Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Long Island State Veterans Home during CMS and state inspections, most recent first.
A recertification survey found that the facility did not ensure vertical ventilation duct penetrations through floors were protected with a minimum 1-hour fire resistance rating, as required by NFPA 101 and NFPA 90A. The issue was acknowledged by facility personnel, who stated that a project to address the deficiency was in the planning phase. A Time Limited Waiver from CMS was in place, set to expire in 2026.
A resident did not have their mouth rinsed after receiving a Symbicort inhaler, a steroid medication, as per physician's orders. The LPN administering the medication admitted to being nervous, leading to the oversight. The facility's policy requires rinsing the mouth to prevent oral thrush, a potential side effect of the medication.
The facility did not submit a Criminal History Record Check (CHRC) 105 Form to the NYSDOH within the required 30-day timeframe for an employee who received a negative determination Hold in Abeyance letter. The employee was removed from their position, but the facility's policy did not specify a timeframe for submitting the form, leading to the deficiency.
A facility failed to submit a resident's Significant Change MDS assessment to CMS within the required 14-day period, resulting in a 35-day delay. The resident had conditions including Atrial Fibrillation and Heart Failure. The delay was due to reliance on a software system that did not list the assessment as due for transmission, and the facility's policy lacked specific timeframes for submission.
Non-compliance with Fire Resistance Standards for Ventilation Ducts
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure that vertical ventilation duct penetrations passing through floors were protected in accordance with NFPA 101 and NFPA 90A standards. Specifically, the resident toilet exhaust ducts extending vertically from the first floor through the third floor were not enclosed with a minimum fire resistance rating of at least 1 hour. This deficiency was noted during the Life Safety Code survey conducted between March 5 and March 6, 2025. In an interview conducted on March 5, 2025, at 10:00 am, the facility's Engineering, Support, Administration, and Life Safety Personnel acknowledged that a project to address this issue was in the planning phase. This project included capital procurement, design, and permit application to install fire-rated dampers at the floor penetration of the vertical ventilation ducts. The facility had received an approved Time Limited Waiver from CMS to comply with the prescriptive code requirement, which is set to expire on October 10, 2026.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. III. The following measures and/or systemic changes will be implemented to ensure the deficient practice identified does not recur: Long Island State Veterans Home (LISVH) continues to utilize the Time Limited Waiver approved by CMS on (MONTH) 3, 2025, to address deficiency K-521. Listed below is the project update related to deficiency K-521: LISVH has secured an approved Veteran Affairs Construction Grant to fund the corrective actions required to address the K-521 HVAC bathroom exhaust deficiency. LISVH completed the bidding process to select a consultant to facilitate the design to correct the K-521 deficiency. The design was completed and sent to DOH for CON approval. The DOH approved the project CON on 1/14/2024. LISVH has generated the bid package and selected a construction contractor as well as the electrical vendor for the project. The electrical vendor contract has been awarded. LISVH purchasing department is preparing the construction contract for submittal to the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC). Upon receipt of approval from the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC), LISVH will finalize contract award and work to commence construction. Construction is estimated to begin (MONTH) 2025. LISVH Building Safety Features: - The building is fully sprinklered with quick action heads throughout the facility. - The building is protected by smoke detection and fire alarm pull stations. - Each floor is separated into multiple smoke compartments in the event of an emergency and relocation is required. LISVH additional fire safety protocols: - Staff are trained on Fire Safety upon hire; additional departmental Fire safety training will be conducted annually by the safety specialist and staff will undergo additional training on environment of care and safety, utilizing the facilities electronic education system. - Increase frequency of fire drills for all shifts. - Conduct training related to emergency management and evacuation drills. - Areas under construction will be assessed daily to ensure combustibles are removed and the area is neat and organized, prior to leaving the site each day and more frequently if necessary. - Fire protection system impairment policy shall be implemented in the event of a fire system impairment. - Require a Hot Work Permit. - In the event a partial or full evacuation is necessary, the facility in coordination with the fire department would initiate the necessary facility evacuation plan. This evacuation would occur with evacuating the Residents closest to the fire and then the floors above and below where the fire is located followed by the residents further away from the fire. The residents with higher acuity will be relocated within our facility or nearest hospital and then residents with lower acuity will be evacuated to alternate locations or facilities until the fire department is able to give further direction on the scope and severity of the fire. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will provide updates on the Bathroom Exhaust Project to the LISVH QAPI Committee. V. Responsibility: Director of Support Services
Failure to Rinse Mouth After Symbicort Administration
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, specifically during the administration of medication. On March 6, 2025, during a medication pass observation, a Licensed Practical Nurse (LPN) did not rinse the mouth of a resident after administering a Symbicort inhaler, which is a steroid medication. This omission was contrary to the physician's orders and the facility's medication administration policy, which requires rinsing the mouth to prevent oral fungal infections. The resident, who was cognitively intact, had a diagnosis of Chronic Obstructive Pulmonary Disease and was prescribed Symbicort to be administered twice daily with a directive to rinse the mouth after use. The LPN admitted to being nervous, which led to the oversight. Interviews with the Registered Nurse Educator and the Director of Nursing Services confirmed that the mouth rinse was a necessary step to prevent potential side effects such as oral thrush. The facility's policy clearly outlined the responsibilities of licensed nurses to be aware of medication administration standards, including the need to rinse the mouth after administering steroidal inhalation medications.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Upon notification from the NYS Surveyor that the Licensed Practical Nurse (LPN) failed to rinse resident # 260’s mouth, as per the physician order, the LPN immediately rinsed resident # 260’s mouth as ordered. Resident # 260 was seen and examined by the attending physician (MD) on 3/10/2025 at 1:22 pm. The MD documented that there was no evidence of thrush or oral plaques noted. In addition, beginning on 3/10/2025, the nurse who was observed, as well as all other medication administration nurses, were re-educated regarding the need to rinse resident’s mouths after administering steroid inhalation medications. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have an order for [REDACTED]. The facility’s Director of Pharmacy (DOP) will generate a list of all residents who have active orders for all inhalation type of medications by 03/28/2025. The DOP will indicate which of these residents have an inhalation medication that is in the steroidal drug class. Beginning on (MONTH) 31, 2025, the Nursing Informatics Coordinator will review all MD orders for steroidal inhalers to ensure that the order includes directives to rinse the resident’s mouth after administration. Beginning on (MONTH) 1, 2025, the Nursing Educators will conduct medication administration competencies on all facility nurses who are administering steroidal medications to residents to ensure that they are following physician orders, and rinsing the residents mouths after administration. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The Interdisciplinary Team (IDT) reviewed the policy and procedure titled “Medication Administration” on 03/20/2025. There were no necessary changes to the Policy and Procedure upon review. The policy and procedure titled “Medication Administration” was further reviewed by the Director of Nursing, Medical Director and Facility Administrator on 03/24/2025 and approved on 03/24/2025. Beginning on (MONTH) 7, 2025, the Nursing Educators will conduct re-education sessions regarding aspects of medication administration to all facility licensed nursing staff (RN and LPN). The education will include, at minimum, the rights of medication administration, reviewing the MD orders prior to administering medications, a brief review of different types of drug classifications and the importance of rinsing residents mouths after administering steroidal inhalation medications. This education will be completed by (MONTH) 2, 2025. IV. The facility’s compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that nurses administering steroidal inhalation medications are correctly following MD orders to rinse residents mouths after administering the medication. Each month the pharmacist will generate a list of residents who are currently receiving a steroidal inhalation medication. These residents will be added to the developed audit tool to ensure compliance. The Nurse Educators, or designees, will complete a competency assessment on all licensed nurses responsible for medication administration on a monthly basis, based on the list of residents identified by the pharmacist. Deficient practices will be corrected immediately, and nurses who fail to adhere to the MD orders for steroidal inhalation medication will be directed to the nursing education classroom for formal re-education and competency before they are permitted to administer any type of medication to facility residents. These audits will be completed monthly for three (3) months and quarterly for three (3) consecutive quarters, and will be conducted across all shifts. All audit findings will be reported to the facility Administrator and Director of Nursing (DON) following completion. The DON will report results of the audits at the facility’s quality assurance and performance improvement committee meeting. The compliance standard will be set to 100%. At the end of the third quarter, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI review of the audits. Responsibility: Director of Nursing
Failure to Submit CHRC 105 Form in Required Timeframe
Penalty
Summary
The facility failed to ensure that a Criminal History Record Check (CHRC) 105 Form was submitted within the required 30-day timeframe to the New York State Department of Health (NYSDOH) for an employee. This deficiency was identified during a recertification survey, where it was found that the facility received a negative determination Hold in Abeyance letter for an employee on January 8, 2025. The employee was removed from their position on the same day and did not return to work as of March 10, 2025. However, the facility did not submit the required CHRC 105 Form to the NYSDOH within the stipulated 30 days to terminate the employee from the CHRC system. The facility's policy on Criminal Background Checks, last revised in July 2023, assigned the responsibility of timely reporting of all terminations to the Human Resources Department, but did not specify a timeframe for submitting the CHRC 105 Form. During interviews, the Director of Human Resources stated that they did not submit the form because the employee had not received a Denial letter and could potentially return to work if cleared. The Administrator acknowledged that the form should have been submitted within 30 days of receiving the negative determination letter and indicated that the policy would be updated to include the timeframe for submission.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 The following actions were accomplished for the residents identified in the sample: There were no residents identified by this deficient practice. A Criminal History Record Check (CHRC) form 105 for employee #6, who received the Hold in Abeyance letter, was submitted to CHRC on 03/06/2025 which removed them from the CHRC system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents may be affected by this deficient practice if employees who receive hold in abeyance letters are not removed from the CHRC system. On 03/27/2025 the Director of Human Resources reviewed all employees who are pending clearance for employment on the CHRC roster. There were zero (0) employees who have received a negative determination letter from CHRC requiring removal from employment at the Long Island State Veterans Home, and from the CHRC system. III. The following system changes will be implemented to assure continuing compliance with the regulations, and that the same deficient practice does not recur: The policy and procedure titled “Criminal Background Checks- Non-Licensed Personnel” was reviewed by the Interdisciplinary team (IDT). The IDT recommended that the policy be revised to contain language specifying the required time frame for employee removal from the CHRC system as per the regulations under 402.9(b)(2). Specifically, the policy was revised to state “LISVH Human Resources must immediately, but not later than 30 calendar days after the event, notify the Department when an individual is subject to CHRC via 103 submissions; and an individual is no longer subject to CHRC via 105 termination. Terminations include when an employee is no longer subject to CHRC; is no longer employed by the provider; employee death; or when a prospective employee is no longer being considered by the provider. In addition, all employees who receive a “Hold in Abeyance Letter” will be removed from the CHRC system within 30 days. In addition, the policy was revised to include a change in procedure, that no person who is offered employment at the LISVH will be permitted to commence employment without a favorable CHRC legal determination. The facility administrator, Director of Nursing and Medical Director reviewed the revised policy and approved the additional language on 03/26/2025. Beginning on 03/26/2025, the Director of Human Resources educated all Human Resources staff on the revised policy and procedure titled “Criminal Background Checks- Non-Licensed Personnel.” This education will be completed by 03/28/2025. IV. The facility’s compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that employees have a favorable CHRC legal determination in their employee record prior to commencing employment. The Director of Human Resources, or authorized Human Resources staff member prior to each orientation class will review the roster of scheduled new hires to ensure that all individuals have a favorable CHRC legal determination. Individuals who do not have favorable CHRC legal determinations will not be permitted to commence employment. The compliance standard will be set to 100%. This audit will be completed for each orientation for 12 calendar months. The Human Resources staff will report audit findings during the facility’s QAPI committee meetings. At the end of the audit period the QAPI committee will review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: Director of Human Resources
Delayed Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were transmitted to the Center for Medicare and Medicaid Services (CMS) within the required 14-day timeframe. This deficiency was identified during a recertification survey for a resident who had a significant change in condition. The resident, who had diagnoses including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Heart Failure, had a Significant Change MDS assessment completed on January 16, 2025. However, the assessment was not submitted to CMS until March 6, 2025, which was 35 days after completion. The delay in submission was attributed to the facility's reliance on a software system that tracks MDS assessment schedules. The system failed to generate a report listing the resident's assessment as due for transmission, leading to the oversight. Interviews with the MDS Director and Assistant Director revealed that they depended on the system to provide due dates for submissions, and the error was not identified until the survey. The facility's policy did not specify the timeframe for MDS completion and transmission, contributing to the oversight.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 I. The following actions were accomplished for the residents identified in the sample: The Minimum Data Set (MDS) for Resident #25 dated 1/10/25 and completed on 1/16/2025 was supposed to be submitted by 1/22/2025. The MDS director submitted this MDS on 3/6/2025, and it was accepted by the system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have MDS assessments completed have the potential to be affected by the same deficient practice. On (MONTH) 27, 2025, the MDS director generated a report of all MDS assessments that have not been submitted to ensure that there were no assessments that were late to be transmitted. There were no assessments (MDS) that were late to be transmitted. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The interdisciplinary team (IDT) reviewed the policy and procedure, on 03/24/2025, titled “MDS 3.0 Completion”. The IDT recommended adding to the responsibilities of the MDS director the following statement: Submit the MDS to both the CMS database as well as the state veterans home (SVH) databases within the timeframes established within the Resident Assessment Instrument guidelines as well the regulation under 483.20 (f)(1)-(4). In addition, the following statement was added: The MDS director, or designee will, generate the list for submission for all MDS assessments that are completed at a minimum, on a weekly basis. This list will be compared to the MDS calendar which contains all resident assessments that are scheduled, and is prepared by the MDS staff after reviewing the previously completed assessments. This will ensure that all MDS assessments which are due to be completed are submitted timely. The Facility Administrator, Director of Nursing and Medical Director reviewed the policy on 03/24/2025 and approved the addition. Beginning on 03/25/2025, the Director of Nursing (DON) re-educated all MDS staff members regarding the policy and procedure for MDS completion, including the change to the submission guidelines. This education will be completed by 03/28/2025. IV. The facility’s compliance will be monitored using the following Quality Assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that all completed MDS assessments are transmitted as per the RAI guidelines as well as the regulations under 483.20 (f) (1)-(4). Each week the MDS Director, or designee, will generate a list of all completed MDS assessments. They will compare the list of completed assessments to the MDS calendar to ensure that all scheduled assessments due for completion are completed and ready for transmission. Residents that have a completed MDS will be added to the audit tool to ensure compliance with transmittal. If MDS assessments are found to be past the required deadline for transmittal, the facility administrator, Director of Nursing, and Chief Financial Officer (CFO) will be notified immediately. Re-education will be provided to the MDS staff member, by the DON, if any MDS assessments are found to be past the required deadline for transmittal. The MDS director or designee will transmit all MDS assessments that are required to be transmitted. Following transmittal, the MDS director or designee will review the “MDS 3.0 NH Final Validation Report” to ensure that there were no assessments that contained errors or rejections. Any assessments that do contain errors or rejections will be reviewed and transmitted the same day as the original transmittal. These audits will be completed weekly for six (6) months, and then quarterly for two (2) consecutive quarters. The compliance standard will be set to 100%. At the end of the second quarterly audit, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits, and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: MDS Director
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 298 citations issued within 25 miles in the last 12 months — including the 10 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stonybrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jefferson's Ferry | 1.7 mi | ★★★★★ | 0 | 0 |
| St James Rehabilitation & Healthcare Center | 2.5 mi | ★★★★★ | 10 | 0 |
| Luxor Nursing & Rehabilitation At Mills Pond | 2.5 mi | ★★★★★ | 0 | 0 |
| Waters Edge At Port Jefferson For Rehab And Nrsg | 3 mi | ★★★★★ | 11 | 1 |
| Allegria Nursing & Rehab Center Of Port Jefferson | 3.4 mi | ★★★★★ | 0 | 0 |
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