Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Good Samaritan Nursing And Rehabilitation Care Ctr during CMS and state inspections, most recent first.
Inaccurate MDS Documentation of Restraint Use: An MDS assessment incorrectly stated that a resident used a physical restraint in a chair or out of bed, even though the resident was observed in a Geri chair with no restraint. Record review found no physician orders or care plan evidence of restraint use, and staff confirmed the Geri chair was used for positioning, fall risk reduction, and skin integrity rather than as a restraint.
A resident with frontotemporal dementia and depression was observed seated in a Geri chair, but the CNA plan, physician orders, and CCP did not document the resident’s out-of-bed status. Record review showed the resident transferred dependently with a Hoyer lift and two staff, and the Rehab Coordinator and DON stated the Geri chair should have been documented in the ADL CCP.
Unsecured and Expired Medications Found at Bedside: A resident with angina, HTN, and IBS had a bottle of Dicyclomine and a bottle of Nitroglycerin on the nightstand despite being assessed as not able to self-administer meds and having no order for Nitroglycerin or self-administration. The Dicyclomine bottle was also expired. Staff confirmed the meds should have been kept in the locked med cart, not in the resident’s room.
Failure to follow Enhanced Barrier Precautions was identified when a CNA provided hands-on care to a resident with dementia, chronic respiratory failure, incontinence, and wounds without wearing a gown as required. The resident had an order, care plan, CNA instructions, and posted signage directing staff to wear gowns and gloves for high-contact care such as dressing, brief changes, bathing, and hygiene care, but the CNA stated they forgot to put on a gown while giving care.
A resident with impaired cognition and on antiplatelet medication was found with a dressing on the forearm with dried blood from an open purpura. An LPN applied the dressing without conducting a skin assessment, notifying the physician, or obtaining a treatment order, contrary to facility policy. The DON confirmed the LPN should have followed proper procedures.
Two residents were found with medications improperly stored and administered. One resident had an unlabeled Hydrocortisone lotion without a physician's order, while another had a cup of tablets left unattended after requesting to take them post-breakfast. Staff interviews revealed a lack of awareness and adherence to the facility's medication storage policies.
A resident at risk for falls was found on the floor in the dining room. An LPN, instead of calling an RN for assessment, picked the resident up and placed them back in their wheelchair, violating facility protocol. The resident was later found to have a laceration and ecchymosis. Staff interviews confirmed the LPN's acknowledgment of the mistake, highlighting a neglect of resident rights.
Inaccurate MDS Documentation of Restraint Use
Penalty
Summary
The facility did not ensure the Minimum Data Set (MDS) assessment accurately reflected Resident #7’s status. The quarterly MDS assessment dated [DATE] incorrectly documented that the resident used a physical restraint in a chair or out of bed, even though the resident was observed seated in a Geri chair in the main dining room with no physical restraint. Resident #7 had diagnoses including frontotemporal dementia and depression, and the MDS documented severely impaired cognitive skills for daily decision making. Record review showed no physician orders from January 2025 through March 2026 documenting use of physical restraints, and the resident’s comprehensive care plan also contained no evidence of restraint use. The annual Rehabilitation Screen dated 11/06/2025 identified the resident’s wheelchair type as a Geri chair, with no documentation that it was used as a restraint. Staff interviews confirmed the resident did not use restraints: the Rehabilitation Coordinator stated the Geri chair was used for positioning, fall risk reduction, and skin integrity, the MDS Coordinator stated the restraint entry on the quarterly MDS was a mistake, and the DON and Administrator stated the MDS information was expected to be accurate.
Comprehensive Care Plan Did Not Reflect Resident’s Geri Chair Status
Penalty
Summary
The facility did not ensure that Resident #7 had a person-centered Comprehensive Care Plan that accurately reflected the resident’s out-of-bed status and included measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs. Resident #7 had diagnoses including frontotemporal dementia and depression, and the quarterly MDS documented severely impaired cognitive skills for daily decision making. During an observation, the resident was seated in a Geri chair in the main dining room without a physical restraint, but the resident’s CNA Plan of Care, initiated on 01/03/2025 and last reviewed on 12/04/2025, did not show evidence of being out of bed to a Geri chair. Record review also showed that the Rehabilitation to Nursing Correspondence form dated 01/04/2025 documented the resident transferred dependently with a mechanical Hoyer lift with two people, but the current physician orders renewed on 03/16/2026 did not document the resident’s out-of-bed status. Review of the entire Comprehensive Care Plan found no documentation that the resident was out of bed to a Geri chair. During interviews, Rehabilitation Coordinator #1 stated there was no documentation in the CCP regarding out-of-bed status to indicate use of a Geri chair and that there should have been. The DON stated the resident’s Geri chair should have been documented on the Activities of Daily Living Comprehensive Care Plan to show the resident transferred dependently to a reclining Geri chair and that Rehabilitation Coordinator #1 was responsible for adding it.
Unsecured and Expired Medications Found at Bedside
Penalty
Summary
The facility failed to ensure Resident #6’s environment remained free of accident hazards when a bottle of Dicyclomine tablets and a bottle of Nitroglycerin sublingual tablets were observed on the resident’s nightstand. Resident #6 was admitted with diagnoses including angina pectoris, hypertension, and irritable bowel syndrome, and the resident’s MDS documented a BIMS score of 13, indicating intact cognitive function. However, the admission self-medication assessment documented that the resident was not a candidate to self-administer medications, and there was no physician’s order for Nitroglycerin or for the resident to self-administer any medications. The resident had physician’s orders for Dicyclomine 20 mg every eight hours as needed for IBS and Ranolazine 1,000 mg every 12 hours for angina pectoris. The bottle of Dicyclomine on the nightstand was documented with instructions to discard it after 09/11/2025. During observation, the resident stated they preferred to keep the medications on the nightstand for easy access, even though the nightstand had a locked drawer, and stated they could not recall the last time either medication was taken. Staff interviews confirmed the resident could not self-administer medications and that medications, including expired medications, should have been stored in the locked medication cart rather than in the resident’s room.
Failure to Follow Enhanced Barrier Precautions During Hands-On Care
Penalty
Summary
The facility failed to ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for one resident who had a physician’s order for Enhanced Barrier Precautions due to left breast and sacral wounds. The resident had diagnoses including dementia, chronic respiratory failure, and anxiety, and the admission MDS documented that the resident was rarely or never understood, had severely impaired cognition, was dependent on staff for all ADLs, and was incontinent of bladder and bowel. The resident was also admitted with one stage 1 pressure ulcer and one stage 3 pressure ulcer. The facility’s policy required gowns and gloves during high-contact resident care activities, and the resident had an order, care plan, CNA instructions, and posted signage indicating that gowns and gloves were required for dressing, bathing, showering, transferring, changing linens, and hygiene care. During observation, a CNA was providing hands-on care, including changing and checking the brief and dressing the resident, without wearing a gown. The RN supervisor stated the CNA should have used appropriate PPE, and the CNA stated they knew the resident was on Enhanced Barrier Precautions because of wounds but forgot to put on a gown while providing care.
Failure to Follow Skin Condition Protocols
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a recertification survey for a resident with a skin condition. The resident, who had severely impaired cognition and was at risk for skin pressure ulcers due to antiplatelet medication use, was observed with a dressing on the left forearm that had dried blood from an open purpura. There was no documented evidence of a skin assessment, physician notification, or treatment order before the dressing was applied. Licensed Practical Nurse #3 was informed of the skin tear by a Certified Nursing Assistant but failed to notify the Registered Nurse Supervisor or the Physician, and did not obtain a treatment order. The nurse applied a gauze dressing to stop the bleeding but did not follow the facility's policy for changes in skin condition. The Director of Nursing Services confirmed that the nurse should have informed the Registered Nurse Supervisor and obtained a physician's order. The oversight in following proper procedures led to the deficiency noted in the survey.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by regulations. This deficiency was observed during a recertification survey for two residents. The first resident, who had intact cognition and no physician's order for Hydrocortisone lotion, was found with an unlabeled bottle of the lotion on their nightstand. The resident could not recall the origin of the lotion, and multiple staff members, including nurses and a certified nursing assistant, stated they were unaware of the lotion's presence and would have reported it if they had seen it. The second resident, also with intact cognition, was observed with a cup containing four tablets on their overbed table after breakfast. The resident had requested the nurse to leave the medications in the room, intending to take them after eating. The nurse complied, leaving the medications unattended, which was against the facility's policy. The resident had previously expressed a desire not to self-medicate, and there was no physician's order allowing them to do so. The nurse acknowledged the mistake, and the unit supervisor confirmed that medications should not be left unattended. Interviews with the Director of Nursing Services and other staff highlighted that residents should not have medications stored in their rooms without supervision. The facility's policy mandates that all medications be locked and administered by licensed nurses. The failure to adhere to these protocols resulted in the observed deficiencies, as medications were not properly secured and were left accessible to residents without appropriate oversight.
Neglect Due to Failure to Follow Fall Protocol
Penalty
Summary
The facility failed to ensure resident rights to be free from neglect, as evidenced by the actions of a Licensed Practical Nurse (LPN) who did not follow protocol after a resident fell. The incident involved a resident who was at risk for falls and had a history of skin tears. On the day of the incident, the resident was found on the floor in the main dining room by an LPN who was passing medications. Instead of calling for a Registered Nurse (RN) to assess the resident, the LPN picked the resident up and placed them back into their wheelchair. The facility's policy requires that any accident or incident be reported immediately to an RN, who must assess the resident for injuries and determine the need for immediate intervention. However, this protocol was not followed, as the LPN acted independently without notifying an RN. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognitive skills, was later assessed by an RN Supervisor and found to have a laceration on the forehead and ecchymosis on the cheek and knee. Interviews with staff confirmed that the LPN acknowledged the mistake of not calling an RN before moving the resident. The Assistant Director of Nursing and other staff members reiterated that the LPN should have left the resident on the floor until an RN could perform an assessment. This failure to adhere to established procedures resulted in the resident not receiving an immediate assessment by an RN, which is a violation of the resident's rights to be free from neglect.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **ELEMENT 1** The Nurse Practitioner and family were notified of the incident on 6/8/24. Resident #1 new orders: normal saline cleanse and [MEDICATION NAME] to facial injury and left open to air, 1:1 supervision, neuro checks for 24 hours. 30 minute checks in place to monitor resident and prevent future falls. Resident #1 assessed on 6/10/24 by Nurse Practitioner. No obvious injuries noted, but x-rays to bilateral knees, elbows, humerus, and cervical spine were ordered and completed on 6/10/24 with no acute abnormalities. Resident #1 was seen by the social worker on 6/10/24 and psychology on 6/11/2024. Upon review by Administration and the Assistant Director of Nursing, LPN #2 was placed immediately on investigative suspension and was later terminated. LPN #1 was interviewed and counseled regarding policy and procedure and the RN assessment requirement. Facility self-reported the incident to the NYSDOH. **ELEMENT 2** To ensure there were no other residents affected since 6/8/24: All residents with an Accident/Incident that occurred from 6/2024 to present will be reviewed to ensure Policy and Procedure were followed and RN Assessments were performed on all Accidents/Incidents upon discovery. **ELEMENT 3** The following measures will be instituted to prevent reoccurrence: Resident #1 Plan of Care was reviewed on 6/10/24 with no findings. The Accident/Incident Policy was reviewed on 6/10/24 and was found to be in compliance with no revision necessary. All employees will be re-educated regarding the Accident/Incident Policy and Procedure with emphasis on not moving the affected resident until the RN Assessment has been completed and staff are given direction by the RN. All employees will be re-educated on the Abuse, Neglect and Mistreatment Prohibition Policy. All Accident/Incidents for the next 6 months will be reviewed to ensure RN Assessment and compliance with procedures to ensure 100% compliance. The Dayroom Supervision Policy and Procedure will be reviewed and revised. **ELEMENT 4** Performance monitoring to ensure Plan of Correction has prevented reoccurrence: Performance will be monitored weekly to review all Accidents/Incidents for compliance with the Accident/Incident Policy. An audit tool was created to monitor RN assessment compliance with all Accidents and Incidents. The percentage of compliance regarding Accident/Incident Review for 6/24 through 1/25 will be reported to the next PI Committee meeting. The percentage of compliance regarding all future reviews 2/25 through 7/25 will be reported quarterly to the PI Committee. **ELEMENT 5** The Plan of Correction will be completed by: 2/28/2025 Responsibility: Laura Pauze, RN, DON
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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 Sayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Affinity Skilled Living And Rehabilitation Center | 2.1 mi | ★★★★★ | 15 | 1 |
| Sayville Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Momentum At South Bay For Rehabilation And Nursing | 5 mi | ★★★★★ | 6 | 0 |
| Swan Lake Nursing & Rehabilitation | 5.4 mi | ★★★★★ | 5 | 1 |
| Brookhaven Health Care Facility, Llc | 6.8 mi | ★★★★★ | 3 | 0 |
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