Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glengariff Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide enough nursing staff on a resident unit, with staffing schedules showing fewer CNAs than required by the facility's own assessment. Two residents reported delayed care due to short staffing, and nursing staff described overwhelming workloads and the need to prioritize care, especially on weekends. Facility leadership did not update staffing practices or implement new interventions despite being aware of low weekend staffing.
Resident’s Soiled Incontinence Products Left Visible at Bedside: A resident with intact cognition and frequent bowel and bladder incontinence was observed sleeping in bed with a clear plastic bag tied to the bed rail beside the head, visible from the hallway, containing soiled briefs smeared with feces and used tissues. The resident later did not remember who placed the bag there, and staff interviews confirmed that soiled incontinence products should not be left tied by the resident’s bed.
MDS assessments did not accurately reflect resident status for two residents. One resident with DM and HTN had a 5-Day MDS that missed a significant wt loss, even though the record showed a 6.03% loss in one month and the RD acknowledged the error. Another resident with uropathy and functional urinary incontinence had a quarterly MDS that still indicated an indwelling Foley catheter, despite progress notes showing the catheter had been removed after a successful voiding trial and was not reinserted.
Incomplete Person-Centered Care Plans for Oxygen and Diabetes Management: A resident with COPD and severe cognitive impairment had an order for O2 at 2 L/min continuously, but staff observed the resident on 5 L/min and later 3 L/min, while nurses stated they were responsible for ensuring the ordered setting. Another resident with DM used a personal continuous glucose monitor, but the diabetes care plan did not address the device even though staff knew about it and the resident used it to track blood glucose.
Failure to Provide Timely ADL Assistance: A resident with dementia, Alzheimer’s disease, and severely impaired cognition required staff help with dressing, transfers, toileting, and bathing, but was observed in bed or on the side of the bed without full clothing or morning care completed. CNA staff said they delayed care while assisting other residents first, including those going to dialysis or therapy, and the DON stated residents should not still be waiting for care in the afternoon unless they preferred to stay in bed or refused care.
A resident with intact cognition and diagnoses including AFib, anemia, and muscle weakness had a peripheral IV catheter left in place after IV hydration was completed. Staff found a transparent dressing dated weeks earlier, with no documented order for catheter insertion, flushing, or site monitoring, and no nursing documentation of catheter care. The resident said there was still a needle in the arm and did not recall dressing care, while the charge nurse, physician, and DON all confirmed the line should have been discontinued after therapy ended.
Failure to Order Recommended Nutritional Supplement: A resident with urinary obstruction, SOB, and moderately impaired cognition had significant wt loss documented on MDS and a dietitian recommendation for Two Cal HN BID to provide extra kcal and protein. The supplement was listed in the care plan, but there was no physician order or MAR evidence that it was ever ordered or given, and the RD acknowledged the ordering error.
A resident with obstructive uropathy, BPH, COPD, malnutrition, and moderate cognitive impairment had a Foley catheter, and the MD’s notes and urology consult directed the catheter to be flushed with NS/60 cc. However, no physician order was entered for the flushing, and there was no TAR documentation that nursing performed the flushes. Staff stated a physician order was required before Foley flushing could be done and documented.
A resident with DM2, ESRD, and hypotension had an unlabeled tube of Lidocaine and Prilocaine cream observed on the overbed table in the resident’s room, despite no order for the medication and no self-administration assessment. Surveyors found the medication was not stored in a locked compartment, and staff, including an LPN and the DON, confirmed that unattended meds should not be left in the room.
Inaccurate Foley Catheter Documentation: A resident with a history of obstructive uropathy had a Foley removed after a successful voiding trial, but the physician order, care plan, and CNA task instructions continued to show catheter care even though the resident was voiding in briefs and staff confirmed no catheter was present. An LPN and the physician both stated the catheter was no longer needed, while the DON acknowledged the documentation did not match the resident’s actual needs.
An LPN failed to perform hand hygiene between administering meds to one resident and preparing meds for another resident. The first resident received multiple meds, including Lisinopril, Aspirin, Gapagliflozin, and liquid Haloperidol, and the second resident was being prepared to receive Furosemide when the omission was identified. The nurse acknowledged the lapse, and interviews confirmed that hand hygiene is required between residents during med administration.
Residents and a representative were not shown to have a full understanding of binding arbitration agreements before acceptance. Staff said admission documents were reviewed on a tablet and signatures were prepopulated onto attachments, but one concierge was not very familiar with the process and could not clearly explain the agreement. Several cognitively intact residents said they did not remember signing or did not understand the arbitration agreement, and one resident with severe cognitive impairment had signed with the legal rep space left blank; the family member said they did not sign and would have wanted outside representation in a dispute.
A resident with dementia and full cognition was physically abused by an LPN, who placed hands on the resident's neck and pushed them in their wheelchair. The incident was witnessed by several staff members but was not reported as required by policy. The abuse was only discovered after video review related to a separate staff injury, and the resident's care plan was not updated following the event.
The facility failed to report two incidents involving residents as required by state law. One resident had unexplained bruises, and another was involved in an altercation resulting in a fall. Staff did not report these incidents to the New York State Department of Health within the mandated timeframe, citing confusion over the nature of the incidents and lack of evidence.
The facility failed to investigate alleged abuse and injuries for two residents. One resident had an unexplained facial injury, with inconsistent accounts of its cause, and the facility did not rule out abuse or neglect. Another resident was involved in an altercation resulting in a fall, but no investigation was documented. The facility did not adhere to its policy requiring thorough investigations, leading to repeat deficiencies.
An LPN in a LTC facility was found to be conducting assessments and signing as an RN Supervisor, which is outside their scope of practice. This occurred for 17 accident and incident reports, including one involving a resident with a history of falls and cognitive impairment. The facility's leadership was aware of the issue, but the practice continued due to unclear job descriptions.
The facility failed to thoroughly investigate incidents and injuries of unknown origin for three residents, including a resident found on the floor with a hematoma, another with multiple injuries over several months, and a third with a bruise to the left eye. The investigations were incomplete, lacking statements from key staff and timely conclusions, and did not rule out abuse, neglect, and mistreatment.
The facility failed to administer medications within one hour of the ordered time on two units and did not ensure drug records were in order for controlled substances. Nurses did not seek assistance when running late, and discrepancies were found in the controlled substance administration records.
The facility failed to report a resident-to-resident altercation within the required two-hour timeframe. One resident, with severe cognitive impairment, was allegedly pushed by another resident, resulting in a fall. The incident was reported to the New York State Department of Health three days later, contrary to federal regulations and the facility's policy.
A resident was admitted without the required PASARR screening being completed prior to admission, contrary to the facility's policy. The screening was completed two days after admission, and interviews revealed that the Admission department was responsible for ensuring all pre-admission documents were completed beforehand.
A resident with Asthma, End Stage Renal Disease, and Diabetes was found with an unlabeled inhaler in their room without a Physician's order or assessment for self-administration. Staff interviews revealed that the resident's family brought medications from home, but the facility did not have proper orders or assessments in place.
A resident with severe cognitive impairment did not receive a recommended calcium supplement despite the physician's approval. The facility's staff were unclear about the process for implementing pharmacist recommendations, leading to a breakdown in the medication regimen review process.
A resident continued to receive Oxybutynin and Benadryl despite the physician's agreement to discontinue these medications based on the consultant pharmacist's recommendations. The medications were still administered from February to May, even though they were no longer medically required. Interviews revealed that the physician likely gave verbal orders to discontinue the medications but did not ensure the orders were executed.
A resident did not receive timely follow-up dental care as recommended by a dentist. The resident had to schedule their own appointment, and staff were unaware of the need for follow-up. The facility's Medical Director was not notified for medical clearance, leading to a delay in addressing the resident's dental needs.
A resident with severe cognitive impairment fell and sustained a head injury, requiring hospital transfer. The facility failed to notify the resident's designated representative within the required timeframe, as per their policy. The representative was unaware of the incident until a later visit, and there was no documented evidence of timely notification.
A resident with a history of serious health conditions experienced stroke-like symptoms and was examined by a physician who failed to document the findings. Despite the resident's symptoms, the physician did not observe abnormalities and did not write a progress note, leading to a deficiency in documentation. The resident was later transferred to the hospital and diagnosed with a possible acute Cerebral Vascular Insufficiency.
A resident with advanced cancer was not provided timely hospice services due to the unavailability of the social worker over the weekend. Despite a physician's order and family requests, the hospice referral was delayed until Monday, and the resident passed away shortly after. The facility's social work department failed to communicate and document the referral process effectively.
A resident with advanced cancer and a request for hospice services experienced a delay in receiving a referral due to miscommunication and lack of documentation among facility staff. The resident's family requested hospice care, but the referral was not made promptly, and the resident passed away shortly after the referral was finally initiated.
Deficiency Due to Insufficient Nursing Staff on Resident Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on Unit 2, as identified during a recertification survey. Payroll-Based Journal Staffing Data for the specified quarter showed excessively low weekend staffing, and a review of staffing schedules revealed that the number of Certified Nursing Assistants (CNAs) assigned to Unit 2 frequently fell below the facility's own stated par levels. The Facility Assessment indicated that five CNAs were required for a full census of 39 residents during the day shift, but staffing records showed that only three or four CNAs were often scheduled, even when the census was in the mid-30s. The facility did not update its Facility Assessment to reflect actual census or acuity changes and did not implement new interventions despite being aware of low weekend staffing triggers. Two residents in the Resident Council reported concerns about short staffing, especially on weekends, stating that delayed responses to call bells sometimes lasted up to an hour and affected their care. Anonymous nursing staff also expressed that insufficient staffing led to overwhelming workloads, prioritization of certain residents over others, and the need to stay beyond their shifts to complete care tasks. These staff members indicated that the number of residents assigned per CNA was often too high, impacting the timeliness and quality of care provided. Interviews with facility leadership, including the Administrator, Staffing Coordinator, and Director of Nursing Services, revealed a lack of consensus on staffing adequacy. While the Staffing Coordinator and Director of Nursing Services stated that four CNAs were sufficient for the census levels observed, this contradicted the Facility Assessment and staff feedback. The Administrator acknowledged the discrepancy between the Facility Assessment and actual staffing but maintained that the assessment was only a suggestion and not a requirement. No new measures were taken to address the identified low weekend staffing.
Resident’s Soiled Incontinence Products Left Visible at Bedside
Penalty
Summary
The facility failed to ensure that Resident #5 was treated with dignity and respect when a clear plastic bag tied to the resident’s bed rail was observed beside the resident’s head while the resident was sleeping in bed. The bag was visible from the hallway and contained soiled briefs smeared with feces and used tissues, and there was no staff in the vicinity of the room at the time of the observation. The resident had diagnoses including Type 2 diabetes, end stage renal disease, and hypotension, and the Quarterly MDS documented a BIMS score of 14, indicating intact cognition. The resident also had frequent bowel and bladder incontinence, with care plan interventions for incontinence care, changing clothing after episodes, checking every two hours, and assisting with toileting as needed. The record also included physician orders for Sennoside for constipation and Lactobacillus for diarrhea. During follow-up observation, an empty clear plastic bag was again tied to the resident’s bed rail while the resident was out of bed in a wheelchair in the room, and the resident did not remember who placed the bag there. Staff interviews indicated that the CNA did not place the bag there and that the staff expectation was to dispose of soiled incontinence products immediately rather than leave them tied by the resident’s bed. The RN charge nurse, Infection Preventionist, and DON all stated that soiled incontinence products should not be left tied to the resident’s bed and that the resident’s environment should be kept clean.
MDS Assessments Did Not Accurately Reflect Resident Status
Penalty
Summary
The facility did not ensure Minimum Data Set (MDS) assessments were completed to accurately reflect resident status. During the recertification survey, surveyors identified this issue for one resident reviewed for nutrition and one resident reviewed for urinary catheter or UTI. The facility policy titled MDS Accuracy stated that the information captured on the assessment must reflect the resident’s status during the observation period, and the person completing any portion of the assessment must sign certifying the accuracy of that portion. For one resident with diagnoses including diabetes mellitus and hypertension, the 5-Day MDS documented a height of 67 inches, a weight of 190 pounds, and no weight loss of 5% or more in the last month or 10% or more in the last six months. However, the resident’s weight history showed 202.4 pounds on 07/15/2025 and 190.2 pounds on 08/14/2025, which reflected a 6.03% weight loss in one month. The dietitian stated the resident’s weight should have been documented as a 5% or more loss in the last month, and the chief clinical nutrition manager identified the entry as a data error. The MDS assessor signed the assessment, and the DON stated that the final signature attested to the completion and accuracy of the assessment. For another resident with diagnoses including obstructive and reflux uropathy and functional urinary incontinence, the quarterly MDS documented an indwelling catheter and did not rate urinary continence because of catheter use. Medical records showed a Foley catheter order was discontinued after a voiding trial, and progress notes documented the catheter was removed, the resident was voiding well, and a positive trial of void was achieved. A review of progress notes from June through September showed the Foley catheter was not re-inserted, yet the quarterly MDS still indicated an indwelling catheter. The Director of MDS stated the assessment did not accurately reflect the resident’s bladder function, and the DON stated that all MDS assessments should accurately reflect each resident’s condition.
Incomplete Person-Centered Care Plans for Oxygen and Diabetes Management
Penalty
Summary
The facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and time frames to meet residents’ medical and nursing needs. During the recertification survey, this was identified for a resident receiving continuous oxygen therapy and for a resident using a continuous glucose monitoring device for diabetes management. One resident had diagnoses including COPD, end stage renal disease, pulmonary hypertension, pneumonia, and asthma, and had severe cognitive impairment with a BIMS score of 5. The resident had a physician order for oxygen at 2 liters per minute via nasal cannula continuously every shift. The resident’s comprehensive care plan addressed alteration in respiratory status and included oxygen therapy as ordered and monitoring for COPD symptoms. However, during observations the resident was receiving oxygen at 5 liters per minute and later at 3 liters per minute. Nursing staff stated they were responsible for ensuring the resident received the ordered 2 liters continuously, including when the resident returned from dialysis, but interviews showed staff were busy with other tasks and were not consistently checking the oxygen setting. A second resident had diagnoses including type 2 diabetes mellitus and acute respiratory failure and had intact cognition with a BIMS score of 15. The resident received insulin glargine at bedtime, metformin every 12 hours, and insulin lispro with meals. The resident stated they used a continuous glucose monitoring device obtained through insurance, attached to the upper arm, and that it continuously measured blood glucose and alerted them through a cellphone. The resident said facility staff were aware of the device and that the resident still complied with ordered fingerstick checks. The diabetes care plan included medication administration, education, and dietary consultation, but it did not include the resident’s use of the continuous glucose monitoring device. Staff and the DON stated they did not believe a care plan for the device was needed because the resident used it independently, while the MDS assessor stated a care plan should have been developed because the resident preferred to use the device to manage diabetes.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility did not ensure that a resident who was unable to perform ADLs received the necessary assistance to maintain grooming and personal hygiene. Resident #131 had diagnoses of dementia, Alzheimer’s disease, and unsteady on feet, and the admission MDS documented a BIMS score of 4, indicating severely impaired cognition. The resident also had little interest or pleasure in doing things and felt down, depressed, or hopeless. The care plan and CNA Kardex documented that the resident required supervision for sit-to-stand and upper body dressing and partial assistance from one staff member for lower body dressing, along with assistance with bed mobility, transfers, toileting, and bathing as needed. During observations, Resident #131 was seen in bed or sitting on the side of the bed without being fully dressed and without morning care completed. On one occasion, the resident was wearing a hospital gown and blanket and stated they wanted to get changed but did not know who was supposed to help them. On another occasion, the resident was observed sleeping in bed wearing a gray zippered top and a white brief with no bottom clothing, and remained in that condition later in the day. CNA #2 stated they had not yet provided morning care because they were caring for other residents first, including residents going to dialysis or therapy, and had checked on Resident #131 without providing care because the resident was sleeping. The DON stated CNAs should assist residents with ADLs when required and did not expect residents to still be waiting for care in the afternoon unless they preferred to remain in bed or refused care.
Unremoved Peripheral IV Catheter Lacked Orders and Documentation
Penalty
Summary
The facility failed to ensure that Resident #27 received treatment and care in accordance with professional standards of practice related to a peripheral intravenous catheter. Resident #27 had diagnoses including atrial fibrillation, anemia, and muscle weakness, and the quarterly MDS documented intact cognition with a BIMS score of 15. The resident also had a care plan for high nutrition/dehydration risk and had received IV Dextrose-Sodium Chloride hydration orders on 08/27/2025 and 09/01/2025, each for three days, which were completed on 08/30/2025 and 09/04/2025. On 09/11/2025, the resident was observed in bed with a loose Kling wrap on the left wrist and a transparent dressing on the left forearm covering a peripheral IV catheter dated 08/28/2025, even though the resident was not receiving IV therapy. The resident stated there was a needle in the arm and did not remember when nurses last cared for the dressing, and also stated they had not been receiving IV fluids. The record review found no physician order for insertion of the IV catheter, flushing, or monitoring of the site from 08/27/2025 until 09/11/2025, and the electronic record showed no documentation of catheter care or site monitoring by nursing staff. Staff interviews confirmed the catheter remained in place after IV therapy was completed. The charge nurse stated they were not aware the resident had a peripheral IV line and that it should have been discontinued after therapy ended. The physician stated the dressing should be changed every five days, the line should be flushed daily, and nursing should have called to discontinue the catheter after therapy was completed. An LPN later stated the catheter was removed on 09/11/2025 after the physician gave an order to discontinue it, but the removal was not documented. The DON stated the catheter should have been discontinued on 09/04/2025 after IV therapy was completed and that nursing should have documented the resident’s response, the physician order, and monitoring for signs and symptoms of infiltration and infection.
Failure to Order Recommended Nutritional Supplement
Penalty
Summary
The facility did not ensure that Resident #240 maintained, to the extent possible, acceptable nutritional and hydration status when a recommended liquid nutritional supplement was never ordered. Resident #240 had diagnoses including urinary obstruction and shortness of breath, and the 5-Day MDS documented a BIMS score of 9, indicating moderately impaired cognitive skills for daily decision making. The MDS also documented the resident was 60 inches tall, weighed 115 pounds, and had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months, with no physician-prescribed weight-loss regimen. The Weight Loss Nutrition Note written by Dietitian #2 documented that the resident triggered for significant weight loss during the first month of the stay and recommended Two Cal HN Medication Pass twice daily to provide additional calories and protein. The care plan also included an intervention to provide Two Cal HN BID. However, review of the resident’s physician orders and MARs showed no documented evidence that the supplement was ordered or administered. During interviews, Dietitian #2 stated they made an error and should have entered a physician order for the supplement, and the Chief Clinical Nutrition Manager stated the dietitian should have placed the order in the EMR for physician review and signature.
Missing Physician Order for Foley Catheter Flushing
Penalty
Summary
The facility did not ensure that Resident #246’s medical care was supervised by a Physician when the resident’s Foley urinary catheter was to be flushed with normal saline, but no physician’s order was written for the flushing and there was no documented evidence that nursing staff performed the flushes. Resident #246 was admitted with diagnoses including obstructive uropathy, COPD, malnutrition, and BPH, and had moderate cognitive impairment with a BIMS score of 11. The resident had a Foley catheter, and a physician order dated 03/29/2025 directed Foley catheter care every shift, documentation of urinary output, and monthly and as-needed catheter changes. Physician progress notes and a urology consult documented instructions to flush the Foley catheter, including flush with 60 cc twice a day and flush as needed, but the medical record contained no physician order for catheter flushing. Review of the April 2025 TAR showed no documentation that nursing staff flushed the Foley catheter. During interviews, Physician #2 stated that recommendations in progress notes were communicated to nursing so an order could be entered, but could not explain why no order existed. Nursing staff and the RN supervisor stated that a physician order was required to flush a Foley catheter and that the care should then be documented on the TAR.
Unlabeled Medication Left Unsecured in Resident Room
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored in a locked compartment and properly labeled. During the recertification survey, surveyors observed a tube of unlabeled Lidocaine and Prilocaine 2.5 percent cream on top of a resident’s overbed table in the resident’s room, with no nursing staff in the vicinity. The resident was not assessed to self-administer medications, and the cream was not stored in a locked compartment as required by the facility’s medication storage policy. The resident involved had diagnoses including Type 2 diabetes, end stage renal disease, and hypotension. The resident’s MDS documented a BIMS score of 14, indicating intact cognition, and also noted pain with scheduled pain medications. The resident’s record did not contain a physician’s order for the Lidocaine and Prilocaine cream and did not include a self-administration assessment. Staff interviews confirmed that the resident should not have unattended medications in the room, and the DON stated that all medications should be labeled and stored in a locked compartment.
Inaccurate Foley Catheter Documentation
Penalty
Summary
The facility did not ensure that Resident #7’s medical record was complete and accurately documented after the resident’s Foley catheter was removed for a voiding trial. Resident #7 was admitted with diagnoses including Obstructive and Reflux Uropathy and Functional Urinary Incontinence, and the resident’s cognition was documented as intact. Although the Foley catheter was removed in June 2025 and the physician documented that the resident had a successful voiding trial and did not need the catheter at that time, the physician’s order for Foley catheter care remained active until September 2025. The resident’s comprehensive care plan continued to identify the resident as having an indwelling Foley catheter related to Obstructive Uropathy, and the September 2025 nursing task instruction report continued to direct catheter care, including soap-and-water care, checking for leaks, documenting output, and monitoring for pain and discomfort due to catheter use. The Certified Nursing Assistant accountability record showed catheter care was not performed because it was not applicable, and staff interviews confirmed that the resident did not currently have an indwelling catheter. During interviews, the resident stated they did not have a Foley catheter and voided in their brief. An LPN stated the catheter had been discontinued a while ago and was unaware there was still an active physician order for Foley catheter care. The physician stated the resident did not need a Foley catheter at that time and that the order should have been discontinued. The DON stated the documentation did not accurately reflect the resident’s actual needs and that the care profile should be updated when the resident no longer requires the Foley catheter.
Hand Hygiene Not Performed Between Medication Passes
Penalty
Summary
Provide and implement an infection prevention and control program was cited after a medication administration observation showed that Licensed Practical Nurse #5 did not perform hand hygiene between residents. During the observation on 09/12/2025 at 08:30 AM, the nurse administered medications to Resident #238, who had diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Diabetes, and whose Quarterly MDS documented a BIMS score of 15 indicating intact cognition. The nurse prepared and administered Lisinopril, Aspirin, Gapagliflozin, and liquid Haloperidol, then completed the medication pass for that resident without performing hand hygiene before beginning the next resident's medications. Immediately after finishing with Resident #238, the nurse began preparing medications for Resident #99, who had diagnoses including Cerebral Palsy and Muscle Weakness and a Quarterly MDS with a BIMS score of 15 indicating intact cognition. The nurse opened the medication cart drawer, removed Resident #99's Furosemide blister pack, and popped a tablet into a souffle cup before the surveyor intervened and stated hand hygiene had not been performed. The nurse acknowledged the omission, then used alcohol gel and noted hand hygiene wipes were on top of the medication cart, but continued the medication pass without discarding the prepared Furosemide. Interviews with the ADON/Infection Preventionist, RN Educator, and DON confirmed that hand hygiene was required between residents during medication administration.
Residents Did Not Have Full Understanding of Arbitration Agreements
Penalty
Summary
The facility did not ensure that residents and their representatives had a full understanding of binding arbitration agreements before accepting them. The facility’s policy stated that the nature and implications of the agreement must be explained in a way that ensures understanding, including that the resident may be giving up the right to have a dispute decided in court, and that a signature alone is not sufficient acknowledgement of understanding. The policy also required a verbal acknowledgement of understanding to be documented by staff, and allowed residents or representatives 30 days after signing to review and rescind an agreement not understood at admission. During the survey, the Administrator stated the arbitration agreement was part of the admission packet and that, as of 02/15/2025, all residents had accepted arbitration agreements and none had declined. Concierge staff stated they reviewed admission documents with residents and representatives using a tablet, but one concierge said they were not very familiar with the process and could not specifically explain the agreement. The same staff member stated that the resident would be told they were using arbitration and giving up the right to file a lawsuit in court, and that the signature from the admission packet was prepopulated onto attachments when accepted. Four residents reviewed for the arbitration task stated they did not understand or did not remember signing the agreement. Residents with BIMS scores of 13 and 15 said they did not know what the arbitration agreement was or did not remember signing it; one resident said they were surprised they had accepted it and did not know about the 30-day rescission period. A resident with severe cognitive impairment had signed the agreement, but the legal representative space was blank, and the resident was not easily arousable for interview. The resident’s family member stated they did not sign the tablet to accept the agreement and would have wanted outside representation in the event of a dispute.
Failure to Protect Resident from Physical Abuse by LPN
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) physically abused a resident by placing both hands on the resident's neck and pushing them backwards in their wheelchair. This incident was captured on video surveillance and observed by multiple staff members present at the nurse's station. The LPN was seen pointing a finger at the resident's face before the physical contact occurred. The event was not immediately reported by the staff who witnessed or were aware of the altercation. The resident involved had diagnoses including dementia, major depressive disorder, and obesity, but was documented as having full cognition according to a recent mental status assessment. The resident's care plan identified them as at risk for abuse and included interventions such as prompt investigation of all allegations and ensuring a safe environment. However, the care plan was not updated or amended following the incident, and the required reporting procedures were not followed by staff who witnessed or were aware of the abuse. Interviews revealed that staff members who observed or intervened in the incident did not report the abuse to supervisors as required by facility policy. Instead, attention was initially focused on a subsequent incident in which the resident reportedly attacked a staff member. The abuse was only discovered after video review related to the staff injury, indicating a failure in immediate recognition and reporting of abuse as mandated by facility policy and state regulations.
Failure to Report Abuse and Injury Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, or mistreatment within the required 24-hour timeframe to the New York State Department of Health. This deficiency was identified in the cases of two residents. The first resident was observed with bruises on their forehead and above their right eye, with the cause of the injury unknown. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the state authorities. Interviews with staff revealed a lack of consensus on whether the injury was considered abuse, leading to a failure in reporting. The second resident was involved in an altercation with another resident, resulting in a fall and head injury. The incident was not reported to the New York State Department of Health, as required. The facility's staff, including the Administrator and Director of Nursing, failed to complete an Accident and Investigation report. There was confusion regarding the existence of video evidence of the incident, with conflicting accounts from the Administrator and other staff members about whether the video was reviewed and what it showed. Both cases highlight a breakdown in the facility's internal communication and adherence to reporting protocols. The facility's policy mandates immediate reporting of suspected abuse or injuries of unknown origin, yet these incidents were not reported in a timely manner. The lack of documentation and failure to follow through with required procedures contributed to the deficiency identified during the survey.
Failure to Investigate Alleged Abuse and Injuries
Penalty
Summary
The facility failed to ensure thorough investigations of alleged violations of resident abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, for two residents. Resident #1 was observed with an injury of unknown origin on the right side of their face and eyebrow area. Despite multiple interviews and assessments, the facility did not document a thorough investigation to rule out abuse, neglect, or mistreatment. The resident provided inconsistent accounts of how the injury occurred, and the family member suggested it could be from a bug bite. The medical director noted the resident's propensity for bruising due to fragile skin, but the facility did not conclusively determine the cause of the injury. Resident #2 was involved in an altercation with another resident, resulting in a fall and head injury. The facility did not document an investigation into the incident, and there was no Accident and Investigation report completed. The administrator and director of nursing claimed to have reviewed video footage but did not observe the altercation or fall, leading to a lack of formal investigation. The absence of documentation and investigation into the incident represents a failure to comply with regulatory requirements for reporting and investigating potential abuse or neglect. The facility's policy requires all allegations to be thoroughly investigated, with the administrator responsible for initiating investigations. However, in both cases, the facility did not adhere to its policy, resulting in repeat deficiencies. The lack of documented evidence and failure to conduct comprehensive investigations into these incidents highlight significant lapses in the facility's procedures for handling potential abuse or neglect cases.
LPN Conducts RN-Level Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards by allowing a Licensed Practical Nurse (LPN) to perform duties outside their scope of practice. Specifically, the LPN was serving as a Unit Manager and completed assessments for 17 out of 17 reviewed records following accidents and falls on their unit. The LPN signed their name in the space designated for a Registered Nurse (RN) Supervisor, which is beyond the LPN's scope of practice. The job description for the Unit Manager did not specify who should complete the assessments, leading to this oversight. One of the residents involved, who had a history of falls and mild cognitive impairment, had an accident and investigation form completed by the LPN. The form was incorrectly signed by the LPN as the RN Supervisor, and there was no documented evidence that an RN or physician had completed or signed the assessment. Interviews with the facility's Administrator and Director of Nursing confirmed awareness of the issue, yet the practice continued. The LPN stated they were following the job description provided to them, which included completing accident and investigation forms, but denied completing the assessments themselves, claiming they only documented assessments done by an RN or physician, although no such documentation was found.
Inadequate Investigation of Incidents and Injuries
Penalty
Summary
The facility did not ensure that all incidents, including injuries of unknown origin, were thoroughly investigated. This deficiency was identified for three residents. Resident #530 was found on the floor with a hematoma and skin tears, but the investigation was incomplete, lacking statements from key staff and a timely conclusion. The investigation summary was not completed within the required 5-day timeframe, and the facility failed to rule out abuse, neglect, and mistreatment. Resident #140 had multiple injuries of unknown origin over several months, but the facility did not conduct thorough investigations to identify the root cause or rule out abuse, neglect, and mistreatment. The investigation summaries were incomplete, and statements from staff who provided care within the previous 72 hours were not obtained. The Risk Manager and Director of Nursing Services acknowledged that the investigations were not thorough. Resident #133 sustained a bruise to the left eye, but the facility's investigation was inadequate. The investigation did not include statements from all relevant staff, and the conclusion did not determine how the injury occurred. The Director of Nursing Services admitted that the investigation was not thorough and did not include necessary details to rule out abuse, neglect, and mistreatment.
Medication Administration and Controlled Substance Record Deficiencies
Penalty
Summary
The facility did not ensure that medications were administered within one hour of the ordered administration time on two units during unit observations. Specifically, on Unit 2 in the Glengariff building, three residents did not receive their 9:00 AM medications within the required time frame. Licensed Practical Nurse #6 was observed administering medications at 12:02 PM and stated they were still administering the 9:00 AM medications due to being the only nurse for 39 residents. The nurse did not inform their supervisor about the delay. Similarly, on Unit 1 in the Glengariff building, eleven residents did not receive their 9:00 AM medications within the required time frame. Licensed Practical Nurse #1 was observed administering the 9:00 AM medications at 11:12 AM and stated they did not ask for help despite the time-consuming nature of the task. Both unit supervisors confirmed that the medication nurses should have reached out for assistance if they were running late with medication administration. Additionally, the facility did not ensure that drug records were in order and accounted for all controlled drugs on one unit during the medication storage task. Specifically, the controlled substance administration record for a resident indicated a zero balance of Oxycodone 10-milligram tablets, but the medication blister pack had one tablet remaining. Registered Nurse #1 explained that the remaining tablet was put in the double-locked narcotic box after the medication was discontinued. However, Licensed Practical Nurse #7 erroneously documented the administration of Oxycodone on both the discontinued 10-milligram and the active 5-milligram Controlled Medication Administration Record forms. The Director of Nursing Services stated that discontinued controlled medications should be brought to the Nursing Office and not stored on the units. The facility's policies on medication administration and storage of controlled substances were not followed, leading to delays in medication administration and discrepancies in controlled substance records. The Director of Nursing Services and the Medical Director emphasized the importance of timely medication administration and proper documentation, highlighting the need for nurses to seek assistance when necessary to ensure compliance with the facility's policies.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by federal regulations. Specifically, an incident occurred between two residents, where one resident allegedly pushed the other, resulting in a fall. This incident was not reported to the New York State Department of Health until three days later, despite the requirement to report such incidents within two hours if they involve abuse or result in serious bodily injury. The facility's policy mandates immediate reporting and investigation of such incidents, but this protocol was not followed in this case. Resident #151, who has severe cognitive impairment, was allegedly pushed by Resident #82, who is cognitively intact but has a history of Schizophrenia and involuntary movements. The incident occurred in a shared bathroom, and Resident #151 was found on the floor, complaining of pain and claiming to have hit their head. X-rays later showed no acute fractures. Resident #82 claimed that Resident #151 had pushed them first, and they pushed back in response. A witness, another resident, corroborated that Resident #82 pushed Resident #151, causing the fall. Interviews with staff and residents revealed that there were no prior incidents between the two residents. The Director of Nursing Services acknowledged that the incident should have been reported within two hours, as required. The delay in reporting this incident constitutes a failure to comply with federal regulations and the facility's own policies, leading to the identified deficiency.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that preadmission screening for individuals with a mental disorder and individuals with intellectual disability was conducted prior to their admission. This deficiency was identified for one resident who was admitted with diagnoses of Schizoaffective Disorder Bipolar Type, Major Depressive Disorder, and End Stage Renal Disease. The Level 1 Pre-admission Screening and Resident Review (PASARR) screening for this resident was not completed until two days after their admission to the facility, contrary to the facility's policy which mandates that all residents have the required pre-admission screen prior to admission. The screen was eventually completed and signed by the facility's Director of Social Services after the resident had already been admitted. Interviews with the Co-Director of Admission and the Director of Social Services revealed that the Admission department was responsible for ensuring that all admission documents, including the PASARR forms, were present and completed prior to a resident's admission. The Co-Director of Admission, who was not involved in the resident's admission, stated that the screen should have been completed by the transferring facility and obtained before admission. The Director of Social Services noted the missing screen the day after the resident's admission and completed it the following day. The Administrator confirmed that the admission office should have ensured all pre-admission documents were reviewed and completed accurately before the resident's admission.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility did not ensure that Resident #531's environment remained free of accident hazards, as the resident was not assessed to safely self-administer their medications. An inhaler was observed in Resident #531's room without a label indicating the resident's name or directions for administration, and there was no staff member present. Additionally, Resident #531 did not have a Physician's order for the use of the inhaler. The facility's policy requires that only licensed individuals administer medications and that residents may self-administer only if assessed and deemed capable by the attending physician and interdisciplinary care planning team. Resident #531, who has diagnoses of Asthma, End Stage Renal Disease, and Diabetes, was observed with an unlabeled Breo-Ellipta inhaler brought from home. The resident's Physician's orders did not include this inhaler, and there was no assessment for self-administration of medications. Interviews with staff revealed that the resident's family insisted on bringing medications from home, but the facility did not have proper orders or assessments in place. The Director of Nursing Services confirmed that no medications should be left with a resident without supervision and that all medications must be properly labeled and have a Physician's order for administration.
Failure to Implement Approved Medication Regimen Review Recommendations
Penalty
Summary
The facility did not ensure that the medication regimen review recommendations approved by the physician were implemented. This deficiency was identified for a resident with severe cognitive impairment who was recommended by the consultant pharmacist to start a calcium supplement. Although the physician approved the recommendation, no physician's order was written, and the resident did not receive the supplement. Interviews with nursing staff revealed confusion about the process for implementing pharmacist recommendations, with some staff unsure if a verbal order from the physician was required or if the physician needed to update the electronic medical record directly. The Director of Nursing Services and the Medical Director acknowledged issues with the medication regimen review process, noting that a significant percentage of pharmacist recommendations were not being implemented. The Medical Director mentioned that the pharmacist should alert the physician by phone and place the recommendation in the physician's box, while the physician should instruct the nursing supervisor to make the order change and document it in the progress note. Despite these procedures, the calcium supplement order for the resident was not written, highlighting a breakdown in the facility's process for handling medication regimen review recommendations.
Failure to Discontinue Unnecessary Medications
Penalty
Summary
The facility did not ensure that each resident's drug regimen was free from unnecessary medication. This deficiency was identified for one resident who continued to receive Oxybutynin and Benadryl despite the physician's agreement to discontinue these medications based on the consultant pharmacist's recommendations. The resident, who had severe cognitive impairment and was always incontinent of bladder and bowel, continued to receive Oxybutynin from February to May and Benadryl on several occasions in March and May, even though the medications were no longer medically required. The resident's comprehensive care plan and physician's orders documented the need to discontinue these medications, but the orders were not executed. The physician's progress notes indicated that the recommendations to discontinue the medications were appreciated and agreed upon, but there was no documentation of the actual discontinuation. The resident's medication administration records showed that the medications were still being administered despite the discontinuation orders. Interviews with the attending physician and the medical director revealed that the physician likely gave verbal orders to discontinue the medications but could not recall to whom they spoke. Both the attending physician and the medical director acknowledged that the medications should have been discontinued if they were no longer necessary. The medical director emphasized that it was the physician's responsibility to ensure that the medication discontinuation orders were executed.
Failure to Ensure Timely Follow-Up Dental Care
Penalty
Summary
The facility did not ensure that Resident #127 received timely follow-up dental care as recommended by a dentist. The resident, who had diagnoses including Dysphagia, Obesity, and Diabetes Mellitus, was seen by a dentist on 3/18/2024. The dentist recommended a follow-up visit in one week for tooth extraction, requiring medical clearance to stop Aspirin. However, there was no documented evidence that these recommendations were addressed until 5/7/2024. Interviews with the resident and staff revealed a lack of communication and follow-through regarding the dental recommendations. The resident stated that they had to call the dental office themselves to schedule the follow-up appointment. Licensed Practical Nurse #1 and Registered Nurse Supervisor #2 were unaware of the need for a follow-up appointment, and Licensed Practical Nurse #5, who was responsible for scheduling, did not review the dental consultation form or schedule the necessary follow-up. The facility's Medical Director and other physicians were not notified to provide the required medical clearance for the dental procedure. The Director of Nursing Services confirmed that nursing supervisors should have reviewed and addressed the dental recommendations promptly. The failure to ensure timely follow-up care resulted in a delay in addressing the resident's dental needs.
Failure to Notify Resident's Representative of Significant Change
Penalty
Summary
The facility failed to immediately notify the designated representative of a resident following a significant change in the resident's physical status. On 3/17/2024, a resident with severe cognitive impairment, diagnosed with Dementia with Psychotic Disturbance, Anxiety Disorder, and Depression, fell and sustained a scalp laceration after hitting their head on a radiator. The resident was subsequently transferred to the hospital for evaluation. Despite the facility's policy requiring notification of the resident's representative within 24 hours of such incidents, there was no documented evidence that the representative was informed until two days later, on 3/19/2024. Interviews conducted during the survey revealed that the designated representative was not aware of the incident until they visited the resident on 3/26/2024. The representative stated they did not receive any communication from the facility on the dates in question. The Assistant Director of Nursing and the Director of Nursing confirmed that it was the responsibility of the Registered Nurse Supervisor to notify the resident's representative and document the communication in the medical record. However, the Registered Nurse Supervisor responsible for the notification was unavailable for an interview.
Physician Documentation Deficiency During Resident's Stroke-Like Episode
Penalty
Summary
The facility failed to ensure that a physician wrote, signed, and dated a progress note at each required visit, as evidenced during a recertification and extended survey. This deficiency was identified in the case of a resident who experienced stroke-like symptoms on a specific date. Although a physician examined the resident, no documentation of the examination findings was recorded in the resident's medical record. The resident was subsequently transferred to the hospital by emergency medical services and diagnosed with a possible acute Cerebral Vascular Insufficiency. The resident, who was cognitively intact, had a history of End Stage Renal Disease, Diabetes Mellitus, and Depression. On the day of the incident, the resident reported symptoms such as numbness in the hand and slurred speech to a Certified Nursing Assistant, who then notified a Licensed Practical Nurse. The nursing supervisor was informed, and a physician on the unit was asked to examine the resident. Despite the examination, the physician did not document any findings, as they did not observe any abnormalities and deferred further action to the resident's Primary Physician. Interviews with facility staff, including the Medical Director and the Director of Nursing Services, confirmed that the physician who examined the resident should have documented the assessment in the medical record. The lack of documentation was a clear violation of the facility's policy and regulatory requirements, as it failed to provide a complete and accurate account of the resident's condition and the care provided during the incident.
Failure to Provide Timely Hospice Referral for Resident
Penalty
Summary
The facility failed to provide medically-related social services to Resident #380, who was admitted with a diagnosis of advanced stomach cancer, dysphagia, and depression. The resident's care plan included comfort measures and a do-not-resuscitate order. On a Saturday, the resident's designated representative requested a hospice service referral, which was ordered by the physician. However, the facility's social worker or designee was unavailable to process the referral until the following Monday. During the weekend, the family member communicated with the nursing staff about the resident's declining condition and the need for hospice services. Despite this, the social worker on call did not follow up with the family or facilitate the hospice referral. The Director of Social Work was aware of the family's interest in hospice care but did not act on the physician's order for a hospice consult. The referral was finally made on Monday, but the resident passed away shortly after, before the hospice services could be initiated. Interviews with the social worker and the Director of Social Work revealed a lack of communication and documentation regarding the hospice referral. The social worker admitted to rushing the referral process and failing to document it properly. The facility's administrator confirmed that the social work department is responsible for initiating hospice referrals and ensuring follow-up on physician orders. This deficiency highlights a failure in the facility's process for timely hospice referrals, impacting the resident's end-of-life care.
Delayed Hospice Referral for Resident
Penalty
Summary
The facility failed to ensure that a resident, who requested hospice services, was provided with the necessary referral in a timely manner. Resident #380, who was diagnosed with advanced gastric adenocarcinoma, dysphagia, and depression, had a designated representative who requested hospice services. Despite the request being made, the referral was delayed, and the resident passed away shortly after the referral was finally made. The facility's policy on Comfort Care and Palliative Care did not adequately address the criteria for hospice referral or the procedure to transfer residents to a hospice program. This lack of clarity contributed to the delay in providing hospice services to Resident #380. The resident's care plan included directives for comfort measures and do-not-resuscitate orders, indicating the need for hospice care, yet the facility did not act promptly on the family's request. Interviews with facility staff revealed a breakdown in communication and responsibility. The Assistant Director of Nursing acknowledged the request for hospice services but indicated that the social work department was responsible for making the referral. However, the social worker did not document or act on the request over the weekend, and the Director of Social Work was not aware of the physician's order for a hospice consult. This miscommunication and lack of documentation led to the failure to provide timely hospice care for Resident #380.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 947 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glen Cove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerge Nursing And Rehabilitation At Glen Cove | 0.7 mi | ★★★★★ | 0 | 0 |
| Glen Cove Center For Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 6 | 0 |
| The Amsterdam At Harborside | 4.2 mi | — | 0 | 0 |
| Sands Point Center For Health And Rehabilitation | 4.2 mi | ★★★★★ | 8 | 0 |
| Sunharbor Manor | 6.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.