Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Sands Point Center For Health And Rehabilitation during CMS and state inspections, most recent first.
Insufficient weekend nursing staffing was identified across multiple units after PBJ data showed excessively low weekend staffing for several quarters. The facility assessment required specific RN/LPN and CNA coverage on each shift, plus an RN supervisor on weekends, but staffing schedules showed repeated shifts with fewer CNAs than required and at least one shift with no nurse on a unit. The Staffing Coordinator, DON, and Administrator all acknowledged ongoing weekend staffing shortages, frequent call-outs, retention problems, and use of the RN supervisor or reassignments to cover gaps.
Infection control program deficiencies were cited because the facility did not document testing of all portions of the potable water system for Legionella and other waterborne pathogens. The water management plan and related engineering policy lacked a full description of the water distribution systems, flow diagrams, and identified Legionella sampling points, and staff stated the cold-water potable system had not been tested.
Two residents with cognitive impairment and behavioral risk factors were involved in an altercation after one became visibly annoyed when another entered the dining area. A CNA escorted the second resident back to their room but did not inform nursing staff or arrange for monitoring, allowing the resident to wheel themself back to the dining room and re-approach the first resident. While the CNA was occupied on the other side of the room, the first resident became angrier and struck the second resident on the head with an empty meal tray, resulting in an incident that facility leadership later acknowledged could have been prevented with closer supervision and communication.
A resident with gastrostomy, esophageal cancer, and dysphagia had a PEG tube and received tube feeding during the assessment period, but the admission MDS did not indicate the feeding tube in Section K. The Dietician said the omission was an error, the MDS nurse said signing Section Z only verified completion, and the DON stated the assessment should have accurately reflected the resident’s feeding tube status.
Significant medication error involving crushing of extended-release metoprolol. An LPN crushed multiple medications for a resident with HTN, HF, and DM, including an extended-release metoprolol succinate tablet labeled to swallow whole and not crush. The resident had no current order to crush medications, and the DON, physician, and pharmacist all confirmed the extended-release tablet should not have been crushed.
Unlabeled tube feeding and IV solution bags were observed for two residents. A resident receiving continuous enteral feeding had a feeding bottle without the required resident and administration details, and an RN acknowledged the label was forgotten. Another resident receiving IV hydration had an IV bag without resident identification or start date/time on two observations, and staff stated the label should have included the resident’s name, room number, medication information, and start time.
Incomplete documentation of PRN oxygen administration. A resident with COPD, CVA, seizure disorder, and severe cognitive impairment had an order for oxygen at 2 L/min via NC as needed to keep O2 saturation above 90%. Surveyors observed the resident receiving oxygen on multiple occasions, but the MAR/TAR had no nursing signatures showing the PRN oxygen was administered. Staff stated the oxygen was applied when the resident became short of breath and desaturated, but it was not documented as required.
The facility failed to maintain adequate staffing levels, as outlined in their assessment, leading to a 1-star staffing rating and resident complaints. CNAs were often responsible for more residents than the facility's plan allowed, resulting in missed showers and delayed meals. Staff and administration acknowledged the staffing shortages, citing high turnover and callouts as contributing factors.
A resident at risk for pressure ulcers was not provided with a comprehensive care plan, as they were observed without physician-ordered heel boots. The CNA was unaware of the requirement, and the resident had not worn the boots for months due to discomfort. The refusal was not documented or reported, and alternative measures were not explored until after the deficiency was identified.
Two residents with pressure ulcers in an LTC facility were found to have their alternating pressure relief air mattresses set inaccurately according to their weights, contrary to physician's orders. Despite the facility's policy requiring nurses to monitor and adjust the settings every shift, staff failed to do so, leading to inadequate care. Interviews revealed a lack of awareness among nursing staff about the importance of correct weight settings.
The facility failed to maintain a safe environment for three residents. A resident with impaired cognition had a Symbicort inhaler at their bedside without proper assessment for self-administration. Another resident had unauthorized cleaning supplies in their room, and a third resident with severe cognitive impairment had an unsecured oxygen tank next to their bed. These incidents highlight a lack of adherence to facility policies and supervision, posing potential risks to resident safety.
A resident with moderately impaired cognition was found with a Symbicort inhaler at their bedside, contrary to facility policy and physician's orders requiring medications to be stored in locked compartments and administered by nursing staff. Observations and staff interviews confirmed the inhaler should have been stored in the medication cart, highlighting a failure in medication storage protocols.
A deficiency in infection control was identified when a nurse failed to perform hand hygiene and allowed a cleansed wound to contact a dirty surface during wound care for a resident with a heel ulcer. The nurse did not seek assistance to hold the resident's leg, leading to improper wound care practices, as confirmed by the infection preventionist and DON.
The facility's assessment failed to document the necessary nursing staff resources for competent resident care. The staffing plan lacked details on the number of LPNs and RNs per shift and incorrectly calculated CNA numbers based on fewer beds than the facility's capacity. The Administrator acknowledged these omissions during an interview.
Insufficient Weekend Nursing Staffing
Penalty
Summary
The facility did not ensure sufficient nursing staff were available to provide nursing and related services to meet resident needs and maintain resident safety. The deficiency was identified on all five units reviewed for the Sufficient Nursing Staffing Task: Unit 1 Center, Unit 1 North, Unit 1 West, Unit 2 Center, and Unit 2 West. The Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report showed the facility triggered for excessively low weekend staffing for Fiscal Year 2025 Quarter 1 through Quarter 4 and Fiscal Year 2026 Quarter 1. The facility assessment last reviewed on 12/04/2025 documented a bed capacity of 180 and an average daily census of 138.4. For weekend staffing, the assessment required specific RN or LPN and CNA coverage on each unit for day, evening, and night shifts, and also required an additional RN Supervisor on each weekend shift. However, a review of staffing schedules from 10/05/2024 through 12/28/2025 showed multiple shifts where units were staffed below the assessed CNA requirements, including instances where only two CNAs were assigned on units that required three to four CNAs, and instances where only one CNA was assigned on night shift units that required two CNAs. The report also noted one occasion where the RN Supervisor covered Unit 1 Center and there was no nurse on Unit 2 West. During interviews, the Staffing Coordinator stated the facility had low weekend staffing over the past year, especially with CNAs, and that they tried to staff four CNAs per unit but at least three should be assigned if there were staffing problems. The DON stated staff called out frequently, retention had been a concern, and when weekend staffing was short the RN Supervisor sometimes covered unit nursing needs, including an instance where a nurse was moved from Unit 1 North to Unit 2 West, leaving Unit 1 North with only one RN even though it was a subacute unit requiring two nurses each shift. The Administrator stated the facility had longstanding nurse staffing shortages and weekend coverage concerns related to transportation access and staffing availability.
Infection Control Program Lacked Complete Water Management Documentation
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and help prevent the development and transmission of communicable diseases and infections. During the Infection Control Task, surveyors found that the facility did not provide documented evidence of testing all portions of the potable water system for Legionnaires' and other waterborne pathogens, and it also did not provide documents describing the building's water distribution systems to identify Legionella sampling points. The facility's undated Engineering & Facilities policy titled Section: Engineering Management Subject: Legionella Tessing did not document a description of the water distribution systems in the building, did not include a flow diagram of the water distribution systems, and did not identify Legionella water sampling points. The Laboratory Certificate of Analysis showed water samples were collected from four hot water sinks and reported no Legionella isolates, but there was no documented evidence that the facility identified other areas with a high probability of opportunistic pathogens in the building's water distribution systems. During interviews, the Director of Plant Operations and Environmental Services stated they were not aware of testing the cold-water potable water distribution system and that the water management plan would be amended to identify additional sampling points and include a description and flow diagrams of the water distribution systems. The Administrator also stated the current Water Management Plan would be reviewed and revised to include a full description of the water distribution systems with flow diagrams and additional Legionella sampling points.
Failure to Adequately Supervise Residents Leading to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accident hazards during an interaction between two residents in the dining/dayroom. One resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, severely impaired cognition (BIMS score of 7), and a history of agitation and verbal outbursts entered the dining room where another resident was present. The second resident had a traumatic brain injury, seizures, hemiplegia of the left dominant side, moderately impaired cognition (BIMS score of 12), and was care planned as being at risk of being abused or mistreated by others and having the potential to abuse or mistreat others, with interventions including monitoring mood and providing early intervention on changes observed. Both residents used wheelchairs for locomotion. On the day of the incident, CNA #3 was monitoring the dining/dayroom shortly before 5:45 PM when the resident with traumatic brain injury appeared annoyed or upset upon the entry of the resident with Alzheimer’s disease. In response, CNA #3 escorted the resident with Alzheimer’s disease back to their room and then immediately returned to the dining room. CNA #3 did not notify the nurse or another CNA that the resident with traumatic brain injury was upset with the other resident, nor did they arrange for monitoring of the resident who had been redirected to their room to ensure they did not return to the dining room. Shortly afterward, the resident with Alzheimer’s disease wheeled themself back to the dining/dayroom and approached the table of the resident with traumatic brain injury. At that point, the resident with traumatic brain injury became angrier, picked up an empty meal tray, and struck the other resident on the head. CNA #3 was present in the dining room but was on the other side of the room assisting another resident and was unable to intervene in time to prevent the altercation. The resident who was struck was assessed and had no visible injuries, and the physician was notified. The other resident was sent to the hospital for evaluation and returned the next day with no recommendations. Facility leadership stated that the incident could have been prevented if the resident who had been redirected had been closely supervised or if staff had been informed of the potential for an altercation between the two residents.
MDS Did Not Accurately Reflect Feeding Tube Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to complete an admission MDS that accurately reflected a resident’s status. Resident #1 was admitted with diagnoses including gastrostomy, malignant neoplasm of the esophagus, and dysphagia, and had a PEG tube placed prior to the admission assessment period. The admission MDS documented a BIMS score of 8, indicating moderate cognitive impairment, but did not indicate that the resident had a feeding tube while in the facility. The record showed the resident had a PEG tube and received tube feeding during the assessment period, including physician’s orders for Jevity 1.5 via PEG tube with water flushes. A hospital and community patient review instrument documented the PEG tube placement, and care plans referenced the gastrostomy tube and tube feeding. During interviews, the Dietician stated Section K of the admission MDS should have indicated the feeding tube because the resident had one during the assessment period, and the omission in K0502 was an error. The MDS Assessment Nurse stated they signed Section Z only to verify completion, not the accuracy of each section, and the DON stated each staff member completing MDS sections is responsible for accuracy and the assessment should have reflected the feeding tube.
Significant Medication Error Involving Crushing of Extended-Release Metoprolol
Penalty
Summary
Resident #15, who had diagnoses including hypertension, heart failure, and diabetes mellitus, was observed during medication administration with a BIMS score of 11 and no documented swallowing disorder on the MDS. The resident had an order for a regular diet with thin liquids and no current physician’s order to crush medications. During the medication pass, an LPN prepared aspirin, Januvia, Lasix, metoprolol succinate extended-release, and potassium chloride extended-release for the resident. The LPN stated the resident had trouble swallowing and diluted the potassium chloride tablet in water, then crushed the other tablets together in a plastic bag with a pill crusher, including the extended-release metoprolol succinate tablet, despite the blister pack directions stating to swallow whole and not chew or crush. The crushed medications were placed in applesauce and administered to the resident, and the diluted potassium chloride was given in water. The record review confirmed there was no physician’s order in place to crush medications at the time of administration. During interviews, the LPN acknowledged the metoprolol succinate label said not to crush it, the DON stated there should have been a physician’s order and that the extended-release metoprolol succinate should not be crushed, and the physician stated the order to crush medications should have been in place before crushing occurred. The pharmacist stated crushing the extended-release metoprolol succinate changes its mechanism of action and causes the medication to be released at once.
Unlabeled tube feeding and IV solution bags
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles for two residents receiving tube feeding and intravenous hydration. The report identified that a resident with diagnoses including cerebrovascular accident, seizure disorder, and dysphagia, and with severe cognitive impairment, was receiving continuous Osmolite 1.5 tube feeding when the feeding bottle was observed without the resident’s name, room number, start time, flow rate, or the name of the nurse who started it. The facility policy for ready-to-hang feedings required complete labeling information, including resident name, room, date, start time, and rate. During observation, the tube feeding pump showed a flow rate of 55 milliliters per hour and formula remained in the bottle, but the bottle itself had no resident label. The unit manager stated the bottle should have been labeled with the resident’s identifying information and feeding details, and the medication nurse acknowledged forgetting to place the label on the bottle after starting the feeding. The Director of Nursing Services stated the nurse must place a resident label on the tube feeding bottle to ensure the right resident receives the right formula, rate, and volume. A second resident with diagnoses including anemia, adult failure to thrive, and heart failure, and with severe cognitive impairment, had an order for Dextrose 5% and 0.45% sodium chloride intravenous solution at 30 cc per hour. On two separate observations, the IV bag was infusing through a midline catheter but had no label showing resident information or the date and time the solution was initiated. The nurse stated the bag should have been labeled with the resident’s name and room number and acknowledged that the start date and time were not always indicated, while the unit manager and DON stated the IV label must include the resident’s name, room number, medication information, and start date and time.
Incomplete Documentation of PRN Oxygen Administration
Penalty
Summary
Medical records were not maintained in accordance with professional standards because the facility did not document administration of as-needed oxygen for one resident. The resident had diagnoses including cerebrovascular accident, seizure disorder, and chronic obstructive pulmonary disease, and the quarterly MDS documented severe cognitive impairment with a BIMS score of 5. The resident also had shortness of breath when lying flat and received oxygen therapy while in the facility. A physician’s order dated 01/22/2026 directed oxygen at 2 liters per minute via nasal cannula as needed, with oxygen saturation to remain greater than 90%. During observations on 03/09/2026, 03/10/2026, and 03/11/2026, the resident was seen receiving oxygen via nasal cannula, and the concentrator was set at 2 liters per minute during at least two of those observations. Review of the March 2026 Treatment Administration Record showed no nursing signatures documenting that the as-needed oxygen had been administered for that month. During interviews, the unit manager stated oxygen had been applied that morning because the resident became agitated, short of breath, and had an oxygen saturation of 88%, but there was no chance to document it. Staff Development and the DON stated nurses should sign off in the treatment administration record and document when oxygen therapy is administered.
Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by a 1-star staffing rating and numerous complaints from residents about short staffing. The facility's staffing plan outlined specific ratios for Certified Nurse Aides (CNAs) during different shifts, but these ratios were not consistently maintained. For instance, during the night shift, the facility assessment required a ratio of one CNA to 13 residents, but records showed instances where one CNA was responsible for up to 36 residents. Similarly, during the day and evening shifts, the required ratio of one CNA to eight residents was often exceeded, with CNAs sometimes caring for up to 17.5 residents. Interviews with staff and residents further highlighted the impact of short staffing. Residents reported missing showers and receiving bed baths instead, and meals were delayed, resulting in cold food. CNAs described being overworked and unable to provide timely care due to the high number of residents assigned to them. The facility's staffing coordinator and Director of Nursing Services acknowledged the staffing shortages, attributing them to high staff turnover and frequent callouts, which left the facility unable to maintain the staffing levels outlined in their assessment. The facility's administration, including the Administrator and Director of Nursing Services, recognized the ongoing staffing challenges. They noted that the facility struggled with recruiting and retaining staff, which contributed to the inability to meet the required staffing ratios. Despite efforts to manage the situation, such as the Director of Nursing Services stepping in to assist with care, the facility continued to operate with insufficient staff, compromising the quality of care provided to residents.
Failure to Implement Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was implemented for a resident at risk for developing pressure ulcers. Resident #86, who had a history of Diabetes Mellitus, Cerebrovascular Accident, and Hemiplegia, was assessed to be at risk for pressure ulcers and had physician orders to wear protective heel boots while in bed. However, the resident was observed multiple times without the heel boots, and the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the requirement. The resident stated they were not informed about the heel boots and had not worn them for months, citing discomfort as the reason for refusal. The CNA did not report the resident's refusal to wear the heel boots to the Registered Nurse (RN) or document the refusal in the resident's medical record. Consequently, the care plan was not updated to reflect the resident's needs or preferences, and alternative measures for offloading the heels were not explored until after the deficiency was identified. The Director of Nursing Services acknowledged that staff should have consulted with the physician and rehabilitation department for alternative solutions when the resident expressed discomfort with the heel boots.
Inaccurate Air Mattress Settings for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for two residents who were using alternating pressure relief air mattresses as per physician's orders. For Resident #126, the air mattress was not set accurately according to the resident's weight, which was 157 pounds, but the mattress was set at 305 pounds. This discrepancy was observed on multiple occasions, and the responsible nurses did not verify the weight setting, merely signing off on the electronic medical record without proper checks. Resident #124, who had an unstageable right hip pressure ulcer, also experienced similar issues with the air mattress settings. The resident's weight was recorded as 166 pounds, yet the air mattress was set at 325 pounds. Nurses documented that the mattress was functioning properly without ensuring the weight setting was correct. Interviews with nursing staff revealed a lack of awareness and understanding of the importance of setting the air mattress according to the resident's weight. The facility's policy required nurses to monitor the air mattress every shift and ensure it was set correctly according to the resident's weight. However, interviews with the Director of Nursing Services and other staff indicated that this was not being done, leading to the deficiency. The failure to adhere to the policy and physician's orders resulted in inadequate pressure ulcer care for the residents involved.
Failure to Maintain a Safe Environment Free from Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. Resident #140, who had moderately impaired cognition and was receiving oxygen therapy, was found with a Symbicort inhaler at their bedside. The resident was not assessed or care planned to self-administer medications, and the inhaler was supposed to be stored in the medication cart and administered by nursing staff. Despite this, the resident self-administered the inhaler and informed the nurse afterward, indicating a lack of supervision and adherence to the facility's medication policy. Resident #58, who was cognitively intact, was observed with an air freshener spray and a multi-surface disinfectant cleaner spray at their bedside. These items were brought in by a family member, contrary to the facility's policy prohibiting outside chemicals. Despite staff awareness and previous discussions with the resident and family, the cleaning supplies remained in the room, indicating a failure to enforce the policy and remove potential hazards. Resident #91, with severe cognitive impairment, had an unsecured oxygen E-Cylinder tank next to their bed. The tank was not in a rolling safety stand as required by the facility's policy, posing a risk of falling and potential injury. The resident no longer had an order for oxygen use, and the tank should have been removed. Staff oversight and lack of adherence to the oxygen storage policy contributed to this deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by state and federal regulations. This deficiency was identified during a recertification survey when a resident was observed with a Symbicort inhaler stored at their bedside without staff supervision. The facility's policy mandates that medications be stored in locked areas and accessed only by authorized personnel. However, the resident, who had moderately impaired cognition and was receiving oxygen therapy, was found self-administering the inhaler, contrary to the physician's orders that required nursing staff to administer the medication and store it in the medication cart. The incident was confirmed through observations and interviews with facility staff, including the LPN responsible for administering medications and the Charge Nurse. Both acknowledged that the inhaler should not have been left at the resident's bedside and should have been stored securely in the medication cart. The Director of Nursing Services also confirmed that the inhaler should not have been accessible to the resident, as it posed a risk of unsupervised self-administration. This oversight highlights a failure to adhere to medication storage protocols, potentially compromising resident safety.
Infection Control Deficiency in Wound Care
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. The deficiency involved improper wound care for a resident with a left heel ulcer. The resident, who had a history of diabetes mellitus, peripheral vascular disease, and a non-pressure chronic ulcer of the heel, was observed receiving wound care from a registered nurse. The nurse failed to perform hand hygiene after cleaning the wound and allowed the cleansed wound to come into contact with a dirty bed sheet. This was contrary to the facility's policy and competency requirements, which mandate hand hygiene and the use of clean gloves after wound cleaning. The incident was observed by a surveyor, who noted that the nurse did not have assistance to hold the resident's leg, resulting in the wound resting on the mattress. The nurse admitted to being nervous and acknowledged the mistake of not sanitizing their hands. Interviews with the infection preventionist and the director of nursing services confirmed that the nurse should have sought assistance and maintained proper hand hygiene. The failure to follow proper procedures was a clear breach of the facility's infection control protocols.
Inadequate Staffing Assessment in Facility
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately documented the necessary resources to care for residents competently during day-to-day operations. Specifically, the assessment did not include the overall number of qualified nursing staff required to meet each resident's needs. The staffing plan outlined in the assessment lacked specific details regarding the number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) assigned to each shift, including day, evening, and night shifts. This omission indicates a significant gap in the facility's ability to plan and allocate appropriate nursing resources. During an interview, the Administrator acknowledged that the facility assessment was reviewed but failed to notice the missing details about the number of licensed nurses per shift. Additionally, the Administrator admitted that the staffing plan for Certified Nurse Aides (CNAs) was incorrect, as it was based on a lower number of beds than the facility's actual capacity of 180 certified beds. This discrepancy resulted in an inadequate number of CNAs to maintain the required ratio of one CNA to eight residents, further highlighting the deficiency in the facility's staffing assessment.
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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 Port Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Amsterdam At Harborside | 1.5 mi | — | 0 | 0 |
| The Grand Rehabilitation And Nursing At Great Neck | 3.9 mi | ★★★★★ | 0 | 0 |
| Sunharbor Manor | 4 mi | ★★★★★ | 0 | 0 |
| Emerge Nursing And Rehabilitation At Glen Cove | 4.2 mi | ★★★★★ | 0 | 0 |
| Glen Cove Center For Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 6 | 0 |
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