Cobble Hill Health Center Inc

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility failed to ensure that residents are free from physical abuse. This was evident for one of six residents (Resident #1) sampled for abuse. Specifically, the facility surveillance video dated 06/14/2026 from 09:38:24 AM through 09:39:55 AM revealed Certified Nursing Assistant #1 running out of the dining room chasing Resident #1 who walked out of the dining room into the hallway holding a banana. In the hallway, Certified Nursing Assistant #1 grabbed Resident #1 at the back of their neck and used their right hand to hit Resident #1 on the top of their head. During the incident, Resident #1 fell on the floor and hit their head on another resident's wheelchair. Resident #1 did not sustain any visible injuries. This resulted in Immediate Jeopardy to resident health and safety at Past Non-Compliance.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation result in serious bodily injury, to the State Survey Agency. This was evident in one (1) (Resident #370) of five (5) residents reviewed for accidents. Specifically, Resident #370 had an unwitnessed fall on 03/20/2026 and was later diagnosed with an acute subcapital left hip fracture on 03/23/2026. The resident had severe cognitive impairment and was unable to provide information regarding the circumstances of the fall. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised following a significant change in condition and ongoing pain management interventions. This was evident in one (1) of three (3) residents reviewed for pain management out of 35 total sampled residents. Specifically, Resident #1's comprehensive care plan for potential pain was not reviewed and revised despite the resident exhibiting actual pain.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the Minimum Data Set assessment accurately reflected each resident's status. This was evident in two (2) (Resident #236, Resident #306) of five (5) residents reviewed for accuracy of assessment. Specifically, 1.) Resident #306's Minimum Data Set assessment did not accurately reflect the indwelling catheter status; and 2) Resident #236's Minimum Data Set assessment did not accurately reflect the use of wander guard.

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated survey (NY00307820), the facility failed to ensure that the services provided or arranged by the facility meets professional standards of quality. This was evident in 1 out of 3 residents (Resident #1) sampled. Specifically, on 12/27/22 at approximately 06:30am on the night shift (11:00pm-07:00am), Resident #1 was observed on the floormat in their room and was picked up and put back into their bed by Registered Nurse #1. An x-ray result dated 12/28/22 documented that Resident #1 sustained an acute nondisplaced right femur intertrochanteric fracture. The facility's Investigation Summary dated 12/29/22, revealed that Registered Nurse #1 did not report the fall. There was no documented evidence that Resident #1 was assessed by Registered Nurse #1. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 2/08/2024 to 2/15/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during kitchen observation. Specifically, expired food was observed in the kitchen refrigerator.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 02/08/2024 to 02/15/2024, the facility did not ensure a person-centered Comprehensive Care Plans was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #36) of 2 residents reviewed for Urinary Catheter out of 38 total sampled residents. Specifically, Resident #36's Comprehensive Care Plan was not developed with interventions to address their urinary (Foley) catheter.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #243) of 3 residents reviewed for Limited Range of Motion out of 38 total sampled residents. Specifically, Resident # 243 did not have bilateral hand rolls in place according to Physician's Order.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey 02/08/2024 to 02/15/2024, the facility did not ensure a resident requiring dialysis services received such services consistent with professional standards of practice. This was identified for 1 (Resident #645) of 38 total sampled residents. Specifically, there was no Physician's Orders for Resident #645 to receive hemodialysis treatment.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (NY00316471) from 2/8/2024 to 2/15/2024, the facility did not ensure allegations involving abuse were reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 2 (Resident #246 and #210) of 38 total sampled residents. Specifically, Residents #246 and #210 were involved in a resident-to-resident altercation that was not reported to the New York State Department of Health within 2 hours.

Inspectors wroteBased on observation, staff interview, and record review conducted during the Recertification survey, the facility did not ensure food storage in accordance with professional standards. Specifically, undated and expired food was observed in the Kitchen and Storage Room during the Kitchen Task.

Inspectors wroteBased on interviews and records review conducted during the recertification and complaint survey (NY00281549), the facility did not ensure that an alleged violation involving Abuse was reported to the New York State Department of Health (NYSDOH) within the acceptable timeframe. Specifically, one allegation of resident to resident abuse, involving Resident #122 and #203, was not reported within 2 hours. This was evident for 2 of 8 residents reviewed for Abuse (Resident #122 and #203).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant (CNA) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC and hands between residents. This was evident for 1 of 5 floors (Unit - 5B) observed for Infection Control.