Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Island Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident was observed with scheduled meds left on the bedside table and stated they usually take them when ready. The resident had diagnoses including COPD, MDD, and OA, and was cognitively intact, but there was no physician order, assessment, or care plan authorizing self-administration. Staff confirmed the meds were routinely left at bedside despite the facility policy requiring interdisciplinary determination and a physician order.
Failure to follow a two-person care requirement: A resident with COPD, MDD, and OA had care plans and a physician order directing a two-person approach for care, with door signage used to alert staff. During observation, an CNA provided care alone in the resident’s room, and records for prior months showed no documented evidence of the required two-person approach during care.
Controlled drug records were not reconciled after a resident refused scheduled Tramadol and Lorazepam. An LPN left the medication cart unattended with medication cups on it, kept the refused meds on the cart because they did not want to waste them, and did not document the refusal or destroy the controlled meds with another nurse. The RN supervisor was not notified, and the DON stated the controlled substance record should be reconciled immediately after meds are administered or destroyed.
An LPN left a medication cart unattended and unlocked with an unlocked narcotic box and medications left on the cart, including controlled drugs that had been refused by a resident. In a separate event, an LPN left another resident’s medications at the bedside even though there was no MD order, care plan, or assessment for self-administration. The DON and RN supervisor stated the cart, narcotic box, and bedside medications should not have been left unsecured or available in that manner.
A survey found that the facility had insufficient nursing staff, particularly on weekends, leading to delays in resident care. Observations and resident interviews confirmed that Units 2 and 3 were understaffed, with fewer CNAs than required. Residents reported long waits for assistance with personal care, and staff interviews highlighted the challenges of understaffing.
A resident receiving Hospice care was not accurately assessed in the MDS, as the assessment failed to document Hospice services. Despite the resident's Comprehensive Care Plan and Physician's order indicating Hospice care, the MDS nurse did not include this information, which was confirmed by the DON.
The facility failed to develop comprehensive care plans for residents with specific needs, including a resident with a chronic skin condition, another using a Miami J Cervical Collar, and a resident with limited English proficiency. These deficiencies were identified during a survey, revealing gaps in care planning and communication.
The facility failed to update comprehensive care plans for two residents, one with hydration issues and another with dental pain. The resident with hydration concerns had significant changes in condition, but care plans were not revised. The resident with dental pain had recommendations for X-rays, but these were not reflected in the care plan. Staff interviews revealed that unit managers were responsible for updates, but the required revisions were not made.
A facility failed to ensure proper physician supervision for two residents. One resident's cardiac pacemaker was not monitored as per the physician's order for nearly a year due to scheduling issues with an external vendor. Another resident wore a Miami J Cervical Collar without a physician's order, as the facility did not obtain the necessary documentation upon admission. These cases highlight lapses in communication and adherence to facility policies.
A resident with moderate cognitive impairment and dental pain did not receive recommended dental X-rays due to miscommunication and lack of follow-up between facility staff and the Dental Service Vendor. Despite initial recommendations in March, the X-rays were not scheduled until September, and the appointment was canceled without rescheduling.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility did not ensure a resident’s right to self-administer medications when Resident #8 was observed with a souffle medication cup containing four pills and a small disposable cup with white powder left on the bedside table. The resident stated they told the nurse to leave the medications on the overbed table so they could take them when ready, and said nurses frequently allowed them to self-administer medications. The resident’s record showed diagnoses including COPD, major depressive disorder, and osteoarthritis, and the Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The record review found no physician’s order, no comprehensive care plan, and no documented assessment showing the resident had been approved to self-administer medications. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and only by physician order, with bedside medications kept in a locked box. Staff interviews confirmed the medications were routinely left at the bedside, that the resident was not assessed for self-administration, and that the resident did not have an order or care plan for this practice. The LPN identified the 8:00 AM medications left at the bedside as aspirin, hydrochlorothiazide, metoprolol succinate, and Glyco-Lax powder.
Failure to Follow Two-Person Care Requirement
Penalty
Summary
Resident #8, who had diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Osteoarthritis, was assessed as cognitively intact with a Brief Interview for Mental Status score of 15 and had no behavioral issues documented on the Quarterly Minimum Data Set. The resident’s comprehensive care plans for Non-Compliance and for Accusatory and Verbally Abusive behaviors both included interventions requiring a two-person approach for care, and a physician’s order also directed a two-person approach. A magnet sign with an icon of two people was displayed on the door frame of the resident’s private room to alert staff to this requirement. During an observation, Certified Nursing Assistant #1 was seen providing care in the resident’s room while changing bed linens and collecting laundry and soiled linens without a second caregiver present. The CNA stated the magnet indicated the resident required a two-person approach during care, but also stated the resident usually accepted care from them alone. Facility staff interviews confirmed the magnet was intended to alert staff to the two-person requirement, and the Director of Nursing stated residents should receive care from two staff members when a two-person approach is required. Review of the CNA Accountability record for June and July 2025 showed no documented evidence of a two-person approach during care, although August 2025 documentation reflected a two-person approach on each shift.
Controlled Drug Record Not Reconciled After Refused Medication
Penalty
Summary
Drug records were not kept in order and did not account for all controlled drugs for one resident on Unit 3. During a medication storage and administration task, the Controlled Substance Administration Record was not reconciled to reflect that the resident refused Tramadol hydrochloric acid at 9:00 PM on 07/31/2025. The facility policy dated January 2025 stated that when a resident refuses a controlled substance after it has been poured, the medication must be destroyed with a witness, the back of the Controlled Drug 24-Hour Administration Record must be completed, and the Nursing Supervisor must be notified. Resident #60 had diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Anxiety Disorder, and a Significant Change MDS documented a BIMS score of 4, indicating severely impaired cognition. The resident required assistance with all ADLs and received antianxiety medication during the assessment look-back period. The physician's orders included Tramadol 25 mg twice daily for pain and Lorazepam 0.5 mg at bedtime for anxiety. During observation, a Unit 3 medication cart was left unattended in the hallway with medication cups containing tablets. The LPN stated the resident refused the scheduled Tramadol and Lorazepam, but the medications were kept on the cart because they did not want to waste them, the cart and narcotic box were not locked, and the refusal was not documented or destroyed with another nurse. The RN supervisor stated they were not aware the medications had not been destroyed or reconciled, and the DON stated the Controlled Substance Administration Record should be reconciled immediately after a medication is administered or destroyed.
Unsecured Medication Storage and Unauthorized Bedside Medication Access
Penalty
Summary
Drugs and biologicals were not stored in locked compartments as required. During a medication administration observation on 08/01/2025 at 5:41 AM, a Unit 3 medication cart was left unattended in the hallway, unlocked, with an unlocked narcotic box. Two medication cups were left on the cart, including one containing two white tablets and another containing one white tablet, with no staff nearby. The facility’s policies stated controlled substances and narcotics were to be kept in a double-locked cabinet or double-locked medication cart, and all medications were to be contained in a locked cart and/or cabinet in a locked room. During interview, an LPN stated Resident #60 had refused scheduled Tramadol 25 mg and Lorazepam 0.5 mg, and that the second cup contained Melatonin 3 mg, but the medications were left on the cart because the nurse did not want to waste them. The LPN stated the cart and narcotic box were not locked because they were called into a resident’s room to assist a CNA. An RN supervisor stated medications should not be left on the cart for safety reasons and that medication carts must be locked when unattended, with narcotic boxes double locked per policy. The DON later stated it was not safe to leave medications on an unattended cart and that the cart and narcotic box should not be left unlocked when unattended. Resident #8, who had diagnoses including COPD, major depressive disorder, and osteoarthritis, was cognitively intact on the quarterly MDS. During observation, the resident was sitting in a wheelchair next to an overbed table with a soufflé medication cup containing four pills and a small disposable cup with white powder. The resident stated staff often left medications on the overbed table and that they would take them when ready, and an LPN stated they always left the medications at the bedside and that the resident self-administered them. The record showed no physician’s order, no care plan, and no assessment to self-administer medications, and the DON stated the resident did not have an order to self-administer and medications should not have been left at the bedside.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents, particularly on weekends, as identified during a Recertification and abbreviated Survey. The survey revealed that Units 2 and 3 were consistently understaffed, with fewer Certified Nursing Assistants (CNAs) than required by the Facility Assessment. This staffing shortage was corroborated by the Payroll-Based Journal (PBJ) Staffing Data Report for the first quarter of 2024, which indicated excessively low weekend staffing levels. Residents reported delays in receiving care due to the staffing shortages. Thirteen out of twenty-six sampled residents complained about the slow response to call bells and delays in attending to their needs. Specific instances included residents having to wait for assistance with personal care, such as changing briefs and getting to the bathroom, and missing preferred activities like showers and rehabilitation appointments. These delays were attributed to the lack of sufficient CNAs on duty, particularly during the evening and night shifts. Observations during the survey confirmed the staffing deficiencies, with Units 2 and 3 operating with fewer CNAs than required. Interviews with staff, including a CNA and the Staffing Coordinator, highlighted the challenges faced due to understaffing, especially on weekends. The facility's Administrator and Director of Nursing Services acknowledged the difficulties in recruiting CNAs and the impact of the nationwide nursing staffing shortage on their ability to maintain adequate staffing levels.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving Hospice care, as identified during a Recertification Survey. The deficiency was noted for a resident with diagnoses including Dementia, Protein-Calorie Malnutrition, and Hypothyroidism. The Quarterly Minimum Data Set (MDS) assessment did not reflect that the resident was receiving Hospice care, despite documentation in the Comprehensive Care Plan and the current Physician's order indicating the resident was on Hospice services. The MDS assessment nurse acknowledged the error, stating that Hospice services were not documented under the Special Treatments section of the MDS. Interviews with the Registered Nurse responsible for the MDS assessment and the Director of Nursing Services confirmed the oversight. The nurse admitted to the mistake and the Director of Nursing Services affirmed that the MDS should have accurately reflected the resident's Hospice care status. This oversight was a violation of the facility's policy and procedure for MDS 3.0 Completion, which requires comprehensive and accurate assessments to identify care needs and develop an interdisciplinary care plan.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for residents with specific needs, as identified during a recertification survey. One resident with a chronic skin condition, including pruritis and lesions, did not have a care plan addressing these issues despite multiple medical evaluations and treatments. The resident's condition was ongoing, with symptoms persisting, yet the care plan was not updated to reflect the necessary interventions for managing the chronic skin condition. Another resident, who used a Miami J Cervical Collar for comfort and support, did not have a care plan or physician's order in place for its use. The resident was observed wearing the collar during various activities, but the facility failed to document its use in the care plan until after the survey observations. Staff interviews revealed a lack of clarity regarding responsibility for assisting the resident with the collar, indicating a gap in care planning and communication. Additionally, a resident with limited English proficiency did not have a care plan addressing their communication needs. Despite the facility's policy for communication with non-English speaking residents, there was no system in place to ensure effective communication for this resident. Staff relied on gestures and occasional assistance from Spanish-speaking staff, but there was no consistent access to translation services or communication aids, leaving the resident without adequate support for their language needs.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that person-centered comprehensive care plans were reviewed and revised to address the needs of residents, specifically for one resident with hydration issues and another with dental service needs. For the resident with hydration concerns, there was no documented evidence that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment. This resident had a history of seizure disorder, dehydration, and altered mental status, requiring substantial assistance for eating and was on diuretic medication. Despite significant changes in the resident's condition, including increased lethargy and seizure-like activity, the care plans were not updated in conjunction with the Minimum Data Set assessments conducted on multiple occasions. For the resident reviewed for dental services, the facility did not update the dental care plan to reflect the resident's dental pain concerns and the need for dental X-rays as recommended by the dentist. The resident, who had moderate cognitive impairment, experienced shooting pain in the teeth and required dental X-rays, which were approved but not reflected in the care plan. Despite multiple entries in the progress notes documenting the resident's complaints of oral pain and recommendations for dental consults, the care plan was not revised to include these interventions. Interviews with facility staff, including the Director of Nursing Services and the Assistant Director of Nursing Services, revealed that the responsibility for updating care plans lay with the unit managers. However, the care plans for both residents were not updated as required, and the staff could not provide reasons for the oversight. The facility's policy required care plans to be reviewed and revised at intervals not exceeding 92 days, which was not adhered to in these cases.
Deficiencies in Physician Supervision and Documentation
Penalty
Summary
The facility failed to ensure that each resident's medical care was supervised by a physician throughout their stay, as evidenced by two specific cases. In the first case, a resident with a cardiac pacemaker was not monitored as per the physician's order for quarterly checks. Despite having a physician's order for pacemaker checks every three months, the resident's pacemaker was not checked for nearly a year. Interviews revealed that the facility's scheduling process with an external vendor for pacemaker checks was flawed, as the vendor required a minimum number of residents for a visit, which was not met. The facility staff, including the Unit Secretary and Director of Nursing Services, were unaware of the resident's need for regular pacemaker checks, leading to a significant oversight in the resident's care. In the second case, another resident was observed wearing a Miami J Cervical Collar without a physician's order. The resident was admitted with the collar, but the facility failed to obtain the necessary physician's order for its use and monitoring. The Director of Rehabilitation and nursing staff acknowledged the oversight, indicating that the nursing department was responsible for obtaining the order. The physician was unaware of the collar's use until it was brought to their attention, highlighting a lapse in communication and documentation within the facility. These deficiencies indicate a lack of adherence to facility policies and procedures regarding medical supervision and documentation. The failure to monitor the cardiac pacemaker and the absence of a physician's order for the cervical collar demonstrate significant gaps in the facility's processes for ensuring residents' medical needs are met according to physician directives.
Failure to Provide Timely Dental X-rays for Resident
Penalty
Summary
The facility failed to ensure that Resident #37 received necessary dental X-rays, which were recommended by a dentist due to complaints of mouth pain. The resident, who had moderate cognitive impairment and was diagnosed with Non-Alzheimer's Dementia, Anxiety Disorder, and Osteoarthritis, was experiencing shooting pain in the upper left and lower left teeth. Despite the dentist's recommendation for dental X-rays in March 2023, there was no documented evidence that these X-rays were ever completed. The process for obtaining the dental X-rays was hindered by a lack of communication and follow-up between the facility staff, the Dental Service Vendor, and the dental service providers. Although the dentist submitted the necessary paperwork for medical clearance and oral surgery consults, the facility did not make the appointment for the X-rays until September 2023, after receiving approval from the Dental Service Vendor. However, the appointment was canceled by the dental X-ray facility, and no further attempts were documented to reschedule the X-rays. Interviews with facility staff, including the Unit Secretary and the Director of Nursing Services, revealed that there was confusion and miscommunication regarding the approval and scheduling process for the dental X-rays. The Unit Secretary stated they did not receive approval until September 2023, while the Dental Service Vendor indicated that approval was given earlier. The Director of Nursing Services acknowledged that the X-rays should have been completed when initially ordered in March 2023.
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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 Holtsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medford Multicare Center For Living | 2.1 mi | ★★★★★ | 0 | 0 |
| Swan Lake Nursing & Rehabilitation | 4 mi | ★★★★★ | 5 | 1 |
| Brookhaven Health Care Facility, Llc | 4.1 mi | ★★★★★ | 3 | 0 |
| Sayville Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Quantum Rehabilitation And Nursing Llc | 5.6 mi | ★★★★★ | 2 | 0 |
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