Sprain Brook Manor Rehab

Inspectors wroteBased on observations, interviews, and record review conducted during survey, the facility failed to ensure residents were free from accident hazards for three of five residents (Residents #1, #5 and #12) sampled for accident hazards. Specifically, 1) On 02/07/2026, Resident #5, who was identified as high risk for falls, with a history of falls, had an unwitnessed fall in the dayroom when the day room was not monitored by facility staff. Resident #5 was transferred to the emergency room on [DATE] with a laceration on left side of face, facial fractures, and an acute subarachnoid hemorrhage (medical emergency characterized by bleeding in space between the brain and the tissues that cover it). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a survey, the facility did not ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents. This was evident for two (Residents #1 and #11) of three residents reviewed for staff competency. Specifically, 1) Certified Nurse Aides #2 and #3 did not properly inspect a transfer sling prior to transferring Resident #1 with a mechanical lift. During the transfer, the sling broke, causing Resident #1 to fall on the floor and sustain swelling and bruising to the left side of their face, and 2) Certified Nurse Aide #10 and Certified Nurse Aide #4 were observed transferring Resident #11 with a mechanical lift on [DATE] . [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a survey, the facility did not ensure a resident was free from restraints for one (Residents #12) of 3 residents sampled for restraints. Specifically, Resident #12, an ambulatory resident at risk for falls, was observed with another resident's recliner and a chair positioned to prevent the resident from getting out of bed on 06/28/2026. Resident #12 was observed unable to move freely.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (Resident #95) reviewed for dignity that care was provided in a manner to maintain dignity. Specifically, Resident #95's urinary (Foley) catheter tubing and drainage collection bag were not concealed to prevent direct observation by other residents and their families to maintain dignity and privacy.

Inspectors wroteBased on observations, record review and interviews, during the recertification survey conducted from 5/7/24 to 5/14/24, the facility did not ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for 2 of 4 residents reviewed for accidents. Specifically, (1) Resident #7 had an unwitnessed fall on 3/9/24 and the Fall Care Plan was not updated to reflect new interventions to prevent a fall; (2) Resident #215 had an unwitnessed fall on 4/18/24 and the Fall Care Plan was not updated to reflect new interventions to prevent a fall.

Inspectors wroteBased on observation record review and interviews during the recertification survey conducted from 5/7/24 to 5/14/24, the facility did not ensure treatment and care were provided in accordance with professional standards to meet the needs of one of three residents (Resident #55) reviewed for skin conditions. Specifically, for Resident #55 skin impairments were not identified or reported.

Inspectors wroteBased on observation, record review and interviews during the recertification and abbreviated surveys (NY00328628) conducted from 5/7/24 to 5/14/24, the facility did not ensure residents were provided timely dental services for one of one resident (Resident #13) reviewed for dental services. Specifically, Resident #13's dentures were discovered lost on 6/28/2023, and the resident did not get their dentures replaced until 12/6/2023, six months later.

Inspectors wroteBased on observations and interviews during the recertification survey conducted from 5/7/2024 to 5/14/2024, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, 1) opened perishable food was not covered properly; and 2) expired food was not discarded.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure proper preparation, storage and service of food in accordance with professional standards for food safety. Specifically, perishable foods were not labeled and/or dated, and thermometers used to monitor food temperatures were not properly sanitized.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that one resident (Resident #72) reviewed for urinary incontinence received the necessary care and services to maintain urinary continence. Specifically, urinary incontinence was not identified and a plan of care was not developed to restore bladder continence. The finding is: Resident # 72 was admitted on [DATE] with diagnoses and conditions including acute embolism and thrombosis of right femoral vein, cerebral infarction and muscle weakness. The admission Minimum Data Set (MDS; a resident assessment and screening tool) dated 1/24/19 documented the resident had moderately impaired cognitive skills for decision making; required extensive assist of two people for transfer and toilet use and was always continent of bowel and bladder. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, the trash compactor area was not maintained in sanitary condition. The finding is: An inspection of the trash compactor area was conducted on 2/14/19 at approximately 12:00 PM with the Director of Maintenance (DOM) and Food Service Director (FSD) and revealed a visually estimated two (2) yard by three (3) yard area behind the trash compactor littered with debris. This included pieces of various vegetables, paper and plastic food and beverage containers, utensils, plates, cardboard, and disposable gloves. [...]

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that the Office of the Long Term Care Ombudsman (OLTCO) was given written notice of the transfer or discharge of residents. This was evident for 2 of 4 residents ( residents #32, #71) reviewed for hospitalization.