Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Neck Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of urinary incontinence and other medical conditions was provided with an indwelling urinary catheter at their request, despite no documented clinical indication. Staff proceeded with the insertion based on the resident's wishes and a physician's note, but failed to document any education about the risks or clinical implications of catheter use, and the order lacked details such as catheter size. Facility policy required both a valid clinical reason and resident education prior to catheter insertion, neither of which were met in this case.
Respiratory equipment was not maintained as required for two residents with COPD and other cardiac conditions. Observations and record review showed oxygen and nebulizer tubing remained dated beyond the weekly change schedule, and TARs did not document routine nebulizer tubing changes. Staff stated tubing was supposed to be replaced weekly on the overnight shift, but it had not been done as expected.
Food storage and cold food temperature monitoring were not done according to policy. During a kitchen tour, multiple food items were found undated, unlabeled, or stored open to the air, including pudding, sandwiches, cottage cheese, shredded cheese, and cheese omelets. During lunch service, staff checked only hot foods, while cold items on resident trays were not monitored; sandwiches measured 82°F and 72°F, and the temperature log lacked readings for several cold items.
A resident with significant physical disabilities and cognitive intactness was denied their choice of a shower on their scheduled day, receiving a bed bath from a CNA who acted alone and against the resident's wishes. The CNA, unfamiliar with the resident's care needs and unable to secure help, proceeded with the bed bath despite the resident's refusal, failing to follow the care plan requiring two-person assistance and disregarding the resident's expressed preferences.
A resident with significant mobility deficits was given a bed bath by a single CNA, despite a care plan requiring two-person assistance for bed mobility and bathing. The resident refused the bed bath and requested a shower, but the CNA proceeded alone, causing discomfort and disregarding the resident's preferences and assessed needs. Staff interviews confirmed that the CNA did not seek or receive help, resulting in a deficiency related to inadequate supervision and accident prevention.
A resident with severe cognitive impairment and fragile skin had two skin tears on the forearm. An RN applied Xeroform and gauze after speaking with the wound care nurse, but there was no documented skin assessment, MD order, or treatment record until several days later. The wound care nurse later said the resident was seen with dried scabbing and no dressing, but no progress note or MD notification was made at that time.
Daily staff posting information was not posted daily at the beginning of each shift in a prominent area accessible to residents and visitors. Surveyors observed a posting from an earlier date near the reception area with no posting for the prior day, and an RN supervisor and the DON both acknowledged the posting was not updated as required.
A resident with insomnia, COPD, and an anxiety disorder had a PRN Xanax order without a stop date. The consultant pharmacist noted there was no stop order for Xanax, but the physician did not document agreement or disagreement with the recommendation and instead noted a psychiatry consult. The DON stated the physician was responsible for addressing the pharmacy review, and the Medical Director stated PRN anti-anxiety medications should have a documented stop date.
Call Bell Not Kept Within Reach: A resident with a hx of Ogilvie syndrome, ID, and falls had a BIMS score of 15 and required substantial/maximal assistance with transfers and walking. Despite a care plan calling for the call light to be within reach, surveyors repeatedly observed the call bell rolled up on the night table and out of reach while the resident was in bed. The resident stated the call bell was always on the night table and not within reach, and staff confirmed it should have been accessible.
The facility failed to document necessary interventions and physician notes for hospital transfers and discharges. A resident suffered a cardiac arrest, and there was no record of CPR attempts or a physician's discharge note. Another resident also lacked a physician's discharge summary after being transferred to the hospital. Facility policies require such documentation, but it was not followed, leading to deficiencies identified during the survey.
A facility failed to document fluid drainage for a resident with Ascites as per physician's orders. The resident's medical record lacked evidence of fluid drainage on multiple occasions, despite a policy requiring documentation of the procedure and fluid volume. Interviews with nursing staff revealed lapses in documentation, confirmed by the DON.
A deficiency was identified in the care planning process for a resident with hearing difficulties. The facility failed to update the comprehensive care plan to reflect the resident's use of a hearing aid and their preference to keep it at the bedside. Despite the resident's statement and the facility's policy requiring regular updates, staff were unaware of the hearing aid use, leading to inconsistencies in the care plan and Kardex.
Two residents in an LTC facility were found with inadequate personal hygiene care. One resident, dependent on staff due to conditions like Schizophrenia and Diabetes, had long, dirty fingernails, while another resident with severe cognitive impairment had a dirty right hand. Staff failed to maintain hygiene and document care refusals, leading to deficiencies.
The facility failed to provide adequate pressure ulcer care for three residents, including improper repositioning and incorrect air mattress settings. A resident with a Stage 4 ulcer was not repositioned as required, and two residents had air mattresses set incorrectly for their weights. Staff interviews revealed confusion over responsibilities for monitoring and adjusting air mattress settings, contributing to the deficiencies.
A resident with limited ROM did not receive appropriate treatment as ordered, with a Therapy Carrot device not properly positioned in the resident's hand. Observations showed the device resting on the resident's torso, and staff interviews revealed communication and adherence issues to the care plan. The resident's hand showed signs of poor hygiene, and staff were unaware of the proper device positioning.
A resident with COPD was found with an Albuterol inhaler on their overbed table without a physician's order or assessment for self-administration. Staff interviews revealed a lack of awareness and oversight, as the inhaler was not noticed during medication administration, and the resident had hoarding issues. This indicates a failure in ensuring medication safety and supervision.
Two residents in the facility were not provided with the correct oxygen flow rate as per physician orders. One resident with Parkinson's Disease and other conditions was observed receiving higher oxygen levels than prescribed, and nursing staff could not explain the discrepancy. Another resident with Cirrhosis of the Liver was also found to be receiving more oxygen than ordered, with the LPN admitting to not checking the flow rate. The DON confirmed that it is the nurses' responsibility to ensure the correct oxygen amount is administered.
The facility failed to provide timely professional consultations for two residents. One resident, with a brain bleed, did not receive a recommended neurosurgery follow-up, while another, with depression, did not receive a psychiatric evaluation as ordered. Staff interviews revealed communication and procedural lapses, leading to these deficiencies.
A facility failed to document a resident's daily morning finger stick blood glucose levels as ordered by a physician. The MAR lacked a section for these results, leading to incomplete records for July and August. The resident had spinal stenosis, dementia, and type 2 diabetes, with moderately impaired cognition. Interviews with nursing staff confirmed the absence of a designated documentation area on the MAR.
A deficiency in infection control was identified when a nurse failed to change gloves and wash hands during a dressing change for a resident with a sacral pressure ulcer. The resident, with a history of dementia and diabetes, required specific wound care, but the nurse did not adhere to the facility's hand hygiene and dressing change protocols, as confirmed by nursing leadership.
Two residents' bathrooms had toilets inadequately supported by wooden blocks, posing safety and infection control issues. One resident, with morbid obesity, reported the blocks had been in place for months, while another was unaware of them. Facility staff, including the Director of Facility Management and the Administrator, acknowledged the problem and its risks.
A resident requested a copy of their hospital discharge summary upon readmission to the facility, but the facility failed to provide it within the required timeframe. The Social Worker advised the resident to obtain the records directly from the hospital and did not follow up on the request. The facility's policy for processing medical record requests was not followed, resulting in the resident not receiving the necessary documents for scheduling follow-up appointments.
Indwelling Urinary Catheter Inserted Without Clinical Indication or Resident Education
Penalty
Summary
A deficiency occurred when a resident was provided with an indwelling urinary catheter without a documented clinical indication, contrary to facility policy and evidence-based guidelines. The resident, who had diagnoses including dependence on renal dialysis, benign prostatic hyperplasia, and schizophrenia, was cognitively intact and had previously demonstrated the ability to void freely after a trial without a catheter. Despite this, the resident requested a catheter due to urinary incontinence, and staff proceeded with the insertion based on the resident's wishes and a physician's note, but without a valid clinical justification such as urinary retention, wound care, or hospice care. The facility's policy required that indwelling urinary catheters be used only after assessment and documentation of valid clinical indications, and that staff provide education to the resident regarding the clinical implications and risks associated with catheter use. In this case, the order for catheter insertion did not specify the catheter size, and there was no documentation that the resident was counseled about the risks or clinical implications of catheter use. Interviews with nursing staff and the physician confirmed that the catheter was inserted primarily due to the resident's request and not for a clinical reason recognized by facility policy. Additionally, the medical record lacked evidence of staff providing the required education to the resident prior to catheter insertion. The Director of Nursing Services acknowledged that catheter insertion should be reserved for specific clinical indications and not for convenience. The deficiency was identified during an abbreviated survey, with findings supported by record review and staff interviews.
Respiratory Equipment Tubing Not Maintained Weekly
Penalty
Summary
The facility did not maintain respiratory care equipment, including oxygen and nebulizer tubing, in accordance with its policies and physician orders for two residents receiving respiratory services. The deficiency was identified during observations and record reviews for Resident #200 and Resident #142, both of whom had diagnoses including COPD and heart-related conditions. The facility policies stated that oxygen tubing, nasal cannulas, masks, and nebulizer equipment components were to be changed weekly and labeled, with oxygen equipment also to be maintained under aseptic principles. For Resident #200, the record showed an order for continuous oxygen at 2 liters per minute and PRN albuterol nebulizer treatment. During an observation, the resident was receiving oxygen, and the oxygen tubing was dated 08/25/2025; a nebulizer machine was present with tubing dated 08/25/2024. The TAR showed the last oxygen tubing change was documented on 09/07/2025, and there was no documented evidence of routine nebulizer tubing changes. A later observation showed the oxygen tubing and nebulizer tubing dated 09/14/2025. For Resident #142, the record showed orders for oxygen as needed and ipratropium via nebulizer for COPD. During an observation, the oxygen concentrator and nebulizer machine were present, and both the oxygen tubing and nebulizer tubing were dated 08/25/2025. A later observation showed the nebulizer tubing dated 09/14/2025. Review of the TARs for August and September 2025 showed no documented evidence of routine tubing changes for the nebulizer machine or oxygen concentrator. Staff interviews confirmed that tubing was supposed to be replaced weekly on Sundays during the 11:00 PM to 7:00 AM shift, and the LPN stated they did not realize the tubing had remained dated 08/25/2025.
Food Storage and Cold Food Temperature Monitoring Deficiency
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the initial kitchen tour, several frozen and refrigerated food items were observed without proper dating or labeling, including trays of pudding in a three-door roll-in refrigerator, sandwiches, cottage cheese, pudding, and an open bag of shredded mozzarella cheese in a walk-in refrigerator, and an open bag of shredded cheddar cheese without a label or date. In the freezer section of a combination refrigerator/freezer, a box of cheese omelets was observed with the inner plastic bag open and the product exposed to the air. The Food Service Supervisor stated that food should be labeled and dated and should not be exposed to open air. During lunch meal service in a unit day room, cold food items such as milk, juice, yogurt, and desserts were observed in a container with ice, while sandwiches on resident trays were set up on a mobile rack without ice or another cooling mechanism. Dietary Aide #1 was observed taking and recording temperatures of hot food items only and stated that there was no cold food to be checked. When trays were being prepared for service, a turkey sandwich measured 82 degrees Fahrenheit and a chicken salad sandwich measured 72 degrees Fahrenheit. The temperature log for the unit had no documented temperature readings for puree dessert, regular dessert, cold beverage, juice, or sandwiches for breakfast and lunch.
Resident's Right to Choice in Care Not Honored During Bathing
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Multiple Sclerosis, paraplegia, and acute respiratory failure, was denied their right to make choices about their care. The resident, who was cognitively intact and dependent on two staff members for bed mobility and bathing, requested a shower on their scheduled shower day. Instead, a Certified Nursing Assistant (CNA) assigned to the resident provided a bed bath against the resident's wishes, despite the resident's explicit refusal and request for a shower. The CNA, who was unfamiliar with the resident's care needs and assigned to the unit only once, attempted to provide care alone after being unable to secure assistance from other staff. The CNA admitted to giving the resident a bed bath despite the resident's refusal, citing concern about being written up. During the process, the CNA required the resident to turn to their side, which the resident was unable to do independently, and the CNA proceeded to turn the resident themselves. The resident reported that the CNA was rough during care and did not respect their expressed preferences. Facility policies required that residents' rights, including self-determination and choice in care, be honored, and that two staff members assist with bathing and bed mobility for this resident. Documentation and interviews confirmed that the resident's care plan was not followed, and their preferences were disregarded, resulting in care that was not consistent with the resident's needs or wishes.
Failure to Provide Required Two-Person Assistance During Resident Bathing
Penalty
Summary
A deficiency occurred when a resident, who was assessed to require two-person assistance for bed mobility and bathing due to multiple medical conditions including Multiple Sclerosis, paraplegia, and acute respiratory failure, was provided a bed bath by a single Certified Nursing Assistant (CNA) without the required assistance. The resident's care plan and facility policy both specified the need for two staff members to assist with bed mobility and bathing tasks. Despite this, the CNA proceeded alone, citing that other staff were unavailable and expressing concern about being written up for not completing the task. The resident verbally refused the bed bath, expressing a preference for a shower and stating they could not turn on their side without help. The CNA continued with the bed bath against the resident's wishes and attempted to turn the resident alone, which caused the resident discomfort. The incident was reported by the resident to a recreation aide and subsequently to the Assistant Director of Nursing Services. Multiple staff interviews confirmed that the CNA did not seek or receive assistance from other staff members, despite the resident's documented need for two-person assistance. Documentation and interviews further revealed that the CNA was not familiar with the resident's care requirements and did not review the care instructions prior to providing care. The resident was found to be cognitively intact and able to communicate their preferences and needs. The failure to follow the care plan and obtain the necessary assistance resulted in the resident receiving care that did not align with their assessed needs and preferences, constituting a deficiency in providing adequate supervision and assistance to prevent accidents.
Delayed Documentation and Physician Notification for Skin Tears
Penalty
Summary
The facility did not ensure that treatment and care were provided in accordance with professional standards of practice for a resident with two skin tears to the left forearm. Resident #225 had diagnoses including cerebral infarction, peripheral vascular disease, and colon cancer, and the resident’s MDS documented severely impaired cognition and risk for pressure ulcers/injuries. The care plan identified thin, fragile skin and included fragile skin precautions, and it was later updated to include skin risk assessment and protective/preventative skin care. On 09/11/2025, RN #5 observed two open areas on the resident’s left forearm and applied Xeroform and border gauze after being directed by the wound care nurse, but there was no documented skin assessment, physician order, or treatment record in the chart until 09/16/2025. During interviews, RN #5 stated they notified the wound care nurse and did not notify the physician or enter the assessment or order because they believed the wound care nurse would assess the resident. The wound care nurse stated they were not aware of the forearm skin tears until later, saw the resident on 09/14/2025 with no dressing and dried scabbing, did not document a progress note or notify the physician at that time, and only notified the attending physician when the scab reopened on 09/16/2025.
Daily Staff Posting Not Posted Daily
Penalty
Summary
The facility did not ensure that nurse staff posting information was posted daily at the beginning of each shift in a prominent place readily accessible to residents and visitors. During an observation on 09/14/2025 at 09:00 AM, surveyors found a Daily Staff Posting dated 09/12/2025 near the facility reception area, and there was no Daily Staff Posting for 09/13/2025. During an interview on 09/14/2025 at 01:29 PM, the RN Supervisor #3 stated they were responsible for posting the Daily Staff Posting sheet at the front desk reception area and stated they did not work on 09/13/2025, adding there was no excuse for the actual staff posting not being posted for that day. During an interview on 09/18/2025 at 02:37 PM, the DON stated the RN Supervisors were responsible for ensuring the Daily Staff Posting, including the number of licensed and unlicensed staff, was posted daily, and stated they were unable to explain why the 09/12/2025 posting was still displayed on 09/14/2025.
Physician Did Not Address Pharmacist Review for PRN Xanax Order
Penalty
Summary
The facility did not ensure that the attending physician acted on a consultant pharmacist’s drug regimen review recommendation for Resident #12, who was admitted with insomnia, COPD, and an anxiety disorder and had a BIMS score of 15 indicating intact cognition. The resident’s physician orders from July 2025 through September 2025 included Xanax 0.25 mg, 1 tablet by mouth every 12 hours as needed for anxiety, and the order did not include a stop date. The pharmacist’s review dated 07/07/2025 documented “No stop order for Xanax,” but the physician did not document agreement or disagreement with the recommendation and instead wrote “psychiatry consult” on the review sheet. During interviews, the physician stated they did not want Xanax to become a standing order because the resident had COPD, and that the medication was needed on an as-needed basis, with a stop date that should have been documented. The DON stated the pharmacy review was given to the physician to review and that it was the physician’s responsibility to address the pharmacist’s recommendations. The Medical Director stated that whenever a PRN antipsychotic or anti-anxiety medication is ordered, a stop date should be documented and the medication should be evaluated after that stop date to determine whether it is still needed.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility did not ensure that Resident #201’s call bell was within reach at the bedside. The resident was admitted with diagnoses including Ogilvie syndrome, Intellectual Disabilities, and a history of falls. The Minimum Data Set assessment documented a BIMS score of 15, indicating the resident was cognitively intact, and also documented that the resident required substantial/maximal assistance for transfers from bed to chair and for walking 10 feet. The care plan for risk for falls, dated 08/22/2025, included ensuring the resident’s call light was within reach and encouraging use of the call bell for assistance as needed. During observations on 09/14/2025 and 09/15/2025, the call bell was seen rolled up and placed on the night table out of the resident’s reach while the resident was in bed. On 09/15/2025, the resident stated the call bell was always on the night table and was not within reach, and the resident was not sure why staff put it there. A CNA stated the call bell should be left within reach and said it had been on the bed earlier, but they did not know who moved it. The ADON stated the call bell should have been placed within reach and not curled up on the night table, and the DON stated the call bell should be clipped on the bed or within reach of the resident.
Lack of Documentation for Hospital Transfers and Discharges
Penalty
Summary
The facility failed to ensure proper documentation and justification for the transfer and discharge of residents to the hospital. Specifically, for Resident #413, who suffered a cardiac arrest, there was no documentation in the medical record of the cardiopulmonary resuscitation attempts or the use of an automated external defibrillator. Additionally, there was no discharge note from a physician regarding the necessity of the transfer or the resident's disposition after being transferred to the hospital. Interviews with staff revealed that documentation of the emergency response and transfer was expected but not completed. Similarly, for Resident #414, who also suffered a cardiac arrest and was transferred to the hospital, there was no physician documentation regarding the transfer or discharge. The nursing progress notes indicated that emergency procedures were followed, but the attending physician did not provide a discharge summary, as they were away at the time. The covering physician did not document the discharge either, leading to a lack of proper documentation for the resident's transfer and subsequent death at the hospital. The facility's policies require documentation of interventions during emergencies and physician notes for transfers or discharges, but these were not adhered to in the cases of Residents #413 and #414. Interviews with the Director of Nursing Services and the Medical Director confirmed that there was a lack of clarity and adherence to the protocol regarding physician documentation for hospital transfers, contributing to the deficiency identified during the survey.
Failure to Document Fluid Drainage for Resident with Ascites
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with a physician's order to drain fluids from the abdominal cavity using a Pleurex catheter due to a diagnosis of Ascites. The resident's medical record from July 1, 2024, to July 12, 2024, and from August 1, 2024, to August 3, 2024, showed no documented evidence that the abdominal fluid was drained as per the physician's orders for 11 out of 15 opportunities. The facility's policy required documentation of the resident's response to the procedure and the volume of fluid drained, which was not adhered to. Interviews with the nursing staff revealed that the registered nurses assigned to the resident on specific dates failed to document the amount of fluid drained from the Pleurex catheter on the Treatment Administration Record. The Director of Nursing Services confirmed that it was mandatory for nurses to document this information. The deficiency was identified during a recertification survey, highlighting a lack of adherence to the care plan and documentation requirements for the resident's medical needs.
Deficiency in Updating Resident's Communication Care Plan
Penalty
Summary
During a Recertification Survey conducted from August 1 to August 8, 2024, a deficiency was identified in the facility's care planning process for a resident with communication needs. The facility failed to ensure that the comprehensive care plan for a resident, who was hard of hearing, was updated to reflect the use of a hearing aid and the resident's preference to keep it at the bedside. The care plan, last updated on August 5, 2024, did not include the use of a hearing aid, despite the resident's statement that they used one for their left ear and kept it in their bag at the bedside. This inconsistency was noted during interviews with staff, including a Certified Nursing Assistant and Registered Nurses, who were unaware of the resident's use of a hearing aid. The resident, who was admitted with diagnoses including Morbid Obesity, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease, was documented as cognitively intact with moderate hearing difficulty. The facility's policy required care plans to be person-centered and regularly reviewed and revised to reflect the resident's preferences and needs. However, the care plan and the Kardex were not consistent with the resident's current communication status and preferences. The Director of Nursing Services acknowledged that the care plan and Kardex should be consistent and current, reflecting the resident's preferences, goals, and needs.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary services to maintain personal hygiene. This deficiency was identified during a recertification survey for two residents. Resident #5, who was cognitively intact but dependent on staff for personal hygiene due to conditions such as Schizophrenia, Parkinson's Disease, and Diabetes Mellitus, was found with long and dirty fingernails. Despite being dependent on staff for personal hygiene, there was no documentation of refusal of care, and the staff failed to maintain the resident's nail hygiene. Resident #132, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was observed with a dirty right hand emitting a musty odor. The resident's care plan required staff to maintain personal hygiene, including washing and drying the resident's hands. However, the assigned Certified Nursing Assistant (CNA) was unable to open the resident's hand to clean it properly and did not report the difficulty to the charge nurse, resulting in inadequate hand hygiene. The facility's policy on activities of daily living required individualized care plans based on accurate assessments and documentation of any refusal of care. However, the staff failed to adhere to these guidelines, leading to the observed deficiencies in personal hygiene care for the residents. The Director of Nursing Services acknowledged the lapses in care and the lack of proper documentation and monitoring by the staff.
Deficiencies in Pressure Ulcer Care and Air Mattress Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in treatment and services. Resident #5, who had a Stage 4 pressure ulcer on the sacrum, was not repositioned every two hours as required by their care plan. Despite being observed lying flat on their back multiple times, there was no documentation of refusal to reposition or notification to clinicians for alternative interventions. The resident, who was cognitively intact, expressed discomfort from staying on their back, contradicting the certified nursing assistant's claim that the resident did not like to be on their side. Additionally, the facility did not ensure that the air mattresses for Residents #94 and #201 were set according to their respective weights, as required by physician orders. Resident #94, with a Stage 4 pressure ulcer on the sacrum and an unstageable wound on the right heel, had their air mattress set at 300 pounds, despite weighing 134 pounds. Similarly, Resident #201, with an unstageable wound on the right hip, had their air mattress set at 250 pounds, while their weight was 124 pounds. The facility's policy required the Wound Care Coordinator to monitor and adjust the air mattress settings, but there was no documentation of such monitoring. Interviews with staff revealed a lack of clarity regarding responsibilities for adjusting and monitoring the air mattress settings. Certified Nursing Assistant #6 stated that adjusting the air mattress was the responsibility of the nurses, while Registered Nurse #11 indicated that the Wound Care Coordinator was responsible. The Wound Care Coordinator admitted to not remembering the last time the air mattresses were checked and had no documentation of monitoring. This lack of oversight and adherence to care plans contributed to the deficiencies in pressure ulcer care and prevention.
Failure to Ensure Proper Use of Therapy Device for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease of range of motion. This deficiency was identified for a resident who had a physician's order for a right-hand Therapy Carrot, a device meant to be worn at all times to prevent contractures. Observations on two separate days revealed that the resident was not wearing the Therapy Carrot as ordered, with the device found resting on the resident's torso instead of being positioned in the right hand. The resident's right hand was observed in a closed-fisted position, and there were signs of poor hygiene, including dark crusty flakes and a musty odor. Interviews with staff revealed a lack of adherence to the care plan and communication issues. The Certified Nursing Assistant responsible for the resident admitted to having difficulty placing the Therapy Carrot in the resident's hand but did not report this issue to the charge nurse. The Licensed Practical Nurse and the Wound Care Registered Nurse were also unaware of the proper positioning of the device. The Director of Rehabilitation Services confirmed that the device should be in place at all times and that any difficulties should have been reported. The facility's policy required nursing staff to follow the wearing schedule and conduct skin inspections, which were not adequately performed.
Failure to Ensure Medication Safety and Supervision
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. This deficiency was identified during a recertification survey for a resident with multiple diagnoses, including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease (COPD), and Type 2 Diabetes. The resident was observed with an Albuterol inhaler on their overbed table without any staff present. The resident did not have a physician's order for the inhaler or an order to self-administer medications, and there was no assessment conducted to determine if the resident could safely self-administer their medications. Interviews with staff revealed a lack of awareness regarding the presence of the inhaler in the resident's room. The medication nurse did not notice the inhaler during morning medication administration, and the Assistant Director of Nursing Services was unaware of why the inhaler was in the room. The Director of Nursing Services acknowledged that medications should not be left unattended in a resident's room and noted that the resident had hoarding issues, which may have contributed to the oversight. This situation indicates a failure in the facility's processes to ensure medication safety and supervision for residents.
Inaccurate Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care to two residents, as observed during a recertification survey. Resident #42, who has diagnoses including Parkinson's Disease, Osteoporosis, and Type Two Diabetes Mellitus, was ordered by a physician to receive oxygen therapy at 2 liters per minute via a nasal cannula. However, observations on two separate occasions revealed that the resident was receiving higher oxygen flow rates of 3 and 4 liters per minute. Interviews with nursing staff indicated that the oxygen flow rate was not adjusted by the resident, and there was no clear explanation for the discrepancy. The nursing staff acknowledged the expectation to follow physician orders and to notify the physician if an increased oxygen flow rate was necessary. Similarly, Resident #71, diagnosed with Cirrhosis of the Liver and Ascites, was also ordered to receive oxygen at 2 liters per minute. Observations showed that the resident was receiving 3 liters per minute on two occasions. The LPN responsible for the resident admitted to not checking the flow rate at the start of the shift, which led to the resident receiving an incorrect amount of oxygen. The Director of Nursing Services confirmed that it was the nurses' responsibility to ensure the correct oxygen flow rate was administered as per physician orders, and this should be checked at the beginning and throughout the shift.
Failure to Provide Timely Professional Consultations
Penalty
Summary
The facility failed to ensure timely provision of outside professional services for two residents, leading to deficiencies identified during a recertification survey. Resident #222, who was readmitted from the hospital with a diagnosis of Traumatic Subarachnoid Hematoma, did not receive a recommended follow-up consultation with a Neurosurgeon within the specified timeframe. The hospital discharge instructions clearly indicated the need for this consultation, but it was not scheduled or completed by the facility staff. Interviews with the nursing staff revealed a lack of communication and oversight, as the Registered Nurse Supervisor missed the recommendation, and the Unit Clerk did not receive the necessary consultation form to arrange the appointment. Resident #150, admitted with Major Depressive Disorder, was also affected by the facility's failure to arrange necessary professional services. Despite a physician's order for an initial psychiatric evaluation, the consultation was not completed until several months later. The process for initiating psychiatric consultations involved placing the resident's face sheet in a folder for the Psychiatrist, but this step was overlooked. Interviews with the nursing staff and the Psychiatrist indicated a breakdown in the communication and procedural follow-through, resulting in the resident not being seen for the required evaluation. The facility's policy on medical and dental consults, which outlines the procedure for arranging professional services, was not adhered to in these cases. The Director of Nursing Services acknowledged the lapses in following the hospital discharge instructions and physician orders, which contributed to the deficiencies. The lack of timely consultations for both residents highlights significant gaps in the facility's processes for managing and coordinating necessary medical follow-ups.
Incomplete Documentation of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as evidenced by the case of a resident with a physician's order for daily morning finger stick blood glucose monitoring. The Medication Administration Record (MAR) did not include the results of these glucose level checks, and the Vital Signs record showed inconsistent documentation of the results. This deficiency was identified during a recertification survey conducted from August 1 to August 8, 2024. The resident involved had a history of spinal stenosis, dementia, and type 2 diabetes mellitus, with a moderately impaired cognitive status. Despite a physician's order dated July 14, 2024, for daily morning glucose monitoring, the records for July and August 2024 lacked documented evidence of the glucose results on multiple dates. Interviews with the Assistant Director of Nursing Services and the Director of Nursing Services revealed that there was no designated section on the MAR for documenting these glucose levels, which contributed to the oversight.
Infection Control Deficiency in Wound Care
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. Specifically, a registered nurse failed to adhere to the facility's hand hygiene and clean dressing change protocols during a dressing change for a resident with a sacral pressure ulcer. The nurse did not change gloves or wash hands after cleansing the wound and before applying treatment, which is contrary to the facility's documented procedures. The resident involved had a history of non-Alzheimer's dementia, coronary artery disease, and diabetes mellitus, and was dependent on staff for mobility. The resident had a Stage III pressure ulcer that required specific wound care, including the application of Santyl Collagenase ointment. Despite the presence of the Assistant Director of Nursing Services and the Nurse Educator during the procedure, the nurse did not follow the correct aseptic technique, which was acknowledged by both the nurse and the nursing leadership during interviews.
Inadequate Toilet Support in Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the condition of the toilets in the bathrooms of two residents. Specifically, the toilets in the bathrooms of Resident #131 and Resident #5 were inadequately supported, relying on wooden blocks for reinforcement. This issue was identified during a recertification survey and abbreviated survey. Resident #131, who had diagnoses including Morbid Obesity and Type Two Diabetes Mellitus, required partial/moderate assistance with toileting and was observed using a wheelchair. The resident reported that the wooden blocks had been in place for months. Resident #5, with diagnoses including Chronic Obstructive Pulmonary Disease and Schizophrenia, required two-person assistance for toileting and was unaware of the wooden blocks under the toilet. Interviews with facility staff revealed a lack of awareness and understanding of the situation. Housekeeper #1 was unaware of the reason for the wooden blocks and only cleaned around them. The Director of Facility Management acknowledged the use of wooden blocks due to the residents' weight and mentioned that proper brackets had been ordered but not installed. The Director also recognized the use of wooden blocks as unsafe and posing infection control issues. The Administrator confirmed the use of wooden blocks and believed they had been removed after repairs, acknowledging the potential safety and infection control concerns.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident access to their personal and medical records within the required timeframe, as identified during a recertification survey. Specifically, a resident who was readmitted to the facility from the hospital requested a copy of their hospital discharge summary, which was necessary for scheduling follow-up appointments with specialists. Despite the facility receiving the discharge summary upon the resident's return, the requested document was not made available to the resident. The facility's policy required that requests for medical records be processed through the Social Worker, who would provide a HIPAA authorization form and forward the request to the Medical Record Clerk for further processing. However, this process was not followed, resulting in the resident not receiving the requested records. The resident, who had intact cognition as indicated by a BIMS score of 15, repeatedly requested the discharge summary from the Social Worker but was advised to obtain it directly from the hospital. The Social Worker did not follow up to ensure the resident received the records, and there was no documented evidence of the HIPAA authorization form in the resident's medical record. Interviews with facility staff, including the Social Worker, Medical Record Clerk, Director of Nursing Services, and Administrator, revealed that the resident should have been assisted in obtaining the records and that the facility's procedures were not properly followed, leading to the deficiency.
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What surveyors actually found near you
We read the 302 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Babylon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkshire Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 6 | 1 |
| Our Lady Of Consolation Nursing And Rehabilitive C | 2.8 mi | ★★★★★ | 3 | 1 |
| Massapequa Center Rehabilitation & Nursing | 4.2 mi | ★★★★★ | 0 | 0 |
| Parkview Care And Rehabilitation Center, Inc | 5.1 mi | ★★★★★ | 0 | 0 |
| Daleview Care Center | 6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.