Split Rock Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Split Rock Rehabilitation and Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF609Sep 10, 2024

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

• No harm, potential for more than minimal, patternF610Sep 10, 2024

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

• No harm, potential for more than minimal, isolatedF609May 20, 2025

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

• No harm, potential for more than minimal, isolatedF880Jun 8, 2022

  Based on observation, interviews, and record review conducted during the Recertification survey from 6/1/2022 to 6/8/2022, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #8) of 1 resident reviewed for respiratory care and 1 (Resident #5) of 4 residents reviewed for pressure ulcers. Specifically, 1) there were multiple observations of Resident #8 with undated oxygen tubing in use; and 2) Registered Nurse (RN) #2 was observed placing a bag of wound care supplies on an unsanitized surface in Resident #5's room and then returning the plastic bag to a medication cart. The findings are: 1) The facility policy titled Oxygen Therapy dated 04/2022 documented all oxygen tubing will be labeled and changed weekly. […]