Inspection Reports for Glengariff Rehabilitation and Healthcare Center

141 Dosoris Lane, Glen Cove, NY, 11542

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Inspection Report Summary

The most recent inspection on September 11, 2025, cited a deficiency for insufficient nursing staff, particularly on weekends, and lack of a licensed nurse in charge on each shift. Earlier inspections identified recurring issues with timely reporting and investigation of abuse allegations, medication management, and communication with resident representatives and physicians. Inspectors noted deficiencies related to abuse investigations, staff supervision, medication errors, and failure to provide routine dental and hospice care, along with isolated substantiated abuse confirmed by video evidence in 2025. Complaint investigations were mostly unsubstantiated except for one substantiated case of physical abuse by a licensed practical nurse, who was removed and terminated. The facility’s inspection history shows ongoing challenges with staffing and abuse reporting, with some correction of prior deficiencies but continued citations in key areas.

Deficiencies (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/year

Deficiencies per year

12 9 6 3 0
2019
2022
2023
2024
2025

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
NameTitleContext
AdministratorProvided statements regarding Facility Assessment reviews and staffing
Staffing CoordinatorProvided staffing par levels and staffing adequacy statements
Director of Nursing ServicesProvided 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
NameTitleContext
Licensed Practical Nurse #1Licensed Practical NurseNamed in physical abuse finding for pushing Resident #1 and refusing to provide a statement.
Certified Nursing Assistant #1Certified Nursing AssistantWitnessed altercation and intervened to separate Resident #1 and Licensed Practical Nurse #1.
Certified Nursing Assistant #2Certified Nursing AssistantWitnessed incident, did not report altercation, was later attacked by Resident #1.
Registered Nurse Supervisor #1Registered Nurse SupervisorConducted assessment of Resident #1 post-incident and was unaware of abuse incident initially.
Director of NursingDirector of NursingInvestigated incident after viewing video and confirmed abuse by Licensed Practical Nurse #1.
Medical DoctorMedical DoctorAssessed 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
NameTitleContext
Unit Manager Licensed Practical Nurse #1Unit Manager Licensed Practical NurseCompleted accident and incident reports and assessments outside scope of practice; signed as Registered Nurse Supervisor.
Certified Nursing Assistant #1Observed and reported bruise on Resident #1's face.
Director of NursingDirector of NursingInterviewed regarding awareness and reporting of Resident #1's injury.
Licensed Practical Nurse #1Licensed Practical NurseReported bruise on Resident #1 and informed Unit Manager and Assistant Director of Nursing.
Unit Manager #2Unit ManagerDocumented occurrence and interviewed regarding Resident #1's bruise.
Assistant Director of NursingAssistant Director of NursingAssessed Resident #1 and did not report injury as abuse.
Risk ManagerRisk ManagerReviewed incident reports and interviews regarding failure to report.
AdministratorAdministratorInterviewed regarding missing Accident and Investigation reports and video review.
Medical DirectorMedical DirectorExamined 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
NameTitleContext
Registered Nurse #1Nursing SupervisorDocumented accident and incident notes related to resident-to-resident altercation on 8/11/2023.
Registered Nurse #6Unit ManagerAssessed Resident #530 after fall and started accident investigation.
Licensed Practical Nurse #6Medication NurseObserved administering medications late on 4/29/2024.
Licensed Practical Nurse #1Medication NurseObserved administering medications late on 4/30/2024.
Assistant Director of Nursing #2Risk ManagerInterviewed regarding injury investigations and reporting requirements.
Director of Nursing ServicesInterviewed multiple times regarding deficiencies in investigations, medication administration, and dental follow-up.
Physician #2Attending PhysicianApproved discontinuation of unnecessary medications but did not ensure orders were discontinued.
Physician #4Interviewed regarding dental medical clearance and follow-up.
Medical DirectorAttending PhysicianInterviewed 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
NameTitleContext
Registered Nurse #1Nursing SupervisorNamed in resident-to-resident altercation investigation and notification failure
Assistant Director of Nursing #2Risk ManagerInterviewed regarding notification and abuse reporting responsibilities
Director of NursingDirector of Nursing ServicesInterviewed regarding notification, abuse reporting, and investigation oversight
Licensed Practical Nurse #3Medication NurseInvolved in assessment of Resident #126 with stroke-like symptoms
Physician #1Physician who examined Resident #126 but did not document progress note
Medical DirectorPrimary PhysicianResident #126's attending physician, interviewed about lack of documentation
Social Worker #1Social WorkerInvolved in hospice referral delay for Resident #380
Director of Social WorkDirector of Social WorkOn-call during weekend hospice referral delay for Resident #380
Licensed Practical Nurse #5Unit ManagerResponsible for dental consult follow-up for Resident #127
Registered Nurse Supervisor #2Registered Nurse SupervisorInvolved in dental consult follow-up for Resident #127
Physician #4Physician involved in dental clearance for Resident #127
Physician #3Physician who ordered hospice consult for Resident #380
Assistant Director of Nursing #1Involved in communication with family regarding hospice referral for Resident #380
Licensed Practical Nurse #1Involved 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
NameTitleContext
RN #4Registered Nurse (RN) SupervisorIdentified as the overnight supervisor on 3/5/2023-3/6/2023 and involved in follow-up process for lab work
Physician #1PhysicianRe-interviewed regarding communication about lab work not done
Director of Nursing Services (DNS)Director of Nursing ServicesInterviewed 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
NameTitleContext
LPN #9Licensed Practical NurseNamed in finding related to failure to notify physician of elevated blood sugar for Resident #483
LPN #3Licensed Practical NurseNamed in finding related to failure to notify family of IV antibiotic therapy for Resident #432
Physician #5PhysicianOrdered antibiotic treatment for Resident #432; interviewed regarding family notification
Medical DirectorMedical Director and Primary Care PhysicianInterviewed regarding notification expectations and wound care
Director of Nursing ServicesDirector of Nursing Services (DNS)Interviewed multiple times regarding nursing responsibilities, wound care, medication administration, and staffing
LPN #1Licensed Practical NurseNoted wound on Resident #83 and alerted supervisor
ADNSAssistant Director of Nursing ServicesProvided wound care treatment and interviewed regarding wound care process
LPN #11Licensed Practical NurseObserved administering late medications to multiple residents
Physician #4House DoctorOrdered lab tests for Resident #582 and interviewed regarding lab result follow-up
Primary Physician/Medical DirectorPrimary Physician/Medical DirectorInterviewed 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
NameTitleContext
Assistant Director of Nursing ServicesADNSFacilitated in-service training on speaking English around residents.
Director of Nursing ServicesDNSInitiated in-service trainings on customer service and language use; interviewed regarding staff education and compliance.
Director of RecreationReported resident discomfort with staff speaking Haitian and attended Resident Council meetings.
PhysicianAttending PhysicianInterviewed regarding medication risk documentation for Resident #186.
PsychiatristInterviewed regarding psychiatric consultation and medication risk documentation for Resident #186.
Maintenance staff memberResponded to bathroom door lock incident and opened door with pin-type key.
Certified Nursing AssistantCNADiscovered resident locked in bathroom and involved in incident response.

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