are times when Resident #8 will get out of bed, leave their room, and walk down the hallway.

They stated, when this happens, I walk them back to their room, or I will get a chair, or a wheelchair, and sometimes they have Resident #8 sit by the nurses' station.

Certified Nurse Assistant #5 stated they know that they have to monitor Resident #8, as the last thing they want is for them to fall.

Certified Nurse Assistant #5 stated they are aware of which residents should not walk by themselves, it is in their care plans, they see it on Sigma (electronic medical record), and since the unit usually has the same staff, staff know the residents' abilities.

Certified Nurse Assistant #5 stated there are still days Resident #8 has the strength and enough willpower to get up and start walking.During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated they knew about Resident #8's fractured hip because they got a call on the weekend and they had the facility send the resident to the hospital because of the fall and the report that the resident had a shortened leg.

The Medical Director stated they were not given the details of what led to the fall.

The Medical Director stated that to determine how well a resident can ambulate, normally a Physical Therapy assessment is conducted to identify the abilities and limitations of the resident.

The Medical Director stated that a resident that requires supervision should not be walking alone, and someone should be next to them.

The Medical Director stated that they were not told that Resident #8 often stood up on their own and at times would walk down the hall.

The Medical Director stated that if they had known and were aware of all regarding Resident #8, further evaluation might have been needed to determine if closer supervision was warranted, and they might have considered one-to-one supervision.10 NYCRR 415.4(b)

335404 05/26/2026

Renaissance Rehabilitation and Nursing Care Center 4975 Albany Post Road Staatsburg, NY 12580

During an interview on 04/29/2026 at 1:16pm Resident #1 reported the aide smacked them and called them a nigger. Resident #1 stated they have been nervous, and they jump when staff comes into the room.

They stated there was no consultation afterwards. Resident #1 stated that sometimes when they receive care it is provided by one aide and sometimes it is provided by two aides. Resident #1 stated sometimes they are scared, and they will call downstairs for someone to assist them. Resident #1 stated they do not feel safe in the facility.

During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated that they did not get any call regarding the incident, but they heard about it randomly one day during rounding sometime the following week.

They stated that Resident #1 was being followed by a different medical provider who saw the resident on 02/08/2026.

The Medical Director stated that they think they should have been called and would have liked to have been notified of the incident.

The Medical Director stated that they were not aware this incident made it to the local news. 10NYCRR 415.15(b)(2)(iii)