Dry Harbor Nursing Home

Inspectors wroteBased on staff interview and record review during the Recertification Survey conducted from 04/15/2025 to 04/22/2025, the facility did not ensure that 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 involve abuse or result in serious bodily injury, to the administrator of the facility and the State Survey Agency in accordance with State law through established procedures. This was evident in 1 (Resident #270) of 3 residents reviewed for accidents out of 35 total sampled residents. Specifically, on 01/28/2025, Resident #270 was noted with discoloration and complaint of pain to the left hip. X-ray report showed acute fracture of the left hip. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 04/15/2025 to 04/22/2025 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. This was evident in 1 (Resident #277) of 4 residents investigated for Care Planning out of 38 total sampled residents. Specifically, a care plan to address Osteoporosis was not developed for Resident #277.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/15/2025 to 04/22/2025, the facility did not ensure that services provided or aranged by the facility met professional standards of quality. This was evident in 1 (Resident #27) of 5 residents reviewed for unnecessary medications out of 38 total sampled residents. Specifically, Licensed Practical Nurse #2 failed to administer Resident #27's medications as per physician's order, left the medications on resident's overbed table, and documented that the medications were administered in the Medication Administration Record. Cross reference: F-tag 755 Pharmacy Svcs/Procedures/Pharmacist/ Records

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/15/2025 to 04/22/2025, the facility did not ensure that pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, were provided to meet the needs of each resident. This was evident in 1 (Resident #27) of 5 residents reviewed for unnecessary medications out of 38 total sampled residents. Specifically, the facility did not ensure accurate administration of Resident #27's medications. Medications were left on the overbed table.

Inspectors wroteF583 s/s D Based on observation, record review, and interviews conducted during an abbreviated survey (NY00358147), the facility failed to ensure a resident was treated with respect and dignity including the right to privacy and confidentiality. This was evident in one out of three residents (Resident #4) sampled. Specifically, on 10/22/2024 (time not specified), Certified Nursing Assistant #3 did not obtain consent to record or post Resident #4 on their social media account. On 10/22/2024, Certified Nursing Assistant # 4 reported to Risk Manager #2 that they saw a post on Certified Nursing Assistant #3's Tik Tok social media account with Resident #4. The facility's investigation dated 10/22/2024, included a statement from Certified Nursing Assistant #3 documented they posted Resident #4 on their social media account. This resulted in Past Noncompliance with no potential harm.

Inspectors wroteBased on observation and record review during the recertification survey of 8/24/23 - 8/31/23, the facility failed to distribute and serve food in accordance with professional standards for food service safety. This was evident for 2 (unit 7 and 10) of 9 units observed during the Dining facility task. Specifically, staff failed to clean the residents' hands at the time of meal service and handled straws and drinking cups in a method that does not follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint Survey from 08/24/2023 to 08/31/2023, the facility did not ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health (NYSDOH), but not later than 2 hours after the alleged occurrence. This was evident for 2 (Resident # 292 and #235) of 2 residents reviewed for Abuse out of 35 total sampled residents. Specifically, 1) Resident # 292 had an unwitnessed fall with injury that was not reported to NYSDOH within two hours of occurrence 2) Resident # 235 (NY00305970 ) had an injury of unknown origin, swelling of the face and upper lip bruises, that were not reported to NYSDOH within two hours.

Inspectors wroteBased on observation, interview, and record review, during the recertification survey of 8/24/23 - 8/31/23, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, a care plan was not developed and implemented to address the care needs of a resident receiving comfort measures. This was evident for 1 (#253) of 5 residents reviewed for Nutrition.

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that medication and biologicals were labeled properly with the open date based on professional standards of practice. This was evident for 1 of 9 units reviewed for Medication Storage (Unit 8). Specifically, six open insulin flex pens were not labeled with the open and expiration date.

Inspectors wroteBased on observation and staff interview during the Recertification and Abbreviated survey, the facility did not ensure that medications and biologicals drugs were stored and labeled in accordance with currently accepted professional principles. Specifically, 1). the facility did not ensure that medications were properly labeled with opening date and resident name on the vial, and 2). medication refrigerators were not maintained within acceptable ranges and daily checks were not recorded consistently. This were observed during the Medication Storage and Labeling task on 4 of 10 units. (Units 3, 8, 9 and 10)

Inspectors wroteBased on record review and staff interviews during the Recertification survey and Abbreviated survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter and upon request. This is evident for 1 of 2 residents reviewed for Personal Funds out of a resident sample of 39 residents. (Resident #107)

Inspectors wroteBased on interviews and record review conducted during the Recertification and Abbreviated survey, the facility did not ensure that a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs was developed and implemented. Specifically, a care plan was not developed to address the use of anticoagulant medication. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 39 residents (Resident # 189).

Inspectors wroteBased on record review and staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that a resident's person-centered, comprehensive care plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Specifically, three (3) care plans were not reviewed or revised after the quarterly assessment. This was evident for 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 39 residents (Resident #67).

Inspectors wroteBased on observation, record review and interview during the Recertification survey and Abbreviated survey, the facility did not ensure that resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not ensure that a resident with Intravenous (IV) Heplock line and a resident with a Peripherally Inserted Central Catheter (PICC) line, inserted for antibiotic administration were provided with care and services to prevent infection on the catheter sites. This was evident for 2 of 2 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 39 residents. (Resident #421 and Resident #1. The finding is: The facility policy on PICC line Dressing Change dated 01/2021 documented to prevent external infection of the peripheral or venous catheter; [...]

Inspectors wroteBased on observations and staff interviews during the Recertification survey and Abbreviated survey, the facility did not ensure the infection control practices and procedures to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections were maintained. Specifically, residents' oxygen tubing was observed touching the floor on multiple occasions. This was evident for 2 of 2 residents reviewed for Oxygen out of a sample of 39 residents. (Resident #37 and Resident #68)