Inspection Reports for Glengariff Rehabilitation and Healthcare Center
141 Dosoris Lane, NY, 11542
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 34
Capacity: 262
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The recertification survey was initiated to assess sufficient nursing staffing and compliance with regulatory requirements.
Findings
The facility did not ensure sufficient nursing staff to meet resident needs, particularly on weekends, as evidenced by Payroll-Based Journal Staffing Data and resident complaints. Staffing assignments did not reflect the Facility Assessment staffing ratios.
Deficiencies (1)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Report Facts
Facility capacity: 262
Resident census: 34
Certified Nursing Assistants assigned: 4
Certified Nursing Assistants required: 5
Licensed Practical Nurses required: 2
Resident units reviewed: 6
Residents in Resident Council Task: 9
Residents reporting complaints: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements regarding Facility Assessment reviews and staffing | |
| Staffing Coordinator | Provided staffing par levels and staffing adequacy statements | |
| Director of Nursing Services | Provided statements on staffing sufficiency and census/acuity considerations |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 21, 2025
Visit Reason
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of May 30, 2025.
Findings
One isolated Level 2 deficiency for free from abuse and neglect, corrected as of May 30, 2025.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as an abbreviated survey from 03/19/2025 through 04/21/2025 following a complaint regarding physical abuse of Resident #1 by Licensed Practical Nurse #1.
Complaint Details
The complaint investigation was substantiated. Video evidence and staff interviews confirmed abuse by Licensed Practical Nurse #1. The nurse refused to provide a statement. Resident #1 had no physical injuries but was involved in an altercation with staff.
Findings
The facility failed to protect Resident #1 from physical abuse when Licensed Practical Nurse #1 was observed on video surveillance pushing Resident #1 backwards in their wheelchair. The nurse was immediately removed from resident care and terminated. Investigations confirmed abuse occurred, though Resident #1 had no physical injuries. Several staff interviews revealed failure to report the incident timely.
Deficiencies (1)
Failure to protect residents from physical abuse by staff, specifically Licensed Practical Nurse #1 pushing Resident #1 in wheelchair.
Report Facts
Residents reviewed for physical abuse: 3
Residents affected: Few residents affected as stated in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in physical abuse finding for pushing Resident #1 and refusing to provide a statement. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Witnessed altercation and intervened to separate Resident #1 and Licensed Practical Nurse #1. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Witnessed incident, did not report altercation, was later attacked by Resident #1. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Conducted assessment of Resident #1 post-incident and was unaware of abuse incident initially. |
| Director of Nursing | Director of Nursing | Investigated incident after viewing video and confirmed abuse by Licensed Practical Nurse #1. |
| Medical Doctor | Medical Doctor | Assessed Resident #1 after incident with no signs of injury. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Sep 27, 2024
Visit Reason
Three isolated Level 2 deficiencies related to investigation, reporting of alleged violations, and services meeting professional standards, all corrected by November 18, 2024.
Findings
Three isolated Level 2 deficiencies related to investigation, reporting of alleged violations, and services meeting professional standards, all corrected by November 18, 2024.
Deficiencies (3)
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Services provided meet professional standards
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 27, 2024
Visit Reason
The inspection was conducted as an abbreviated survey from 9/3/24 through 9/27/24 to evaluate compliance with reporting, investigation, and professional standards related to alleged resident abuse, neglect, and mistreatment incidents.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse and neglect involving Resident #1 and Resident #2. The allegations included bruises of unknown origin and a resident-to-resident altercation resulting in a fall. The facility did not substantiate timely reporting or thorough investigation of these incidents.
Findings
The facility failed to timely report suspected abuse and injuries of unknown origin to the New York State Department of Health for two residents. Additionally, the facility did not thoroughly investigate alleged abuse incidents for two residents, and a Licensed Practical Nurse improperly completed assessments and signed Accident and Investigation reports outside their scope of practice.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or injuries of unknown origin to the state health department for two residents.
Failure to thoroughly investigate alleged violations of resident abuse, neglect, exploitation, or mistreatment including injuries of unknown origin for two residents.
Licensed Practical Nurse serving as Unit Manager completed assessments and signed Accident and Investigation reports outside their scope of practice.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 2
Accident and Incident reports completed by Licensed Practical Nurse Unit Manager: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager Licensed Practical Nurse #1 | Unit Manager Licensed Practical Nurse | Completed accident and incident reports and assessments outside scope of practice; signed as Registered Nurse Supervisor. |
| Certified Nursing Assistant #1 | Observed and reported bruise on Resident #1's face. | |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness and reporting of Resident #1's injury. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported bruise on Resident #1 and informed Unit Manager and Assistant Director of Nursing. |
| Unit Manager #2 | Unit Manager | Documented occurrence and interviewed regarding Resident #1's bruise. |
| Assistant Director of Nursing | Assistant Director of Nursing | Assessed Resident #1 and did not report injury as abuse. |
| Risk Manager | Risk Manager | Reviewed incident reports and interviews regarding failure to report. |
| Administrator | Administrator | Interviewed regarding missing Accident and Investigation reports and video review. |
| Medical Director | Medical Director | Examined Resident #1 and provided medical opinion on bruises. |
Inspection Report
Recertification
Deficiencies: 9
Date: May 7, 2024
Visit Reason
The Recertification Survey and Extended Survey were initiated on 4/29/2024 and completed on 5/7/2024 to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to timely report alleged abuse, incomplete investigations of injuries of unknown origin, delayed medication administration, improper medication storage and documentation, failure to ensure pre-admission screening was completed prior to admission, failure to ensure residents' drug regimens were free from unnecessary medications, and failure to provide timely routine dental care.
Deficiencies (9)
Failure to timely report alleged abuse involving resident-to-resident altercation on 8/11/2023; incident was reported three days late.
Failure to thoroughly investigate injuries of unknown origin for multiple residents, including incomplete staff interviews and delayed investigation summaries.
Failure to administer medications within one hour of ordered time for multiple residents on two units.
Failure to properly account for controlled substances; one tablet of Oxycodone 10 mg remained in blister pack despite zero balance on record.
Failure to ensure pre-admission screening and resident review (PASARR) was completed prior to admission for Resident #18.
Failure to ensure resident environment was free from accident hazards; Resident #531 had an unlabeled inhaler with no physician order and no staff supervision.
Failure to implement consultant pharmacist medication review recommendations; calcium supplement recommended and approved but not ordered or administered for Resident #24.
Failure to ensure drug regimen was free from unnecessary medications; Resident #166 continued to receive Oxybutynin and Benadryl after physician agreed to discontinue.
Failure to provide routine dental care; Resident #127 had dental consult recommending follow-up and medical clearance for tooth extraction but no follow-up or clearance documented until survey completion.
Report Facts
Residents affected by abuse reporting deficiency: 2
Residents affected by injury investigation deficiency: 3
Residents affected by medication administration delay: 14
Residents affected by PASARR screening deficiency: 1
Residents affected by medication storage deficiency: 1
Residents affected by unnecessary medication deficiency: 1
Residents affected by dental care deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nursing Supervisor | Documented accident and incident notes related to resident-to-resident altercation on 8/11/2023. |
| Registered Nurse #6 | Unit Manager | Assessed Resident #530 after fall and started accident investigation. |
| Licensed Practical Nurse #6 | Medication Nurse | Observed administering medications late on 4/29/2024. |
| Licensed Practical Nurse #1 | Medication Nurse | Observed administering medications late on 4/30/2024. |
| Assistant Director of Nursing #2 | Risk Manager | Interviewed regarding injury investigations and reporting requirements. |
| Director of Nursing Services | Interviewed multiple times regarding deficiencies in investigations, medication administration, and dental follow-up. | |
| Physician #2 | Attending Physician | Approved discontinuation of unnecessary medications but did not ensure orders were discontinued. |
| Physician #4 | Interviewed regarding dental medical clearance and follow-up. | |
| Medical Director | Attending Physician | Interviewed regarding medication regimen review and dental clearance. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 7, 2024
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted from 4/29/2024 to 5/7/2024 to assess compliance with regulatory requirements including complaint investigations and extended surveys.
Findings
The facility was found deficient in multiple areas including failure to immediately notify resident representatives of significant changes, delayed reporting of abuse allegations, inadequate investigation of injuries of unknown origin, failure to ensure physician documentation of visits, failure to provide timely hospice referrals, and failure to ensure routine dental care follow-up.
Deficiencies (7)
Failure to immediately notify the resident's designated representative of a significant change in the resident's physical status (Resident #140 fall and hospital transfer).
Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities (Resident #151 and Resident #82 resident-to-resident altercation).
Failure to respond appropriately to all alleged violations including thorough investigation of injuries of unknown origin (Residents #530, #140, and #133).
Failure to ensure physician wrote, signed, and dated progress notes at each visit (Resident #126 stroke-like symptoms).
Failure to provide medically-related social services to help resident achieve highest quality of life, including delayed hospice referral (Resident #380).
Failure to provide routine and 24-hour emergency dental care, including failure to schedule follow-up dental appointment and obtain medical clearance (Resident #127).
Failure to arrange for provision of hospice services or assist resident in transferring to hospice program timely (Resident #380).
Report Facts
Residents reviewed for Abuse: 3
Residents reviewed for Accidents: 6
Residents reviewed for Hospice and End of Life: 1
Residents reviewed for Dental Services: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nursing Supervisor | Named in resident-to-resident altercation investigation and notification failure |
| Assistant Director of Nursing #2 | Risk Manager | Interviewed regarding notification and abuse reporting responsibilities |
| Director of Nursing | Director of Nursing Services | Interviewed regarding notification, abuse reporting, and investigation oversight |
| Licensed Practical Nurse #3 | Medication Nurse | Involved in assessment of Resident #126 with stroke-like symptoms |
| Physician #1 | Physician who examined Resident #126 but did not document progress note | |
| Medical Director | Primary Physician | Resident #126's attending physician, interviewed about lack of documentation |
| Social Worker #1 | Social Worker | Involved in hospice referral delay for Resident #380 |
| Director of Social Work | Director of Social Work | On-call during weekend hospice referral delay for Resident #380 |
| Licensed Practical Nurse #5 | Unit Manager | Responsible for dental consult follow-up for Resident #127 |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Involved in dental consult follow-up for Resident #127 |
| Physician #4 | Physician involved in dental clearance for Resident #127 | |
| Physician #3 | Physician who ordered hospice consult for Resident #380 | |
| Assistant Director of Nursing #1 | Involved in communication with family regarding hospice referral for Resident #380 | |
| Licensed Practical Nurse #1 | Involved in communication with family regarding hospice referral for Resident #380 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
One isolated Level 2 deficiency related to laboratory services, corrected as of July 17, 2023.
Findings
One isolated Level 2 deficiency related to laboratory services, corrected as of July 17, 2023.
Deficiencies (1)
Laboratory services
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The visit was conducted as an Abbreviated Survey to review the facility's provision of laboratory services to meet the needs of residents, specifically focusing on Nutrition/Hydration for selected residents.
Findings
The facility failed to ensure that laboratory blood work ordered for Resident #1 on 3/5/2023 was actually collected and completed. Interviews revealed a breakdown in communication and follow-up between nursing staff and the laboratory, resulting in the lab technician not collecting the blood sample. The facility plans to implement daily reports to identify any labs not completed.
Deficiencies (1)
Failure to provide timely, quality laboratory services/tests to meet the needs of residents, specifically failure to ensure lab work ordered for Resident #1 was completed.
Report Facts
Residents Affected: 3
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse (RN) Supervisor | Identified as the overnight supervisor on 3/5/2023-3/6/2023 and involved in follow-up process for lab work |
| Physician #1 | Physician | Re-interviewed regarding communication about lab work not done |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding lab work process and follow-up policy |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 9, 2022
Visit Reason
The inspection was a Recertification Survey and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and representatives of changes in residents' conditions, late submission of Minimum Data Set (MDS) assessments, inconsistent wound care treatment and documentation, inadequate supervision to prevent accidents, high medication error rates, failure to promptly notify physicians of abnormal lab results, and incomplete facility-wide staffing assessment.
Deficiencies (8)
Failure to notify physician of elevated blood sugar readings for Resident #483 as ordered.
Failure to notify resident's representative of initiation of IV antibiotic therapy for Resident #432.
Failure to electronically transmit Minimum Data Set (MDS) assessments to CMS within required timeframes for 3 residents.
Failure to provide timely and consistent wound care treatment and documentation for Residents #83, #127, and #118.
Failure to provide adequate supervision to prevent accidents; Resident #7 was observed shaving without supervision.
Medication error rate of 60% during medication pass observation; multiple residents received medications late.
Failure to promptly notify ordering physician of abnormal laboratory results for Resident #582.
Facility assessment did not include sufficient detail on staffing resources necessary to meet residents' needs.
Report Facts
Medication error rate: 60
MDS late submission days: 19
MDS late submission days: 32
MDS late submission days: 21
Licensed nurse hours: 4040
Nurse aide hours: 8184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in finding related to failure to notify physician of elevated blood sugar for Resident #483 |
| LPN #3 | Licensed Practical Nurse | Named in finding related to failure to notify family of IV antibiotic therapy for Resident #432 |
| Physician #5 | Physician | Ordered antibiotic treatment for Resident #432; interviewed regarding family notification |
| Medical Director | Medical Director and Primary Care Physician | Interviewed regarding notification expectations and wound care |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed multiple times regarding nursing responsibilities, wound care, medication administration, and staffing |
| LPN #1 | Licensed Practical Nurse | Noted wound on Resident #83 and alerted supervisor |
| ADNS | Assistant Director of Nursing Services | Provided wound care treatment and interviewed regarding wound care process |
| LPN #11 | Licensed Practical Nurse | Observed administering late medications to multiple residents |
| Physician #4 | House Doctor | Ordered lab tests for Resident #582 and interviewed regarding lab result follow-up |
| Primary Physician/Medical Director | Primary Physician/Medical Director | Interviewed regarding lab result notification responsibilities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 25, 2022
Visit Reason
One deficiency related to criminal history record check process with no harm indicated and no correction date provided.
Findings
One deficiency related to criminal history record check process with no harm indicated and no correction date provided.
Deficiencies (1)
Criminal history record check process
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 19, 2022
Visit Reason
One isolated Level 3 deficiency for free from abuse and neglect, corrected as of May 18, 2022.
Findings
One isolated Level 3 deficiency for free from abuse and neglect, corrected as of May 18, 2022.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 11, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations related to resident rights, safety, medication management, and environmental hazards.
Findings
The facility was found deficient in honoring residents' rights to dignity and respect, ensuring a safe environment free from accident hazards, and performing adequate drug regimen reviews. Specific issues included staff speaking foreign languages in residents' presence causing discomfort, a resident locked in a bathroom for 20 minutes due to staff unfamiliarity with door unlocking procedures, and lack of documented rationale for medication risks in one resident's chart.
Deficiencies (3)
Failure to ensure residents were treated with respect and dignity; staff spoke foreign languages and laughed while providing care.
Failure to ensure resident environment was free from accident hazards; resident locked in bathroom for 20 minutes due to staff inability to open door.
Failure to ensure attending physician documented rationale for continued use of medications despite pharmacy-identified risks.
Report Facts
Residents affected: 3
Residents affected: 3
Duration: 20
Medication review date: Sep 13, 2019
Medication consultation date: Sep 18, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing Services | ADNS | Facilitated in-service training on speaking English around residents. |
| Director of Nursing Services | DNS | Initiated in-service trainings on customer service and language use; interviewed regarding staff education and compliance. |
| Director of Recreation | Reported resident discomfort with staff speaking Haitian and attended Resident Council meetings. | |
| Physician | Attending Physician | Interviewed regarding medication risk documentation for Resident #186. |
| Psychiatrist | Interviewed regarding psychiatric consultation and medication risk documentation for Resident #186. | |
| Maintenance staff member | Responded to bathroom door lock incident and opened door with pin-type key. | |
| Certified Nursing Assistant | CNA | Discovered resident locked in bathroom and involved in incident response. |
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