Allegria Nursing & Rehab Center of Port Jefferson

Inspectors wroteBased on observation and staff interviews during the Recertification Survey initiated on 5/04/2025 and completed on 5/08/2025, the facility did not ensure that it established and maintained 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 infections. This was identified for 1) two (Resident #82 and Resident #73) of five residents reviewed for Medication Administration and 2) laundry room observation conducted during the Infection Control Laundry Task. Specifically, 1) Licensed Practical Nurse #1 did not follow the manufacturer's instructions and did not use the appropriate Environmental Protection Agency (EPA) approved disinfectant to clean and disinfect the shared blood glucose meter between the two residents (Resident #82 and Resident #73). [...]

Inspectors wroteBased on observations and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in a safe operating condition. This was identified during the laundry observation for the Infection Control Task. Specifically, during a tour of the laundry room, a washing machine was observed overflowing and causing the water to accumulate on the floor around the drain. Additionally, the back of the washing machine and dryers had an accumulation of lint and dust. The finding is: The facility's policy titled Laundry Procedures, dated 8/16/2024, documented at the end of each shift, the walls are washed down using disinfectant, washers are wiped down with disinfectant, and then wiped down with stainless steel cleaner. The floors are swept and mopped daily using all-purpose cleaner. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one unit (Unit B) of three units observed during the Dining Task. Specifically, 1) during the lunch meal observation on 5/4/2025, twelve residents were seated at a large table in the Unit B main dining room. Four (Resident #15, Resident #95, Resident #44, and Resident #56) of the twelve residents at the table did not receive their lunch meal until 30 minutes after the other eight residents were served. Resident #15 left the dining room and said they felt disrespected when they were not served their lunch meal at the same time as others. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that all medications and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. This was identified for two (Unit H and Unit B ) of the four units reviewed during the Medication Storage Task. Specifically, Unit H medication carts were not clean and had items stored other than the medications. The Unit H medication refrigerator had yellowish-brown dried substances on the bottom shelf. Unit B Long Hall medication cart contained unidentifiable medication tablets and loose glucometer strips.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, two kitchen refrigerators contained numerous unlabeled and undated food items. The finding is: The facility's policy titled Food Storage with a revised date of 8/4/2024, documented that all food will be dated upon stocking if taken out of its original packaging. If not in the original packaging, all food items must be dated and labeled with the name of the contained food and discarded after three days. During the kitchen tour on 5/4/2025 at 10:21 AM, the refrigerator was observed with 18 egg salad sandwiches that were not labeled and dated. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's right to personal privacy and confidentiality of his or her medical record was maintained. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, Licensed Practical Nurse #4 left Resident #62's electronic medical record open in the hallway with the resident's personal and medical information visible to other staff, residents, and visitors. The finding is: Resident #62 was admitted with diagnoses that included Hypertension, Cerebral Infarction, and Hemiplegia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated intact cognition. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification and abbreviated (Complaint #NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment were reported immediately to the facility administration and not later than 2 hours to the Department of Health after the allegation was made. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Aide #4 pushed them off the bed, resulting in a fall without injury. There is no documented evidence that the facility reported the allegation of abuse to the New York State Department of Health. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Complaint (NY 00377877) Survey, initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that all alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated. This was identified for one (Resident #108) of one residents reviewed for Abuse. Specifically, Resident #108 alleged that Certified Nursing Assistant #4 pushed them off the bed, resulting in a fall without injury. The facility did obtain a statement from the resident and an investigation related to the allegation of being pushed out of bed was not completed. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Abbreviated (NY 00377877) Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident to meet the resident's nursing, mental, and psychosocial needs. This was identified for one (Resident #108) of one resident reviewed for Abuse. Specifically, Resident #108 had a comprehensive care plan intervention to provide care by a male certified nursing aide and/or two aides due to verbally inappropriate behavior towards female staff. An accident/incident report dated 4/5/2025 revealed the resident received care from one female Certified Nursing Aide, Certified Nursing Assistant #4. The finding is: [...]

Inspectors wroteBased on observation, Record review, and staff interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure that each resident's Comprehensive Care Plan was revised by the interdisciplinary team after each assessment to reflect the resident's current status. This was identified for one (Resident #97) of one resident reviewed for Bladder and Bowel Incontinence. Specifically, Resident #97's minimum data set assessments indicated the resident was frequently incontinent of bladder; however, the comprehensive care plan inaccurately documented the resident was occasionally incontinent of bladder. The finding is: The facility's Care Plan policy and procedure, effective 6/20/2024, documented assessment of the resident is ongoing, and care plans are revised as information about the resident and the resident's condition changes. [...]

Inspectors wroteBased on observation, record review, and interviews, during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure the resident's environment remained free of accident hazards as possible. This was identified for one (Resident #62) of nine residents observed for the Medication Administration Task. Specifically, during a medication administration pass for Resident #62, Licensed Practical Nurse #4 left the medication cart unattended and went into the resident's room without ensuring the medication cart was securely locked and was clearly visible to the nurse administering medication. The finding is: The facility's Administrating Medication policy and procedure dated 12/3/2024, documented during administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 5/4/2025 and completed on 5/8/2025, the facility did not ensure its Facility Assessment considered daily staffing needs for each resident unit and for each shift, such as day, evening, and night. This was identified during the Sufficient and Competent Nurse Staffing Review Task. Specifically, the Facility Assessment, last updated on 2/3/2025, only reflected emergency staffing levels and did not consider the daily Nursing staffing needs for each nursing unit. The finding is: The Facility assessment dated [DATE] documented the facility was licensed for 143 residents with an average daily census of 120. The facility assessment identified a total of three units including Unit A, Unit B, and Unit H. The facility assessment did not document the bed capacity for each unit. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified during a review of the Payroll Based Journal (PBJ) Staffing Data Report, and review of the Facility Assessment; concerns raised during the Resident Council meeting; and during the medication administration observation on Sunday (1/28/2024) on one of three nursing units. Specifically, review of the Payroll Based Journal (PBJ) Staffing Data Report and the Facility Assessment (FA) identified that the facility did not ensure adequate staffing was available to meet the residents' needs on multiple days; [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that the facility's medication error rates are not five percent or greater. This was identified for 42 of 53 opportunities for six (Resident #82, Resident #51, Resident #12, Resident #72, Resident #22, and Resident #92) of nine residents observed during a medication pass observation. This resulted in a 79.25% medication error rate. Specifically, 1) Resident #82 did not receive eleven of the 9:00 AM Physician ordered medications until 10:56 AM. 2) Resident #51 did not receive three of the 9:00 AM Physician ordered medications until 11:10 AM. 3) Resident #12 did not receive seven of the 9:00 AM Physician ordered medications until 10:38 AM. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident had a call bell accessible to alert staff of the residents' needs. This was identified for one (Resident #29) of five residents reviewed for the Environmental Task. Specifically, Resident #29 was observed in their room on 1/28/2024 and 1/31/2024 with the call bell out of their reach. The finding is: The facility's policy for the Call System dated 9/18/2023 documented that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized station. Resident #29 was admitted with diagnoses that included Cerebral infarction, Type 2 Diabetes Mellitus, and Osteoarthritis. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical and nursing needs. This was identified for one (Resident #120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 did not have documented evidence that a care plan was initiated for the use of Oxygen at 2 Liters per minute via nasal cannula continuously every shift for Hypoxia (absence of enough oxygen in the tissues to sustain bodily function). The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #114) of two residents reviewed for Skin Conditions. Specifically, Resident #114 was seen for a Vascular Consult on 1/22/2024 and returned with a dressing on their right lower leg. The resident's right lower extremity was observed on 1/28/2024 and 1/29/2024 with a dressing in place; however, there was no indication when the dressing was last changed. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024 the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was identified for one (Resident #8) of one resident reviewed for Limited Range of Motion. Specially, Resident #8 was observed on three occasions without the Physician ordered gauze handrolls in place to prevent decline in range of motion. The finding is: The facility's policy titled, Small Adaptive Devices for Activities of Daily Living Skills dated 9/10/2023 documented proper, safe, and consistent use of small adaptive devices can maximize the resident's level of independence. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that residents who need respiratory care are provided such care consistent with professional standards of practice. This was identified for one (Resident # 120) of five residents reviewed for Respiratory Care. Specifically, Resident #120 had an order for continuous oxygen therapy via a nasal cannula at 2 Liters per minute every shift for Hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The resident was observed on three occasions without the use of the supplemental oxygen as ordered by the Physician. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification survey initiated on 1/28/2024 and completed on 2/1/2024, the facility did not ensure that medical care for each resident was supervised by the Physician including providing orders for the resident's medical status. This was identified for one (Resident #114) of two residents reviewed for Skin Conditions. Specifically, Resident #114 was seen for a Vascular consultation on 1/22/2024. Recommendations were made for the use of bilateral ace wraps to be applied in the morning and to be removed at the hour of sleep to treat the resident's lower extremities edema (swelling caused by too much fluid trapped in the body's tissues). [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00272022) initiated on 7/21/2022 and completed on 7/28/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made if the events that caused the allegation involve abuse to the administrator of the facility and to other officials (including to the state survey agency). This was identified for one (Resident #224) of three residents reviewed for Abuse. Specifically, on 2/22/2021 Social Worker (SW) #1 was informed by the hospital SW of an abuse allegation made by Resident #224 that a Certified Nursing Assistant (CNA) at the Nursing Home had inappropriately touched Resident #224 during perineal care. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00272022) initiated on 7/21/2022 and completed on 7/28/2022, the facility did not ensure that all incidents of alleged abuse are thoroughly investigated to rule out Abuse, Neglect, and Mistreatment. This was identified for one (Resident #224) of three residents reviewed for Abuse. Specifically, Resident #224 reported to the Social Worker (SW) #1 that a Certified Nursing Assistant (CNA) inappropriately touched Resident #224. The facility's Investigation Report lacked documented evidence that statements were obtained from direct care staff that cared for the resident. The finding is: [...]

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey initiated on 7/21/2022 and completed on 7/28/2022 the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #25) of three residents reviewed for Activities of Daily Living (ADLs). Specifically, Resident #25 had a Physician's order for showers to be administered on the 3:00 PM-11:00 PM nursing shift on Wednesdays and Fridays. There was no documented evidence that Resident #25 Comprehensive Care Plan (CCP) was implemented to ensure the Physician's order for showers were followed. The finding is: [...]