Sprain Brook Manor Rehab

In the surveyor’s words

From the most serious findings on record at Sprain Brook Manor Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 13, 2026

  Based 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). […]

• No harm, potential for more than minimal, patternF726Jul 13, 2026

  Based 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] . […]

• No harm, potential for more than minimal, isolatedF550Aug 7, 2026

  Based on observation, record review, and interviews conducted during survey, the facility failed to ensure residents had the right to a dignified dining experience and that staff wore their identification badges while working for two of two residents (Residents #12 and #73) reviewed for dignity. Specifically, 1) Certified Nurse Aide #3 stood over and was not at eye level with Resident #12 while they were feeding Resident #12 their breakfast and 2) Dietary Aide #1, Dietary Aide #2, Certified Nurse Aide #20 and the Director of Social Work were observed without a visible identification badge. The findings include:The policy titled Resident's Rights- Policy and Procedures, revised 03/2025, documented that the facility is committed to protecting and promoting the rights of every resident. […]

• No harm, potential for more than minimal, isolatedF604Jul 13, 2026

  Based 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. The findings are:The facility policy titled Resident Rights dated 2022 documented residents have the right to be free from restraints.Resident #12 had diagnoses of dementia and repeated falls.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #12 was severely cognitively impaired, had trouble sleeping, and displayed no… […]

• No harm, potential for more than minimal, isolatedF550May 14, 2024

  Based 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. The findings are: Resident #95 had diagnoses and conditions including subdural hemorrhage, hemiplegia, and urinary retention. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) dated 4/1/24 documented Resident #95 had moderately impaired cognition; and had an indwelling urinary catheter in place. […]