Glen Island Center for Nursing and Rehabilitation

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that residents had the right to formulate advance directives that would be honored. This was evident for two (2) of three (3) residents (Resident #10, #28) reviewed for Advance Directives out of total 38 sampled residents. Specifically, the facility did not ensure Resident #10 and Resident #28's advance directive wishes were accurately reflected in the medical record.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident for one (1) (Resident #16) of two (2) residents reviewed for rehabilitation and restorative services out of a total sample of 38 residents. Specifically, Resident #16 was observed without a left-hand splint in place as per physician order.

Inspectors wroteBased on record review and interviews, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for three (3) of three (3) residents (Resident #95, #204, and #205) reviewed for Beneficiary Notification out of total 38 sampled residents. Specifically, the facility did not ensure the resident/representative received timely written Notice of Medicare Non-Coverage of potential liability and appeals rights.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that Minimum Data Set 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Internet Quality Improvement Evaluation System (IQIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, resident's Quarterly, Discharge and comprehensive Minimum Data Set were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for, but not limited to, 3 of the 12 residents reviewed for Resident Assessment. (Residents #19, #32 and #48), out of a total of 38 sampled residents.

Inspectors wroteBased on record review and interviews during an abbreviated survey (2654597) the facility did not ensure the residents right to a dignified existence the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 out of 3 residents (Resident #5) reviewed for dignity. Specifically, on 12/05/2025 the Surveyor observed Certified Nurse Aide #2 providing personal care to Resident #5 with the door to their room open. Resident #5 was observed lying in bed, without a shirt on, and was noted to be exposed from the waist up and visible from the hallway.

Inspectors wroteBased on record review and interview during an abbreviated survey and partial extended survey (NY00349917), the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent new ulcers from developing and promote healing of facility acquired pressure ulcers for 3 out of 5 residents (Resident #1, #7, #8) reviewed. Specifically, (1) Resident #1 was admitted to the facility with intact skin and was identified as a low risk for pressure ulcer development. Interventions/measures ordered by the physician to prevent pressure ulcer development were not consistently provided by direct care staff and Resident #1 developed a facility acquired pressure ulcer to their sacrum and bilateral heels. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00349917, NY00347905) and a partial extended survey the facility did not ensure the residents representative was informed of a significant change in the resident's physical status or a need to alter treatment significantly for 3 out of 4 residents (Resident #1, Resident #6, Resident #7) reviewed for notification of changes. Specifically, (1) Resident #1 developed multiple facility acquired pressure ulcers to their right buttocks on 6/20/2024 and bilateral heels on 6/25/2024. There was no documented evidence that Resident #1's representative was notified of these changes in the resident's condition until they inquired about them on 6/26/2024 and 7/1/2024. (2). Resident #6 developed a facility acquired sacral pressure ulcer on 7/27/2024. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00347905) the facility did not ensure that a resident with urinary incontinence received appropriate treatment and services for 4 out of 4 residents (Resident #6, #9, #3, #4) reviewed for incontinence care. Specifically, (1) Resident #6 was incontinent and was dependent on direct care staff for toileting. Review of Resident #6's certified nurse assistant accountability report for July and August 2024 revealed numerous signature omissions for bladder incontinence care indicating care was not provided by direct care staff. (2) Resident #9 was known to be frequently incontinent of urine and always incontinent of bowel. [...]

Inspectors wroteBased on record review and interview during a partial extended survey (NY00349917, NY00347905), the facility did not provide sufficient nursing staff to consistently meet the needs of all residents. The Facility Assessment resident to staff ratios (certified nurse assistant) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the unit staff assignment sheets for June 2024, July 2024, August 2024 and September 2024 revealed staffing was not adequate across various shifts based on the unit needs and the staffing needed as documented in the facility assessment.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure the comprehensive care plans were reviewed and revised in a timely manner for 2 of 4 residents (Resident #7, Resident #8) reviewed for care planning. Specifically, Resident #7 developed a facility acquired stage II pressure ulcer to their right buttocks on 8/21/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer. (2) Resident #8 developed a facility acquired stage III pressure ulcer to their sacrum on 8/14/2024. There was no documented evidence of the potential for pressure ulcer development care plan being revised to reflect the actual pressure ulcer.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00349917, NY00347905), the facility did not ensure a performance review was completed for every nurse aide at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews for 2 of 7 records reviewed. Specifically, (1) Certified Nurse Assistant #7 with a date of hire of 4/28/2015 had no documented annual performance evaluations prior to 11/22/2023 and none for 11/22/2024. (2) Certified Nurse Assistant #8 with a date of 8/1/2014 did not have any documented annual performance evaluations in their personnel file prior to 11/22/2023 and none foe 11/22/2024.

Inspectors wroteBased on record review and interviews during an abbreviated and partial extended survey (NY00349917, NY0034705), the facility did not ensure the Quality Assessment and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, (1) there were no documented evidence of the facilities actionable plans being implemented for their identified facility acquired pressure ulcer issue; (2) there was also no documentation of the continued performance improvement plan for 2 areas discussed in the 2nd quarter meeting.

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 6/10/24-6/14/24, the facility did not ensure that for 1(Resident #57) of 5 residents reviewed for environment, they were provided with reasonable accommodations of needs and preferences. Specifically, the call bell system designated for Resident #57 whom has left sided weakness, was observed not within the resident's reach, on multiple occasions.

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 6/10/2024 to 6/14/2024, the facility did not ensure the development of comprehensive person-centered care plans that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 3 (Residents #47, #51, and #66) of 35 residents reviewed for comprehensive care plans. Specifically, (1) for Resident #47, the facility did not ensure a comprehensive care plan was developed to address the use of indwelling urinary catheter; [...]

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #57) of 5 residents reviewed for Unnecessary Medications. Specifically, Resident #57 was no longer receiving Lorazepam effective 8/4/23 and Apixaban effective 4/8/22 which was replaced with Xarelto on 4/8/22, and the Care Plans were not updated and revised to reflect the discontinuations and the changes with the medications.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated surveys (NY00330768) from 6/10/24 to 6/14/24, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #340) reviewed for skin impairments. Specifically, the Treatment Administration Record for Resident #340 revealed the treatments ordered by the physician were not administered as per order.

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey from 6/10/24 to 6/14/24, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for 2 of 4 residents (Resident #51 and Resident #46) reviewed for position and mobility. Specifically, 1. Resident #51 was observed on 3 occasions without bilateral palm guard and soft hip abductor in place, and 2. Resident #46 was observed without bilateral resting hand splints or palm guard in place.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 6/10/24-6/14/24, the facility did not ensure all residents were provided the appropriate treatment and services to achieve or maintain as much normal bladder/bowel function and prevent urinary tract infections to the extent possible for 1(Resident #66) of 1 residents reviewed for bladder/bowel. Specifically, Resident #66 was not toileted every 2 hours and as needed as per their plan of care.

Inspectors wroteBased on interview and record review conducted during a recertification survey from 6/10/24-6/14/24, the facility did not provide an influenza vaccination for 1 (Resident #19) of 5 residents reviewed for Influenza vaccination after screening and consent was obtained. Specifically, Resident #19 had consent for Influenza vaccine dated 11/29/23 and did not receive the vaccine for the 2023-2024 flu season.