Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Gurwin Jewish Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with muscle weakness, spinal stenosis, moderate cognitive impairment, and dependence on staff for transfers was care-planned and documented by therapy and the CNA Kardex as requiring two-person assistance for all transfers, including tub/shower transfers. Facility policies required CNAs to review the Kardex and follow the care plan for safe transfers. Despite this, an assigned CNA, who reported typically not checking the Kardex but knowing the resident needed two-person assistance, took the resident alone to the shower room and attempted to transfer the resident from a wheelchair to a shower chair using grab bars and then by pivoting the resident by the back of their pants. After the solo transfer, the resident was found with multiple skin tears on both hands and a shin. Nursing documentation and an internal investigation concluded that the injuries occurred because the CNA failed to follow the established two-person transfer plan and did not perform the transfer in accordance with the resident’s assessed needs.
Inaccurate MDS Coding for Physical Restraints: A resident with [NAME] Syndrome, vascular dementia, and DM2 had MDS assessments that incorrectly documented daily use of an other physical restraint in a chair or out of bed, despite no clinical documentation supporting restraint use and an observation showing no restraints in place. The RN Unit Manager and MDS assessor both stated the restraint coding was entered in error, and the Chief MDS Officer noted the audit software excluded the restraint item from review.
Failure to provide hand hygiene and grooming assistance. A resident with severe cognitive impairment, contractures, and dependence for all ADLs was observed with contracted hands containing moisture, brown sticky debris, and a strong odor. A CNA stated the resident's palms were not washed because the hands were difficult to open, and an LPN later confirmed the palms appeared dirty and not properly washed.
A resident with dementia, Parkinson’s disease, and HTN was receiving Ramelteon and Melatonin for insomnia. A pharmacist identified duplicate sleep therapy in the MRR, but the irregularity was not documented on a separate written report to the MD, Medical Director, or DON, and there was no provider response in the chart acknowledging review or action taken. An NP later stopped Melatonin without documenting the rationale or agreement with the pharmacist’s recommendation.
Failure to Follow Contact Precautions for Resident with Shingles: A resident with presumed shingles was on contact precautions with signage requiring gloves and a gown. A CNA entered the room wearing gloves but no gown while making the bed and shaking the linens, despite stating the resident was on contact precautions and the IP stating staff should wear both gown and gloves for room entry and contact with the resident’s environment.
A resident with respiratory needs was observed receiving oxygen at a higher rate than prescribed, and a comprehensive care plan was not initiated in a timely manner. The facility's policy required care plans to be initiated within a week of admission, but this was not followed. Interviews revealed that the admitting nurse failed to initiate the care plan, and the DON acknowledged the oversight.
A resident with a history of Bipolar Disease, Hypertension, and Coronary Artery Disease was involved in a resident-to-resident altercation, resulting in a hematoma. The facility failed to update the resident's care plan to reflect this incident during subsequent quarterly reviews, contrary to their policy requiring interdisciplinary team review and revision after each assessment.
A resident with multiple health conditions was observed receiving oxygen at three liters per minute, contrary to the physician's order of one liter per minute. The nursing staff failed to verify the order, and the resident's care plan initially lacked documentation of oxygen use. The facility's management acknowledged the lapse in following protocols.
A facility failed to maintain a medication error rate below five percent, resulting in an 11.11% error rate during a survey. A resident did not receive three prescribed medications on time, with a delay of 2 hours and 46 minutes. The facility's policy requires medications to be administered within one hour of the prescribed time. The delay was attributed to the nurse being busy with other tasks, and both the CNO and NP acknowledged the delay as unacceptable.
During a survey, expired medications were found in a medication cart and a medication room refrigerator. An LPN administered an expired Fluticasone inhaler to a resident, and another expired intravenous antibiotic solution was found in the refrigerator. The facility's policies on medication expiration were not followed, leading to these deficiencies.
A resident with liver cirrhosis experienced significant weight loss due to the facility's failure to provide meals that met their dietary preferences, specifically a burger, despite expressing dissatisfaction with the food served. The facility's policies require honoring residents' food preferences, but the resident's requests were not consistently met, leading to poor intake and weight loss. Staff cited kosher dietary guidelines as a limitation, but exceptions were possible, indicating a lack of communication and action to accommodate the resident's needs.
Failure to Follow Two-Person Transfer Plan Resulting in Resident Skin Tears
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and that adequate supervision and assistance were provided during transfers. The resident involved had muscle weakness, spinal stenosis, difficulty walking, and functional limitation in range of motion in one lower extremity. A Quarterly MDS documented moderate cognitive impairment with a BIMS score of 11 and indicated the resident was dependent on staff for sit-to-stand mobility, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers, requiring the assistance of two or more helpers. Occupational Therapy and Physical Therapy communication forms, the CNA Kardex for the month, and the comprehensive care plan all documented that the resident required two-person assistance for tub/shower and other transfers and used a wheelchair for mobility. Facility policies titled “Activities of Daily Living” and “Safe Transfers and Movement of Residents” required CNAs to review the CNA Task List/Kardex and to transfer residents only in accordance with their current assessment and care plan, using the required level of staff assistance and appropriate devices. Despite these requirements, on the date of the incident, the assigned CNA took the resident alone to the shower room for a scheduled shower and did not request assistance from other staff. The CNA reported that they typically did not check a resident’s Kardex and acknowledged being aware that this resident required two-person assistance for transfers. In the shower room, the CNA instructed the resident to hold the grab bars and attempted to transfer the resident from the wheelchair to the shower chair without a second staff member. During the first transfer attempt, the resident stood but was unable to turn, and the CNA seated the resident back in the wheelchair. The CNA then attempted the transfer again, this time grabbing the back of the resident’s pants and pivoting the resident from the wheelchair into the shower chair alone. After completing the transfer, the CNA observed that the resident was bleeding and brought the resident to the nursing station. Nursing staff assessed multiple skin tears: one on the top of the right hand, one on the left lateral hand, and one on the left shin. An Accident and Incident Report and an Investigative Summary concluded that the resident sustained these skin tears as a result of the CNA’s failure to follow the established plan of care requiring two-person assistance for all transfers. Interviews with nursing and rehabilitation leadership confirmed that a one-person transfer from the wheelchair to the shower chair was unsafe for this resident and that the transfer was not performed in accordance with the resident’s care plan and therapy instructions. Interviews with nursing staff further established that the CNA did not seek help before attempting the transfer and did not perform a safe transfer as per the resident’s plan of care. The LPN on duty reported that the CNA brought the resident to the nursing station with impaired skin on the left hand and leg and stated that the injuries occurred during the shower. A registered nurse confirmed that the CNA admitted to transferring the resident alone despite the known requirement for two-person assistance. The Assistant Director of Nursing and the Chief Nursing Officer both stated that the resident’s plan of care required two-person assistance for transfers and that the CNA did not follow this plan, resulting in the resident’s multiple skin tears. The overall finding was that the facility did not ensure the resident’s environment remained as free of accident hazards as possible by failing to ensure staff adhered to the resident’s assessed transfer needs and care plan.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility did not ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident’s status. For one resident reviewed for physical restraints, the MDS assessments dated 10/31/2025 and 11/11/2025 documented in Section P0100H that the resident used an other physical restraint in a chair or out of bed daily, even though the medical record contained no documented evidence that the resident used a physical restraint. The resident had diagnoses including [NAME] Syndrome, vascular dementia, and type 2 diabetes mellitus, and the Five Day MDS documented a BIMS score of 12, indicating moderately impaired cognition. During observation on 01/07/2026, the resident was resting in bed with no physical restraints noted and declined interview. The RN Unit Manager stated the restraint entry on the matrix must have been entered in error because the resident did not use any type of restraints, and the MDS assessor stated they had completed both assessments and erroneously entered that the resident utilized restraints. The Chief MDS Officer stated the scrub program excluded Section P0100H from audit for unknown reasons, and the CNO stated the MDS assessor should review the accuracy of the assessments before signing for completion.
Failure to Provide Hand Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. Resident #30 had diagnoses including cerebral infarction, dysphagia, and dementia, with severely impaired cognition, was rarely or never understood, and was dependent on staff for all ADLs with impairment to both upper and lower extremities. The care plan identified self-care and mobility deficits and included bathing assistance and monitoring for immobility-related issues such as contractures and skin breakdown. During observation, the resident was found lying in bed with both hands contracted into closed fists, and when a CNA opened the hands, there was a strong foul odor and an accumulation of moisture and brown sticky substance in the palms. The CNA acknowledged not washing the resident's palms because the hands were difficult to open and stated the hands had not been cleaned. An LPN later observed that the palms were dirty and appeared not to have been washed properly, and the wound care nurse described the substance as a buildup of sweat and debris from the hands not being washed properly for a while.
Pharmacy review irregularity not documented on separate written report or in provider response
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review irregularities were documented on a separate written report and that the attending physician documented review of the irregularity and the action taken. The deficiency was identified for one resident reviewed for unnecessary medications. The facility’s policy required pharmacy recommendations to be communicated and documented in a manner that included a written medication regimen review form for medical staff response, with completed reviews maintained in the pharmacy department and scanned into the resident’s permanent medical record. Resident #358 had diagnoses including dementia, Parkinson’s disease, and hypertension, and the Quarterly MDS documented moderately impaired cognition with a BIMS score of 11. The resident was receiving Ramelteon 8 mg at bedtime for insomnia and Melatonin 3 mg at bedtime for sleep-wake cycle. The care plan addressed insomnia and included medication administration as ordered and monitoring for effectiveness and adverse signs and symptoms. On 12/2/2025, the pharmacist documented in the resident’s medical record that Melatonin and Ramelteon represented duplicate treatment for sleep. There was no separate written report sent to the attending physician, Medical Director, or DON, and there was no physician response, signature, or date acknowledging the recommendation in the medication regimen review progress note. The resident’s record contained no medication regimen review form related to the pharmacist’s recommendation. Nurse Practitioner #1 later discontinued Melatonin without documenting the rationale or documenting agreement with the pharmacist’s recommendation in the medical record. Interviews confirmed that the pharmacist used an electronic communication channel rather than a separate written report, and that the medical providers did not document their review and action taken in the resident’s record.
Failure to Follow Contact Precautions for Resident with Shingles
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. Resident #432 had diagnoses including COPD and gastrostomy status, and the admission MDS documented a BIMS score of 12, indicating moderate cognitive impairment. A physician’s order dated 12/28/2025 documented Contact Precautions for a left flank rash/presumed shingles, and the care plan included maintaining contact isolation precautions for herpes zoster (shingles). During an observation on 12/31/2025 at 11:41 AM, contact precaution signage was posted on the resident’s doorway indicating staff must wear gloves and a gown before entering the room. Certified Nursing Assistant #1 was observed inside the resident’s room wearing gloves but not a gown while making the resident’s bed and touching and shaking the blankets and bedsheets to smooth them. During interview, the CNA stated they had removed their gown after providing care, changed gloves, and then made the bed, believing a gown was not needed for that task. The Infection Preventionist stated staff should wear gloves and a gown when entering a room under contact precautions and should not shake blankets or linen while making the bed. The Chief Nursing Officer stated staff should follow contact precaution directions and wear appropriate PPE, and that entering a contact isolation room without proper PPE could spread infection to other residents and staff.
Deficiency in Timely Care Plan Development for Respiratory Care
Penalty
Summary
The facility failed to ensure a timely and accurate development and implementation of a person-centered care plan for a resident requiring respiratory care. Specifically, the resident had a physician's order for oxygen therapy at one liter per minute via nasal cannula, but was observed receiving oxygen at three liters per minute on multiple occasions. There was no documented evidence that a comprehensive care plan for the resident's respiratory status was developed in a timely manner, as it was not initiated until the day of the survey. The facility's policy required that a comprehensive care plan be initiated within one week of admission and finalized within 21 days. However, the care plan for the resident's respiratory status was delayed, and the oxygen therapy was not administered according to the physician's order. Interviews with nursing staff revealed that the admitting nurse was responsible for initiating the care plan, but this was not done. The Director of Nursing Services acknowledged that the care plan should have been initiated by the admitting nurse or any registered nurse manager or supervisor, and that the oxygen therapy should have been administered as per the physician's order.
Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for Resident #90 was reviewed and revised by the interdisciplinary team following a resident-to-resident altercation. Resident #90, who has a history of Bipolar Disease, Hypertension, and Coronary Artery Disease, was involved in an incident on 8/11/2023 where they sustained a hematoma on their left forearm after being hit by another resident with a rubber-soled shoe. Despite this incident, the care plan was not updated to reflect the altercation during the subsequent quarterly care plan reviews on 12/7/2023 and 2/29/2024. The facility's policy requires that care plans be reviewed and revised by an interdisciplinary team after each assessment, including both comprehensive and quarterly reviews. However, interviews with facility staff, including Social Work #1 and the Director of Nursing Services, revealed that the care plan was not updated as required. The Director of Nursing Services acknowledged that the care plan should have been revised by any registered nurse assigned to the resident's unit or by the Registered Nurse Risk Manager to reflect the altercation and any changes to the plan of care.
Failure to Adhere to Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for a resident. Specifically, a resident with diagnoses including Pulmonary Hypertension, Congestive Heart Failure, Non-Alzheimer's Dementia, and Atrial Fibrillation was observed receiving oxygen at a rate of three liters per minute on three separate occasions, despite a physician's order specifying one liter per minute. The resident's care plan did not initially include documentation of oxygen use, and the discrepancy in oxygen administration was not addressed by the nursing staff. Licensed Practical Nurse #3 confirmed the incorrect oxygen flow rate and admitted to not checking the physician's order. The Education Coordinator and Director of Nursing Services both stated that nurses are expected to follow physician's orders and should have verified the order if there were concerns. The failure to adhere to the physician's order was acknowledged by the nursing staff and management, indicating a lapse in following established protocols for administering oxygen therapy.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during a Recertification Survey conducted from May 15 to May 23, 2024. Specifically, the survey identified an 11.11% medication error rate during a medication pass observation. This deficiency was noted when a resident did not receive three of their physician-ordered medications at the prescribed time of 8:00 AM. Instead, the medications were administered at 11:46 AM, which was 2 hours and 46 minutes late. The facility's policy mandates that medications should be administered within one hour of their prescribed time unless otherwise specified. The resident involved had diagnoses including Dementia and Hypertension and was assessed to have intact cognition. The medications in question included Escitalopram Oxalate for Depression, Apixaban for a history of venous Thromboembolism, and Albuterol Sulfate for Chronic Obstructive Pulmonary Disease. Registered Nurse #4, responsible for the late administration, attributed the delay to being busy with other tasks. Both the Chief Nursing Officer and a Nurse Practitioner acknowledged the delay as unacceptable and contrary to the facility's policy, which requires timely administration of medications.
Expired Medications Found in Medication Cart and Room
Penalty
Summary
The facility failed to ensure that all drugs were labeled and stored in accordance with professional standards, specifically regarding expiration dates. During the Recertification Survey, it was observed that a medication cart on Unit 2 contained an expired Fluticasone inhaler labeled for a resident with an expiration date of 5/15/2024. The inhaler was administered to the resident on 5/22/2024, despite being expired. The LPN responsible admitted to not checking the expiration date before administration. The Assistant Pharmacy Director confirmed that the inhaler should have been discarded 45 days after opening, as per the manufacturer's guidelines. Additionally, in the medication room on Unit 4, a bag of intravenous antibiotic solution for another resident was found in the refrigerator with an expiration date of 5/20/2024. The LPN on duty stated that they check for expired medications daily but failed to notice the expired bag. The RN Manager and the Assistant Pharmacy Director both stated that expired medications should not be stored in the medication room refrigerator, and the pharmacy was not notified of the expired medication. The facility's policies on dispensing and storing medications were not followed, leading to the presence of expired medications in both the medication cart and the medication room refrigerator. The Chief Nursing Officer acknowledged that the medication nurse should have checked expiration dates before administration and that expired medications should not be stored in the refrigerator. The facility has an in-house pharmacy, which should have been utilized to replace expired medications promptly.
Failure to Meet Resident's Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of a resident, identified as Resident #36, during a recertification survey. The resident, who has diagnoses including liver cirrhosis and had experienced significant weight loss, expressed dissatisfaction with the food served and requested a burger as a preferred meal. Despite the resident's clear preference and significant weight loss, the facility only provided a burger meal once in three weeks, failing to honor the resident's dietary preferences as outlined in their policies. The facility's policies on nutritional services and resident food preferences require that residents' food and meal preferences be regularly updated and honored. However, the resident's preferences, including a burger with sliced onion and pudding with sugar, were not consistently met. The resident reported disliking the facility's food, which led to poor intake and significant weight loss. Interviews with the dietician and other staff revealed a lack of communication and action to accommodate the resident's preferences, with the dietician unaware of the possibility of providing burgers more frequently. The facility's adherence to kosher dietary guidelines was cited as a reason for not providing the requested meals, but staff interviews indicated that exceptions could be made if requested. Despite this, the resident continued to receive meals they disliked, leading to further refusal to eat and continued weight loss. The facility's failure to provide meals that met the resident's preferences and nutritional needs resulted in a deficiency under 10 NYCRR 415.14.
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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 Commack
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ross Center For Nursing And Rehabilitation | 4.4 mi | ★★★★★ | 11 | 0 |
| Maria Regina Rehabilitation And Nursing | 4.8 mi | ★★★★★ | 0 | 0 |
| Apex Rehabilitation & Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Carillon Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 0 | 0 |
| Huntington Hills Center For Health And Rehabilitat | 5.6 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.