Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Our Lady Of Consolation Nursing And Rehabilitive C during CMS and state inspections, most recent first.
The facility failed to immediately report several abuse-related allegations to the state as required. One resident with dementia and moderate cognitive impairment reportedly told a representative that someone twisted their arm, but multiple staff, including social work, nursing leadership, and the administrator, interpreted this as a figure of speech, did not clarify the statement with the resident or representative, and did not report it. Another resident with stroke-related hemiplegia and diabetes alleged that a CNA was rough, left them unclothed in front of guests, and transferred them alone with a mechanical lift despite a two-person requirement; the DON completed an investigation, reassigned the CNA, documented that the allegation was credible in error by their later account, did not interview the resident, and did not report the allegation. A third resident with moderate cognitive impairment alleged a CNA was rough and tossed them around during care; the CNA was removed from the assignment after an internal investigation, but the RN Unit Manager did not consider it abuse and did not escalate or report it. Leadership, including the DON and administrator, stated they only reported allegations to the state within two hours if they were substantiated or involved willful harm, and the medical director reported not knowing the difference between a grievance and an abuse allegation or the reporting requirements.
The facility failed to thoroughly investigate multiple allegations of abuse, rough handling, and dignity violations reported through its grievance process. In separate incidents, a resident told a representative that someone twisted their arm, another resident with hemiplegia reported a CNA was rough, left them unclothed in front of guests, and transferred them without the required 2-person mechanical lift assist, and a third resident with moderate cognitive impairment reported being roughly handled and "tossed around" by a CNA. Investigations were either not initiated or were limited to brief interviews and a single staff statement, with no documented physical assessments, no exploration of all specific allegations (such as failure to follow the transfer care plan), and no interviews with other residents cared for by the accused staff. Leadership and the medical director described treating these concerns as general grievances rather than abuse allegations and demonstrated uncertainty about when rough handling constitutes abuse, resulting in incomplete investigative practices.
Surveyors found that the facility did not ensure hot foods were served at a safe and appetizing temperature, as required by its own policy. A complaint alleged that a resident’s meals had consistently been served cold, and another resident reported that meals delivered to their room were often cold. During a lunch service on one unit, observers tracked the timing of food preparation, transport, and tray service, then measured a test tray and found the hot entrée and vegetable well below the required 140°F. Although dietary staff reported having obtained acceptable temperatures before service, both the Dietary Ambassador and Food Service Director acknowledged that hot foods should not be served below 140°F.
A Recertification Survey revealed that the facility's policy on the use and storage of foods brought by family and visitors did not ensure assistance for residents unable to eat independently. The facility did not provide accommodations for heating or storing external food items, and staff only assisted residents with facility-prepared meals. The Director of Culinary Services confirmed the lack of storage and reheating provisions for outside food and the limited feeding assistance policy.
The facility failed to ensure proper food storage and labeling practices. Unlabeled and undated trays of coconut custard pie and diet vanilla pudding were found in the walk-in refrigerator, and an opened carton of liquid eggs lacked proper dating. Additionally, a pan of frozen leftover cornflake chicken had been stored for over two months without clear discard guidelines.
A facility failed to ensure resident dignity during meal assistance when a CNA was observed standing over a resident while assisting with their meal, contrary to the facility's policy requiring staff to sit at eye level. The resident, who had severe cognitive impairment and required substantial assistance, expressed discomfort with this practice. Interviews confirmed the importance of sitting at eye level to preserve dignity.
The facility failed to ensure that a resident's tube feeding and hydration bottles were labeled with the necessary information, as required by policy. The resident, who had severely impaired cognition and required tube feeding as the primary source of nourishment, had unlabeled feeding bottles on two separate occasions. Staff acknowledged the oversight during interviews.
A resident with Chronic Obstructive Pulmonary Disease was observed receiving 4 liters of oxygen instead of the prescribed 3 liters, and there was no documentation of oxygen therapy administration in the medical record. Nursing staff were unsure where to document the oxygen administration, leading to a deficiency in providing respiratory care consistent with professional standards of practice.
Failure to Timely Report Multiple Abuse Allegations to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations of abuse and rough care to the New York State Department of Health (NYSDOH) within the required two-hour timeframe. Facility policy titled “Abuse Prohibition” dated August 2024 stated that all alleged cases of abuse, neglect, or mistreatment would be reported to the Department of Health or other appropriate agencies by the Administrator and/or the President of Clinical Services, and that alleged cases of abuse must be reported within five days, with confirmed cases reported immediately. Despite this, surveyors found no documented evidence that several specific allegations were reported to NYSDOH as required. The facility’s leadership, including the Administrator and Director of Nursing (DON), stated that they only reported allegations within two hours if they were substantiated or if they believed there was evidence of willful harm. One resident with atrial fibrillation, respiratory failure, dementia, and a moderate cognitive impairment was the subject of an email grievance from their designated representative, who reported that the resident stated someone twisted my arm this morning. The email was sent to a social worker and forwarded to the Director of Social Work/Grievance Official and the RN Unit Manager. The Director of Social Work/Grievance Official, Social Worker, RN Unit Manager, DON, and Administrator all stated they interpreted the phrase someone twisted my arm as a figure of speech rather than a physical act, and therefore did not investigate it as an abuse allegation or report it to NYSDOH. The RN Unit Manager stated they interviewed the resident and the representative about other concerns in the email but did not document the interview and did not ask about the arm being twisted. There was no documented evidence that this allegation was reported to NYSDOH. Another resident with cerebral infarction, hemiplegia/hemiparesis, and type 2 diabetes, and with intact cognition, reported via a grievance form that a CNA was rough and hurt them at times during care, left them unclothed for extended periods including in the presence of guests, and transferred them alone with a mechanical lift despite a requirement for a two-person transfer. An investigative summary dated the day after the grievance documented that there was credible evidence that this allegation was credible, that there was no evidence of abuse or mistreatment, and that the CNA would no longer be assigned to the resident. The DON later stated that the phrase there was credible evidence that this allegation was credible was written in error and should have read there was no credible evidence that this allegation was credible, and also stated they did not interview the resident. The DON further stated that at the time of the allegation, they only reported allegations of abuse to NYSDOH within two hours if they found evidence of willful harm. There was no documented evidence that this allegation was reported to NYSDOH. A third resident with urinary tract infection, hereditary hemorrhagic telangiectasia, transient cerebral ischemic attack, and moderate cognitive impairment reported via a grievance form that a CNA was rough with me, tossed me around, and had a nasty disposition. The grievance investigation documented that the resident was interviewed and stated the CNA was rough removing their pants, that a statement was taken from the CNA, and that the CNA was removed from the assignment. There was no documented evidence that this allegation was reported to NYSDOH. The RN Unit Manager stated they did not report this alleged abuse to the Assistant DON or DON because they did not think the allegation was abuse. The Assistant DON stated that abuse was documented as a grievance, an investigation was completed, and if they felt abuse occurred then it was reported to NYSDOH within two hours. The DON and Administrator both stated that they reported allegations to NYSDOH within two hours only if they found evidence of willful harm or if the allegation was substantiated. The Medical Director stated they did not know the difference between a grievance and an allegation of abuse/incident and did not know if an allegation of abuse should be reported to NYSDOH. Immediate Jeopardy was identified related to these failures.
Failure to Thoroughly Investigate Multiple Abuse and Rough-Handling Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, mistreatment, or neglect reported through its grievance process. For one resident with atrial fibrillation, respiratory failure, and dementia, a designated representative emailed the social work staff stating the resident reported that someone twisted their arm that morning. The email was forwarded to the Director of Social Work/Grievance Official and the DON. The only documented investigation attached to this grievance addressed skin tears sustained on the same date, with no separate or specific investigation into the allegation that the resident’s arm had been twisted. The Director of Social Work stated they did not recall seeing the twisting allegation, and the DON stated they interpreted the phrase about twisting the arm as a figure of speech and therefore did not investigate it as a possible physical abuse incident. Another deficiency component concerns a resident with a history of cerebral infarction, hemiplegia/hemiparesis, and diabetes, who required extensive assistance of two staff via mechanical lift for transfers. This resident reported to therapy staff that a CNA was rough during care, hurt them at times, left them unclothed for extended periods in the presence of guests, and transferred them without the required second staff person and mechanical lift support. A grievance form documented these concerns, and a social worker’s interview note recorded that the resident did not want to report anything but acknowledged being left exposed. The investigative summary stated there was credible evidence that the allegation was credible but concluded there was no evidence of abuse or mistreatment, and it did not address the allegation of transfers being done without a second person as required by the care plan. The CNA’s written statement denied leaving the resident exposed or causing harm and described using the mechanical lift, but did not address the specific allegation of performing one-person transfers. The DON later stated that the wording in the investigative summary about credible evidence was a typo, acknowledged not documenting the telephone interview with the CNA, and confirmed that no documentation addressed the allegation of not following the transfer plan of care or included interviews with other residents cared for by the CNA. A third component involves a resident with urinary tract infection, hereditary hemorrhagic telangiectasia, and a history of transient cerebral ischemic attack, who had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. This resident filed a grievance stating that a CNA was rough, tossed them around, and had a nasty disposition. The grievance investigation form documented that the resident was interviewed, the CNA provided a statement denying rough treatment or attitude, and the CNA was removed from the assignment. A nurse’s progress note on the same date documented that the resident was a two-person approach due to accusatory behavior. The RN Unit Manager reported that no other interviews were conducted beyond the resident and the accused CNA. Facility leadership, including the Administrator, DON, ADON, and Medical Director, described handling such concerns as grievances, often limiting investigations to interviews with the resident and the accused staff member, without routinely performing physical assessments, notifying the physician in the absence of visible injury, or interviewing other residents cared for by the accused staff. The Medical Director stated they did not know the difference between a grievance and an allegation of abuse/incident and were unsure if rough handling constituted abuse, and the DON confirmed that interviewing other residents cared for the accused staff was not part of their investigative process. Across these three residents, the surveyors found no documented evidence that the facility conducted thorough investigations into the specific abuse-related allegations, including physical mistreatment (arm twisting, rough handling, being tossed around), dignity violations (being left unclothed in front of guests), and failure to follow the plan of care for transfers. The facility’s own policy required investigation of allegations of abuse, neglect, or mistreatment, yet the documentation and staff interviews showed that key allegations were either not investigated at all or were investigated in a limited manner that did not address all components of the complaints. This pattern of incomplete or absent investigation of alleged abuse and mistreatment formed the basis of the cited deficiency under 10 NYCRR 415.4(b).
Failure to Maintain Safe and Appetizing Temperatures for Hot Food
Penalty
Summary
The facility failed to ensure hot foods were served at a palatable, attractive, and safe appetizing temperature for residents, as required by its policy that all hot foods be cooked, held, and served at a minimum of 140 degrees Fahrenheit. A complaint intake documented that since admission, all of one resident’s meals were served cold; this resident had diagnoses including atrial fibrillation, respiratory failure, and dementia, with a Minimum Data Set (MDS) indicating moderate cognitive impairment, but the resident had been discharged and was unavailable for interview. Another resident, with diagnoses including muscle wasting and atrophy, Parkinson’s disease, and syncope and collapse, and an MDS indicating intact cognition, reported during interview that they preferred to eat meals in their room and that the food was often served cold. During an abbreviated survey focused on the DePorres Unit lunch meal service, surveyors observed the meal delivery process and measured food temperatures. Steam table pans for the unit were prepared and placed in the unit warming box at 11:46 AM, arrived on the unit at 11:50 AM, were placed on the steam table with plating beginning at 11:55 AM, and the last tray was served at 12:28 PM. A test tray taken at 12:29 PM showed the salmon teriyaki entrée at 81 degrees Fahrenheit and the carrots at 100 degrees Fahrenheit, both below the facility’s required minimum of 140 degrees Fahrenheit for hot foods. The Dietary Ambassador stated they had taken temperatures before serving and recorded 145 degrees Fahrenheit for the salmon and 140 degrees Fahrenheit for the carrots, and acknowledged that hot foods should be served at a minimum of 140 degrees Fahrenheit. The Food Service Director also stated that hot food should be served at a minimum of 140 degrees Fahrenheit and that residents should not receive hot food that is cold.
Deficiency in Policy for Food Brought by Visitors
Penalty
Summary
During a Recertification Survey conducted at the facility, it was found that the policy regarding the use and storage of foods brought to residents by family and other visitors did not ensure that residents who were unable to eat on their own were assisted in accessing and consuming the food. The facility did not provide accommodations for heating and storage of food brought in from outside, and staff only offered feeding assistance to residents when consuming facility-prepared food. The facility's policy on food brought in from outside sources stated that while residents could have food delivered from external venues, the facility would not reheat or store such food items. The policy did not outline how residents would be assisted in consuming food brought in by family or visitors if they were unable to do so independently. The Director of Culinary Services confirmed that the facility would not store any food brought in from outside sources and that feeding assistance was only provided when residents were consuming facility-issued meals.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen observation, multiple trays of coconut custard pie and diet vanilla pudding were found unlabeled and undated in the walk-in refrigerator designated for dairy products. The Director of Culinary Services and the Culinary Ambassador confirmed that the items were prepared that morning but were not labeled and dated as required. Additionally, a carton of liquid eggs in another walk-in refrigerator was found opened and dated without any indication of when it was first opened. The kitchen supervisor was unable to clarify the date's significance and acknowledged that the carton should have been labeled and dated upon opening. In the walk-in freezer, a pan of frozen leftover cornflake chicken was found labeled and dated 1/23/2024. The kitchen supervisor stated that leftover foods could be reused when the menu cycled, but could not explain why the cornflake chicken had been kept for over two months. The Director of Culinary Services, who was new to the facility, admitted unfamiliarity with the facility's policy on tracking and discarding leftover foods. The facility's policies on food storage and labeling did not adequately address the storage of prepared foods or leftovers, contributing to the observed deficiencies.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This deficiency was identified during a lunch meal observation where a Certified Nursing Assistant (CNA) was observed standing over a resident while assisting them with their meal. The facility's policy requires staff to sit at eye level with residents during meal assistance to ensure a comfortable and dignified experience. However, the CNA admitted to standing while assisting the resident because they did not like to sit, despite being aware of the policy and its importance for maintaining the resident's dignity. The resident involved had severe cognitive impairment and required substantial assistance with meals due to conditions such as Parkinson's Disease, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. The resident expressed discomfort with staff standing over them during meal assistance. Interviews with the CNA, the unit's Charge Nurse, and the Director of Nursing Services confirmed that staff should be seated at eye level with residents during meal assistance to preserve their dignity and facilitate interaction. The failure to adhere to this policy resulted in a deficiency citation under 10 NYCRR 415.3(d)(1)(i).
Failure to Label Tube Feeding Bottles
Penalty
Summary
The facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. Specifically, Resident #199's tube feeding and hydration bottles were not labeled with the resident's name, flow rate, date, and time the feeding was initiated. This was observed on two separate occasions on 4/07/2024. The facility's policy requires that the feeding product container be labeled with the date, time, rate of flow, and the nurse's initials, which was not followed in this case. Resident #199 was admitted with diagnoses of Epilepsy, Diabetes Mellitus, and Hypertension and had severely impaired cognition. The resident required tube feeding as the primary and only source of nourishment and hydration. During interviews, both the Nurse Manager and Registered Nurse acknowledged that the tube feeding bottles should have been labeled according to the facility's policy. The Director of Nursing Services also confirmed that the nursing staff should verify and label the feeding bottles to ensure accuracy with the physician's orders.
Failure to Document and Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, Resident #608 had a physician's order to administer 3 liters of oxygen via a nasal cannula as needed; however, on one occasion, the resident was observed receiving 4 liters of oxygen instead of the prescribed 3 liters. Additionally, there was no documented evidence in the medical record that the resident was being administered oxygen therapy as ordered by the physician. The facility's policy on oxygen therapy required checking the physician's orders for oxygen therapy and the liter flow rate, ensuring the liters ordered are accurate on the oxygen supply source gauge, and signing the Medication Administration Record that oxygen was applied. These steps were not followed for Resident #608, leading to the deficiency noted in the report. Resident #608 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Chronic Kidney Disease. The resident had intact cognition and frequently used oxygen to help them breathe better. Despite the physician's order and the facility's policy, there was no documentation in the Medication Administration Record or the Treatment Administration Record from 4/1/2024 to 4/10/2024 that the resident was receiving oxygen therapy. Interviews with nursing staff revealed confusion about where to document the oxygen administration, and it was confirmed that the nursing staff should have been documenting the oxygen administration in the resident's medical record, which they failed to do.
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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 West Islip
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Neck Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 10 | 0 |
| Berkshire Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 6 | 1 |
| Sunrise Manor Ctr For Nursing And Rehabilitation | 4.4 mi | ★★★★★ | 1 | 0 |
| Maria Regina Rehabilitation And Nursing | 6.1 mi | ★★★★★ | 0 | 0 |
| Momentum At South Bay For Rehabilation And Nursing | 6.8 mi | ★★★★★ | 6 | 0 |
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