Glen Island Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Glen Island Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, patternF686Nov 27, 2024

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

• No harm, potential for more than minimal, patternF610Jan 5, 2026

  Based on record review and interviews during a survey, the facility did not ensure that all alleged violations are thoroughly investigated for 3 out of 3 residents (Resident #2, Resident # 3, Resident #4) reviewed for falls. Specifically, (1) on 11/09/2025 Resident #2 had an unwitnessed fall. The Accident/Incident report was missing the time of supervisor notification and did not document if the Physician and the family representative were notified. In addition, the certified nurse aide occurrence statement had no time the resident was last seen. The top portion of the post occurrence investigation conclusion statement -steps taken that led to conclusion dated 11/10/2025 was not completed. […]

• No harm, potential for more than minimal, patternF580Nov 27, 2024

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

• No harm, potential for more than minimal, patternF690Nov 27, 2024

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

• No harm, potential for more than minimal, patternF725Nov 27, 2024

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