Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Jefferson's Ferry during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependent transfer needs was moved from bed to a reclining chair by a single CNA using a mechanical lift, contrary to the care plan requiring two-person assistance. While the CNA adjusted the chairback, the resident fell forward to the floor, sustaining a skin tear, shoulder pain, and a head injury, and was sent to the hospital for evaluation.
The facility failed to ensure residents were free from physical restraints unless medically necessary. Alarms were used on 17 residents without documented assessments or physician's orders. Staff considered alarms a safety measure, not restraints, and did not require physician's orders, despite facility policy stating otherwise.
The facility failed to monitor cold food temperatures, leading to a deficiency identified during a survey. A tray of key lime pie was found at 66.5°F, above the safe range for cold foods. The facility's policy required temperature logging, but only hot food temperatures were recorded. Interviews confirmed the oversight, and the use of ice blankets was deemed insufficient.
Improper Transfer Leading to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent for transfers, and requiring a mechanical lift with two-person assistance was improperly transferred by a single Certified Nursing Assistant (CNA). The CNA used a mechanical lift to move the resident from bed to a reclining chair without the required assistance of a second staff member, as specified in the resident's care plan and facility policy. After placing the resident in the chair, the CNA attempted to adjust the chairback while standing behind the chair. During this process, the resident fell forward out of the chair onto the floor. As a result of the fall, the resident sustained a skin tear to the right lower extremity, bilateral shoulder pain, and a hematoma with an abrasion to the left forehead. The resident was subsequently transported to the hospital for evaluation and treatment. The incident was confirmed through staff interviews, record review, and facility documentation, which indicated that the CNA did not follow the prescribed care plan or facility procedures for safe transfers, constituting neglect as defined by facility policy.
Improper Use of Alarms as Restraints Without Medical Necessity
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment. This deficiency was identified during an abbreviated survey, where 17 residents were observed with alarms that were used as restraints without documented assessments for medical necessity. The facility's policy on physical restraint use states that restraints should only be used to assure the physical safety of residents, yet there was no evidence of assessments or physician's orders for the alarms used on these residents. Resident #1, who had a history of chronic obstructive pulmonary disease, acute respiratory failure, and gout, was observed with chair and bed alarms. Despite being a high fall risk, there was no documented evidence of an assessment for the use of these alarms or a physician's order. Interviews with staff revealed that alarms were used for resident safety, but they did not consider them restraints, and thus did not require a physician's order. Similarly, Resident #2, with a history of osteoarthritis and hypertensive heart disease, was observed with a clip alarm and bed alarm despite not being initially assessed as a fall risk. The alarms were implemented after an incident of unsafe ambulation, but again, there was no documented assessment or physician's order. Resident #3, diagnosed with Alzheimer's disease and cerebral ischemic attack, was also observed with alarms without documented assessments or orders. Staff interviews consistently indicated that alarms were used as a nursing intervention for safety, not as restraints, and did not require physician's orders.
Failure to Monitor Cold Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature, as required by professional standards for food service safety. This deficiency was identified during a recertification survey for one of the residents on Unit 2 West. Specifically, the facility did not monitor the temperatures of cold foods served to residents. During a lunch meal observation, a tray of key lime pie with whipped cream was found to have a temperature of 66.5 degrees Fahrenheit, which is above the safe temperature range for cold foods. The facility's policy required that all food temperatures be taken and logged immediately upon arrival at the designated unit, with any food in the danger zone (40-140 degrees Fahrenheit) requiring immediate corrective action. However, the temperature logs for Unit 2 only recorded hot food temperatures, and cold food temperatures were not noted for the first two weeks of May 2024. Interviews with the Assistant Director of Culinary Services and the Director of Culinary Operations confirmed that cold food temperatures were not being recorded, and the use of ice blankets under cold food items was insufficient. The President of Culinary Operations acknowledged the necessity of performing temperature checks for cold items and stated there was no excuse for the oversight.
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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 South Setauket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Island State Veterans Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Allegria Nursing & Rehab Center Of Port Jefferson | 2 mi | ★★★★★ | 0 | 0 |
| Waters Edge At Port Jefferson For Rehab And Nrsg | 2.7 mi | ★★★★★ | 11 | 1 |
| John T Mather Memorial Hosp T C U | 3.2 mi | ★★★★★ | 0 | 0 |
| St James Rehabilitation & Healthcare Center | 3.5 mi | ★★★★★ | 10 | 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.