Split Rock Rehabilitation and Health Care Center

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00373021), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in one (1) out of five (5) residents sampled (Resident #1). Specifically, on 02/26/2025 at approximately 3:30 PM, Resident #1 reported to Social Worker #1 that they were missing seven thousand dollars, and that Certified Nursing Assistant #1 took their money during care. The facility completed their investigation on 03/11/2025 and submitted the findings to New York State Department of Health on 03/11/2025 at 4:23 PM. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 09/03/2024 to 09/10/2024, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations of abuse were made to the New York State Department of Health. This was evident in 1 (Resident #140) of 4 residents reviewed for Abuse out of 36 total sampled residents. Specifically, 1.) On 09/03/2023, Resident #140 alleged that they were inappropriately touched by a staff. 2.) On 09/05/2024, Resident #140 alleged that, months ago, they were sexually assaulted by a male Certified Nursing Assistant who worked on the evening shift. The facility did not report both allegations to the New York State Department of Health.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 09/03/2024 to 09/10/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #140) of 4 residents reviewed for Abuse out of 36 total sampled residents. Specifically, 1.) On 09/03/2023, Resident #140 alleged that they were inappropriately touched by a staff. The facility investigation did not address the allegation. 2.) On 09/05/2024, Resident #140 alleged that, months ago, they were sexually assaulted by a male Certified Nursing Assistant who worked on the evening shift. There was no documented evidence that the allegation was investigated.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #8) of 1 resident reviewed for respiratory care and 1 (Resident #5) of 4 residents reviewed for pressure ulcers. Specifically, 1) there were multiple observations of Resident #8 with undated oxygen tubing in use; and 2) Registered Nurse (RN) #2 was observed placing a bag of wound care supplies on an unsanitized surface in Resident #5's room and then returning the plastic bag to a medication cart.

Inspectors wroteBased on observations and interviews during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, dirty chairs were observed on the 4th floor, broken furniture and privacy curtains loosely hung with missing hooks on the 3rd floor (Rooms 329, 330, 331, 332, 337). This was evident for 4 out of 6 units reviewed for Environmental Observations (Units 3 North, 3 South, 4 North, and 4 South).

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, (1) the Minimum Data Set (MDS) assessment incorrectly coded a resident received dialysis when they did not and (2) the MDS did not capture a resident's hand mitten as a restraint. This was evident for 3 out of 38 sampled residents (Resident #s 223, 143, and 165). The facility policy for MDS Completion /Transmission revised/reviewed 10/2018 documented every department will be responsible for accurate completion of assigned MDS sections.

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, the robot coupe R6N was still covered with grime and debris after staff cleaned it. This was evident for the Kitchen Observation task. The finding is: On 08/16/19 at 04:26 PM and 08/19/19 at 03:28 PM, the robot coupe was observed with brown grime around the on and off knobs. On 08/19/19 at 03:28 PM, the Dietary Aide (DA) was interviewed. The DA stated equipment is cleaned and sanitized at night and sanitized in the morning before use. The DA was observed cleaning the robot coupe, with a toothbrush brushing around the metal pole in the center of the base. The DA wiped the base with soap and water, sanitized, and wiped the dry. The DA stated that the substance around the knobs was rust and discoloration. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did ensure that Infection Control protocols were maintained to help prevent the development and transmission of communicable disease and infections. Specifically, (1) a Respiratory Therapist (RT) did not practice appropriate hand hygiene before and during Tracheostomy care for two residents (Resident #155 and #116); and, (2) a Licensed Practical Nurse did not practice appropriate hand hygiene during a dressing change (Resident # 125). This was evident for 2 of 2 residents observed during Tracheostomy care and 1 of 2 residents observed during wound care out of a sample of 38 residents.

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect during care. Specifically, during an observation of Tracheostomy care, the Respiratory Therapist failed to knock on the door before entering the resident's room. This was evident for 1 of 2 residents reviewed for Dignity (Resident #155). The finding is: The facility policy entitled Dignity, Privacy and Confidentially dated 8/20/2019 documented: it is our policy to provide care and services to residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. It is our policy to maintain residents personal privacy and confidentiality, in all care and communication settings. [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was provided with personal privacy during care. Specifically, during observations of Tracheostomy care and suctioning for two residents, the Respiratory Therapist did not close the door and draw the curtain. This was evident for 1 of 3 residents reviewed for Ventilator/Tracheostomy (Resident #155) and one random observation (Resident #116).

Inspectors wroteBased on observations, record review and interviews, the facility did not develop and implement a Comprehensive person-centered Care Plan that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, no care plan to address the care concerns for restraint use was developed for a resident with a hand mitten (Resident #165). The finding is: The facility policy entitled Physical Restraints documented under the section Philosophy All residents with restraints will be monitored for continued need and justification as need arises. Documentation by nursing and physician shall state the medical symptom requiring the needs for the restraint and the need for the restraint and the continued use in the CCP and all other relevant documentation. [...]