Renaissance Rehabilitation and Nursing Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident was free from verbal and mental abuse. This was evident for one of three residents reviewed for abuse (Resident #1). Specifically, on 01/25/2026, Certified Nurse Assistant #1 used vulgar/foul language and screamed at Resident #1 while providing care. This incident caused Resident #1 to experience mental distress which resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The undated facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property documented that an owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Under abuse definition section 'A.' Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. [...]

Inspectors wroteBased on record review, and interviews conducted during survey, the facility failed to ensure adequate supervision and implementation of an identified intervention for two of three residents (Resident #9 and Resident #8) reviewed for accidents. Specifically, on 03/15/2025, Resident #9 who required two-person assistance for bed mobility was provided with one staff assist by a certified nurse assistant which resulted in a fall from bed and Resident #9 sustained a fracture to their right hip. On 11/26/2025, Resident #8, who was severely cognitively impaired and required close supervision for ambulation, walked unassisted and without monitoring and fell and fractured their right hip. These incidents resulted in actual harm to Resident #9 and Resident #8 that was not Immediate Jeopardy. [...]

Inspectors wroteBased on record reviews and interviews conducted during a Survey, the facility did not ensure for three of six residents (Resident #1, Resident #8, and Resident #9) that were reviewed for abuse and falls, that all alleged violations involving abuse and injuries were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegations involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey agency, in accordance with State law through established procedures. Specifically, on 03/15/2025, Resident #9 while receiving assistance for bed mobility fell out of bed and sustained a fracture to their right hip. [...]

Inspectors wroteBased on record reviews and interviews conducted during a Survey the facility did not revise or update a resident care plan after a significant change was noted in the resident's psychosocial and physical wellbeing. This was noted for three of three residents (Resident #9, Resident #4, and Resident #1) reviewed for care planning. Specifically, on 02/02/2025 Resident #9 had a fall from bed and care plan for falls was never updated; on 11/20/2025 at 5:24pm Physical Therapist #1 documented that Resident #4 was voicing suicidal ideation upon evaluation, and this information was never addressed and there was no update to the care plan for Psychosocial well-being; and on 01/25/2026 after an incident of abuse Resident #1 voiced that they did not feel safe, and there was no update to the potential for victimization care plan. [...]

Inspectors wroteBased on record reviews and interviews conducted during a Survey (2809204), the facility did not ensure that two of three residents reviewed for behavioral health (Resident #4 and Resident #1) were assessed and provided necessary services after making a suicidal statement and having a traumatic incident. Specifically, on 11/20/2025 at 5:24pm Physical Therapist #1 documented that Resident #4 was voicing suicidal ideation upon evaluation; and on 01/25/2026 Resident #1 experienced a situation and voiced that they did not feel safe. In the facility assessment last revision dated 11/17/2025 under Mental Health and Behavior it documented that the facility is dedicated to effectively managing medical conditions and medication-related issues that may contribute to psychiatric symptoms and behavioral challenges. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. Specifically, upon review of the staffing schedule for multiple days on all three shifts and for each floor for July and August 2025, the facility did not provide adequate numbers of Certified Nurse Aides to meet the needs of the residents.

Inspectors wroteBased on observation, interview, and record review conducted on an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure that a Registered Nurse was on duty for at least 8 consecutive hours a day, 7 days a week for four (4) of nine (9) weekends reviewed from 07/01/25 through August 31,2025. Specifically, no Registered Nurse worked during the 24-hour period on the following weekends 7/5/25 to 7/6/25, 7/12/25 to 7/13/25, 7/19/25 to 7/20/25 and 8/2/25 to 8/3/25. Additionally, during the times when no Registered Nurse was scheduled, two (2) residents (Resident #4 and #6) fell, another sustained a burn (Resident #7), and they were not assessed by qualified staff (registered nurse, physician or nurse practitioner) (See F684).

Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure residents received treatment and care in accordance with professional standards of quality for three of three residents (Residents #7, #6, and #4) reviewed for quality of care. Specifically, 1) Resident #7 was not assessed timely by a registered nurse after being observed with three open wounds on the left thigh; 2) there was no documented evidence that Resident #6 with complaint of pain was assessed by a registered nurse prior to being transferred from the floor to bed after an unwitnessed fall; and 3) there was no documented evidence that Resident #4 was assessed by a registered nurse prior to being transferred from the floor to bed after an unwitnessed fall.

Inspectors wroteBased on observation, interview, and record review conducted during the abbreviated survey (2574633), the facility did not ensure each resident received adequate supervision consistent with resident's needs to prevent accidents for one (1) of three (3) residents (Resident #7) reviewed for accidents. Specifically, Resident #7 sustained an upper left lateral thigh burn on 04/12/2025 after they spilled a hot beverage. The facility did not thoroughly investigate the accident and implement interventions to prevent reoccurrence. Subsequently, Resident #7 sustained second degree burns on the left upper thigh on 08/04/2025 after placing their hot cup of coffee next to their thigh while self-propelling in their wheelchair. Additionally, the facility did not report either burn incident to the New York State Department of Health.

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (2579539), the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (1) of three (3) residents reviewed for activities of daily living. Specifically, Resident #3 was dependent on staff assistance for bathing and did not consistently receive showers twice per week per the resident's care plan and preference.

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (2579539) from 10/28/2025 to 10/30/2025, the facility did not ensure that residents were provided with appropriate treatment and services to achieve or maintain as much bladder and bowel function as possible for one (1) (Resident #3) of three (3) residents reviewed for activities of daily living. Specifically, Resident #3 was admitted with occasional incontinence of urine and bowel, was not provided services to maintain or improve incontinence. The resident expressed their preference not to wear adult briefs, was not trialed on a toileting program, and their incontinence episodes increased.

Inspectors wroteBased on interview and record review conducted during an abbreviated survey (2582016) the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident for one (1) (Resident #1) of three (3) residents reviewed for medications., Specifically, Resident #1 was not administered six (6) doses of eszopiclone to treat insomnia.

Inspectors wroteBased on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 9/5/24 to 9/13/24, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility to ensure regulatory compliance. Specifically, the large elevator was not working consistently since the spring of 2024 and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service.

Inspectors wroteBased on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254, NY00345799 and NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for the entire facility. Specifically, the large elevator was out of order since the spring of 2024.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/5/2024 to 9/13/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment. This was evident during environmental observations of resident Units 1 and 2. Specifically, on Unit 2, resident rooms were observed with sticky floors, garbage receptacles overflowing, garbage was strewn the floor, and soiled adult briefs were observed lying on floor; and on Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage, and appeared stained and the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays were still on tables at 12:35 PM.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00346428), conducted 9/5/24 to 9/13/24, the facility did not ensure each resident remained as free of accident hazards as possible for 4 of 5 residents (#35, #161, #18, and #87) reviewed for accidents. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 09/05/24 to 9/13/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the actual staffing from April 1, 2024 through June 30, 2024 and August 9, 2024 through September 9, 2024 on all three shifts for each unit, the facility did not provide adequate nurse staffing to meet the needs of the residents on multiple occasions during each of the months reviewed, based on the Facility-Wide Assessment.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, it was determined that the facility did not use the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a Registered Nurse had worked 4/12/24, 4/13/24, 4/27/24, and 5/18/24.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure certified nursing aide performance reviews were completed at least once every 12 months for 5 of 5 Certified Nurse Aides ( #8, #19, #20, #21, #22) reviewed.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, meat, mashed potatoes, milk, and super shake were not maintained within the acceptable temperature range for food safety during a dinner observation on 9/5/24. Additionally, perishable foods were not labeled and dated and nonperishable foods were expired during observations in the kitchen. The undated facility policy, Dietary Department -Food Temperatures documented it is the policy of the dietary department to take temperatures of all food items served to residents before the tray line begins. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service. [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) The facility did not have a current Water Management Plan in place that defined potential areas of Legionella risk that was updated yearly, 2) infection control precautions were not properly implemented for residents with Covid-19 infection, 3) during administration of medication there was a breach in infection control practices with a glucometer, and 4) the facility was not implementing Enhanced Barrier Precautions.

Inspectors wroteBased on record review and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide documentation of tracking antibiotic use which included appropriate use of antibiotics and duration of antibiotic treatment.

Inspectors wroteBased on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure the Infection Preventionist completed specialized training in infection control prior to starting their role. Specifically, the facility designated Infection Preventionist was the Director of Nursing, and did not have documented evidence of completed specialized training in infection prevention and control.

Inspectors wroteBased on record review, and interviews during the recertification and abbreviated surveys (NY00340278, NY346428) from 9/5/24 to 9/13/24, the facility could not provide evidence that training was provided annually to their staff on resident abuse prevention.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure 1 of 1 residents (Resident #161) reviewed for death, had the right to formulate advance directives. Specifically, Resident #161's Medical Orders for Life Sustaining Treatment were completed by Resident #161 who presented with changes in cognition, and there was no documentation that the physician determined the resident's capacity at the time of the Medical Orders for Life Sustaining Treatment completion.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00346428) from [DATE] to [DATE], the facility did not ensure that the designated representative of 1 of 3 residents (#161) reviewed for notification of change was promptly informed of a change in the resident's declining condition and change in advance directives. Specifically, there was no documented evidence that the resident representative was promptly informed of the resident's change in advance directives to Do Not Hospitalize on [DATE] and was not notified until [DATE], and the resident expired on [DATE]. The finding is: Resident #161 was admitted with diagnoses including metabolic encephalopathy, white matter disease, and delusional disorder. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage form CMS-10123. This was evident for one (1) of three (3) (Resident #43) residents reviewed for Beneficiary Protection Notification.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure residents right to be free from abuse for 1 of 3 residents (Resident #14) reviewed for abuse. Specifically, on 7/30/2024 Resident #14 who was known to be physically/verbally abusive punched Resident #45 in the stomach, and new intervention of 30-minute safety checks were not initiated or carried out to prevent further abuse.

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure that all alleged violations involving abuse and neglect were thoroughly investigated to rule out abuse/neglect and were reported to The New York State Department of Health for 1 of 3 residents (Resident #161) reviewed for abuse. Specifically, Resident #161 went to a Vascular appointment on 6/24/24 and alleged abuse by a staff member when the provider inquired about a bruise on their forehead. The provider contacted the facility regarding the alleged abuse on 6/24/24 and spoke to the Social Worker and Nurse Practitioner who determined the bruise was from a fall and did not investigate or document the allegation until 7/2/24.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood for 2 of 2 residents (Residents #38 and #18) reviewed for hospitalization. Specifically, Resident #38 and Resident #18 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident representatives.

Inspectors wroteBased on record review and interviews during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents or resident's representatives were notified in writing of the facility policy for bed hold for 1 of 2 residents (Resident #38) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the resident or their representative.

Inspectors wroteBased on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the resident highest practicable physical mental and psychosocial well-being for 1 of 2 residents (Resident #162) reviewed for dialysis. Specifically, Resident #162 did not have a care plan for dialysis.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 2 of 5 residents (#87, #18) reviewed for accidents. Specifically, 1) Resident #87 had falls on 2/8/24 and 2/29/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 2) Resident #18 had a fall on 8/2/2024 and sustained a hip fracture the fall care plan was not updated with new interventions to prevent a recurrence.

Inspectors wroteBased on record review, interview and observation during the recertification survey conducted from 9/5/24 to 9/13/24, the facility did not ensure that residents received the necessary services to maintain good personal hygiene for 3 of 6 Residents ( Residents #45, #66, #78) reviewed for activities of daily living. Specifically, Resident #45, Resident #66, and Resident #78 who required staff assistance for personal hygiene and toileting did not receive morning cares in a timely manner.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #45) reviewed for skin conditions. Specifically, Resident #45 was not assessed and a care plan was not put in place in a timely manner for changes in the Resident's skin condition. Resident #45's diagnoses included cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder. The 8/12/24 Quarterly Minimum Date Set assessment documented the resident had severe cognitive impairment. The annual Minimum Data Set documented the Resident no ulcers, wounds and skin problems. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey from 9/5/24 to 9/13/24/202, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 4 residents (Resident #78) reviewed for pressure ulcers. Specifically, Resident #78 had care plan interventions and physicians order recommendations to offload heels while in bed; however, the resident was observed in bed with their heels resting directly on the mattress and there was no pillow on the mattress for the resident's feet.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure residents who required dialysis (a process that filters blood for the kidneys) received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #13 and #162) reviewed. Specifically, 1) Resident #13 had no dialysis communication book, and 2) Resident #162 received hemodialysis treatments at a community-based dialysis center and did not have on going assessments and oversight before and after dialysis treatments.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure timely identification and removal of expired medications. Specifically, two bags of IV Vancomycin had expiration dates of 7/17/24, one bag of IV Vancomycin had an expiration date of 7/18/24, one bag of IV Vancomycin had an expiration date of 8/7/24, and two bags of IV Vancomycin had expiration dates of 8/10/24 were located in the first floor unit medication room.

Inspectors wroteBased on record review and interviews during the recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that the attending provider documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, actions had been taken to address it. This was identified for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. Specifically, the Medication Regimen Review for Resident #43 dated 4/26/2024 documented a recommendation from the consultant pharmacist for Enoxaparin 40 mg injection to be reviewed for a stop date and appropriate use based on diagnosis and patient mobility. The provider agreed with the recommendation and documented that the medication was discontinued; however, did not address the recommendation and did not document the plan in Resident # 43's medical record.

Inspectors wroteBased on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for anticoagulation. This was evident for 1 of 5 residents (Resident # 43) reviewed for unnecessary medications. Specifically, there was inadequate monitoring of an anticoagulant medication.

Inspectors wroteBased on observations, interviews, and record reviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, it was determined that the facility did not ensure residents were free from significant medication errors for 3 (Residents #38, #104, #89) of 23 residents reviewed for medication administration. Specifically, 3 residents did not receive medications in accordance with the prescriber's orders and accepted health standards established by national boards and councils. This included but was not limited to antibiotic, antidiabetic pill, vitamin, supplement, antihypertensives, inhaler for chronic obstructive pulmonary disease, and antipsychotic which were not administered at the prescribed time on 9/5/24.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice. Specifically, the 2nd floor unit south side medication cart was observed with expired 22-gauge insyte autogaurd needles which are used to administer intravenous medications.

Inspectors wroteBased on record reviews and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides ( #9, #19, #20, #21, and #22), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The Facility Assessment Tool Report, dated 7/1/24, documented: In accordance with New York State Department of Health requirements, in-service training is provided for Certified Nurse Aides sufficient to ensure their continuing competence. Training is at least 12 hours per year and includes dementia management and resident abuse prevention training. [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey and abbreviated survey (301827) conducted from 10/3/2022-10/12/2022 the facility did not maintain a safe, clean, comfortable, and home-like environment for 2 of 2 units (Units 1 and 2). Specifically,(1) the facility did not ensure that adequate housekeeping services were provided to maintain floors, bathrooms, and resident sinks on unit 2. the facility did not maintain an appropriate hot water temperature for the residents.

Inspectors wroteBased on observation, resident and staff interviews and record review conducted during a Recertification Survey and Abbreviated Survey (294084) the facility did not ensure that sufficient nursing staff was consistently provided for 2 of 20 residents interviewed and 7 of 10 residents who attended a group meeting (Resident Council) who expressed complaints regarding lack of sufficient staffing, delay in and not receiving care in a timely manner. Additionally, according to the Facility Assessment resident to staff ratios, Nurse and Certified Nurse Aide (CNA) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey the facility did not ensure that 3 of 10 randomly reviewed Certified Nursing Assistants (CNAs), CNAs #5, #6 and #7, completed the required 12 hours of annual in-service training. In addition, 2 of 10 randomly reviewed CNAs, CNA #6 and CNA #7 recently hired, did not receive a facility orientation

Inspectors wroteBased on observation, interview and record review conducted during a Recertification Survey conducted from 10//22-10/12/22 the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 7 out of 10 alert and oriented residents from 2 out of 2 units, that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack, they were not provided with an evening snack.

Inspectors wroteBased on observation, interview conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure proper maintenance of the unit pantry refrigerator according to professional standards for food safety. Specifically, a pantry refrigerator was not maintained in a sanitary condition in accordance with standards for food service safety. This was evident for 1 of 2-unit pantries (Unit 2).

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure that a Comprehensive Care Plan was developed to ensure treatment and services were provided to maintain the resident's highest practicable physical well-being for 1 of 3 residents (Resident #101) reviewed for pain management. Specifically, a pain management care plan was not developed for Resident #101 who was prescribed Neurontin and Tramadol for chronic pain syndrome. The Findings Are: The facility Policy and Procedure titled Comprehensive Care Plan (CCP) undated documented the CCP will include measurable goals to meet the resident's medical, nursing, psychosocial needs. Problems, strengths, or needs identified by members of the Comprehensive Care Plan team will be included in the CCP as appropriate. [...]

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey between 10/3/2022-10/12/2022 it was determined that the facility did not ensure that each resident and/or resident representative was offered the opportunity to be involved in the their care plan for one of four residents reviewed for care planning, Specifically, Resident #95 was not invited to participate in the care plan meeting with the interdisciplinary team. The Finding Is: The Policy and Procedure titled Comprehensive Care Plan undated documented Responsibility of the Social Worker she will schedule initial quarterly annual significant change and Medicare Comprehensive Care Plan Meeting for each resident as appropriate. The Social Worker chairs and lead the meeting to ensure that all medical records for the resident being discussed are present at the meeting. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for Residents # 60 and #89 who were reviewed for ADL's. Specifically, 1. Resident #60 did not receive twice a week showers as per the care plan and unit shower schedule and 2. Resident #89 was observed wearing the same attire for multiple days, and a Comprehensive Care Plan (CCP)was not revised timely to address the resident's refusals with ADL cares.

Inspectors wroteBased on interview and record review during the recertification survey conducted 10/3/22-10/12/22, it could not be ensured that the facility maintained acceptable parameters of nutritional status for 2 of 5 residents (Residents #51 and #42) reviewed for Nutrition. Specifically, Resident #51 received nutrition via G-Tube, had a significant weight loss, and was not reassessed by clinical nutrition staff until10/05/22 and Resident #42 was assessed for 19.69% significant weight loss in one month on 8/30/22 and orders for supplements were not added until 10/3/22.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification Survey conducted from 10/03/22-10/12/22, the facility did not ensure that medical supervision was provided for 1 of 5 residents (#51) reviewed for nutrition. Specifically, the Physician and/or the Nurse Practitioner did not address the resident's significant unplanned weight loss between 7/7/22 and 8/25/22 of 8.6 pounds through the review date of 10/11/22. The finding is: Review of the facility's policy and procedure revised 9/2022 titled, Height and Weight Monitoring documented that if a weight change of (+) or (-) 5 lbs. [...]

Inspectors wroteBased on record review and interview during the Recertification and Complaint Survey (NY00302051) conducted from 10/3/22-10/12/22, the facility did not provide pharmaceutical services to assure the administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 residents (#70) reviewed for drugs and medications. Specifically, the facility did not ensure that an anxiety medication, was administered as ordered. Subsequently, the Resident did not receive Xanax on 9/23/22 and the resident's Medication Administration Record had Xanax documentation omissions on 8/21/22, 8/29/22, 9/23/22, and 9/28/22. The finding is: The Resident was admitted to the facility on [DATE] with diagnoses including but not limited to Anxiety Disorder, Depression, and Acute & Chronic Respiratory Failure. The Minimum Data Set (MDS; [...]

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey and Abbreviated Survey ( NY 00301827, 00294084 and NY00302051) conducted from 10/3/2022- 10/12/2022, the facility did not ensure that medical records were complete and accurately documented for 2 of 2 residents (Residents # 119 and #120) reviewed for Pressure Ulcers and 1 of 6 residents (Resident #70) reviewed for Medication Administration. Specifically, the Certified Nursing Assistant (CNA) documentation for turning and positioning task for (Residents #119 and #120) was incompete, and the Medication Administration Record documentation for Xanax administration for Resident #70 was incomplete.