Below 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 Smithtown Center For Rehabilitation & Nursing Care during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, and severe cognitive impairment had physician orders and a care plan for use of two half side rails for bed mobility. Following an OT assessment, a physician ordered discontinuation of the side rails, and they were removed, but there was no documentation that the resident’s designated representative/POA was notified of this treatment change as required by facility policy. The representative reported only learning of the removal when visiting and seeing staff taking the rails off, while the rehab director stated they relied on unit nurses for such notifications and the DON acknowledged that representatives should be informed of changes in treatments or nursing interventions.
Surveyors identified that a resident with bilateral above-knee amputations, intact cognition, and no use of prostheses or footwear was inaccurately coded on the Annual MDS as needing substantial/maximal assistance with putting on and taking off footwear, despite other documentation and direct observation confirming the resident did not utilize footwear and had ADL limitations related to amputations and osteoarthritis. The OT who completed the MDS and facility leadership acknowledged that the ADL item should have been coded as not applicable and that the assessment did not accurately reflect the resident’s functional status.
A resident with osteoarthritis, idiopathic peripheral autonomic neuropathy, type 2 DM, and bilateral above-knee amputations had a care plan for falls that included encouraging use of bed siderails for bed mobility. Although therapy assessed the resident, determined siderails were no longer needed, and the IDT agreed to remove them, the physician’s order for siderails was discontinued, and the siderails were physically removed, the comprehensive care plan was not updated to reflect their discontinuation, leaving the documented interventions inconsistent with the resident’s current status.
A resident with a history of COPD and other respiratory conditions did not receive all prescribed inhaler medications upon admission due to delays in pharmacy authorization and delivery. Only Ventolin was initially available and administered, while Symbicort and Tudorza Pressair were not provided until several days later. The LPN notified the pharmacy and physician about the missing medications and administered Ventolin for shortness of breath, but did not document its administration. The DON confirmed that the facility could have used a local pharmacy to obtain the medications and that it was the RN Supervisor's responsibility to ensure timely administration.
A resident with complex respiratory conditions did not receive all prescribed inhaler medications for several days after admission because the pharmacy required facility authorization to dispense high-cost medications. Only one inhaler was available and administered initially, while the others were delayed due to incomplete authorization and delivery processes. Nursing staff notified the pharmacy and physician, but documentation was incomplete, and the DON confirmed that alternative sourcing options were not utilized.
Failure to Notify Designated Representative of Side Rail Discontinuation
Penalty
Summary
Surveyors found that the facility failed to notify a resident’s designated representative when a treatment was discontinued, as required by facility policy and regulation. The facility’s policy on Physician Orders, revised January 2025, stated that the resident and/or designated representative would be updated on any medication or treatment changes. One resident with diagnoses including dementia, Alzheimer’s disease, and lack of coordination had a severe cognitive impairment per a recent MDS, required supervision or touching assistance for bed mobility, and setup assistance for transfers. This resident had a physician’s order dated 09/06/2025 for two half side rails for bed mobility, and the comprehensive care plan documented the use of two half side rails to enable bed mobility. On 10/16/2025, an OT progress note documented that the resident was screened by rehabilitation for removal of bed siderails to maintain a safe environment and promote overall quality of life, and a physician’s order on the same date directed discontinuation of the two half side rails. There was no documentation that the resident’s designated representative/power of attorney was notified of this change. During observation on 01/22/2026, the resident was seen in bed without side rails. In an interview, the designated representative stated they were not informed of the removal until they arrived for a visit and observed staff in the process of removing the side rails, and expressed that they would have liked to participate in the decision-making process. The Director of Rehabilitation stated they assessed the resident for side rail removal but did not inform the representative, indicating that unit nurses were responsible for notifications. The DON stated that if there was a change in treatments or nursing interventions, the designated representative should have been informed.
Inaccurate MDS ADL Coding for Resident With Bilateral Above-Knee Amputations
Penalty
Summary
Surveyors found that the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident reviewed for Activities of Daily Living. The facility’s policy on MDS assessments, dated March 2025, required comprehensive assessments that describe each resident’s capability to perform daily life functions and identify significant functional impairments. For this resident, the Annual MDS documented a Brief Interview of Mental Status score of 13, indicating intact cognition, and noted bilateral lower extremity impairments, wheelchair use for mobility, and no use of limb prostheses. The same MDS assessment recorded that the resident required substantial/maximal assistance with putting on and taking off footwear, even though other sections documented that sit-to-stand and walking 10 feet were not applicable/not attempted. Record review and interviews established that this documentation did not reflect the resident’s actual status. The resident had diagnoses including orthopedic aftercare following bilateral above-the-knee surgical amputation, type 2 diabetes mellitus, and primary generalized osteoarthritis, and the comprehensive care plan for ADLs identified a self-care deficit related to physical limitations from the bilateral amputations and osteoarthritis. During observation, the resident was seen in bed, stated they did not have legs, and revealed bilateral above-the-knee amputations, further stating they did not use prosthetic devices or footwear. The occupational therapist who completed the Annual MDS confirmed in interview that the resident did not use footwear and acknowledged that documenting a need for substantial/maximal assistance with footwear was incorrect, stating that “not applicable” should have been selected instead. The Director of Rehabilitation and the Director of Nursing Services both stated that the MDS for this resident was not completed accurately and that the assessment should accurately document that the resident did not utilize footwear due to bilateral above-the-knee amputations.
Failure to Update Care Plan After Bed Siderail Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect the discontinuation of bed siderails, as required by facility policy and regulatory standards. The facility’s bed rail policy stated that when the interdisciplinary care plan team determined a bed rail reduction was warranted, a bed rail assessment would be initiated and, if appropriate, the care planning process would be used to facilitate removal of the bed rails. The comprehensive care plan policy required that care plans be updated as needed based on occurrences and changes relevant to the resident’s care. For one resident with diagnoses including primary generalized osteoarthritis, idiopathic peripheral autonomic neuropathy, and type 2 diabetes, the Minimum Data Set documented intact cognition, no use of bed rails, and a need for partial/moderate assistance with bed mobility and transfers. This resident’s comprehensive care plan for falls, initiated earlier and revised at a later date, documented that the resident was at risk for falls due to bilateral above-knee amputations and included an intervention to encourage use of side rails to promote bed mobility. A physician’s order had been in place for two half side rails as enablers and was later discontinued. An occupational therapy progress note documented that the resident was screened for removal of bed siderails, that the resident could perform functional bed mobility without siderails with extensive assistance of one person, and that the interdisciplinary team agreed to remove the bilateral bed siderails. Observations on two separate days confirmed that the resident no longer had siderails on the bed, and the resident reported they had been evaluated and the siderails removed over a month prior. Despite these changes and team agreement, the comprehensive care plan was not revised to remove the intervention encouraging siderail use, leaving the care plan inconsistent with the resident’s current status.
Delayed Administration of Prescribed Inhalers Due to Pharmacy Authorization Issues
Penalty
Summary
A deficiency was identified when a resident with a complex pulmonary history, including bronchiectasis, respiratory failure, and COPD, did not receive all prescribed inhaler medications as ordered upon admission. The resident was admitted with orders for Symbicort, Ventolin, and Tudorza Pressair inhalers, but only Ventolin was initially available and administered. Symbicort and Tudorza Pressair were not administered until several days after admission due to delays in obtaining the medications from the pharmacy, as documented in the Medication Administration Record and confirmed by staff interviews. The delay occurred because the pharmacy required authorization from the facility to dispense the high-cost inhalers, and this authorization process was not completed promptly. The pharmacy received the physician's orders in the evening and contacted the facility for authorization, which was not provided until the following days. As a result, the resident did not receive Symbicort and Tudorza Pressair until two to three days after admission, despite having ongoing respiratory symptoms and requiring oxygen therapy. Staff interviews revealed that the LPN notified both the pharmacy and the physician about the missing medications and administered Ventolin as needed for shortness of breath. However, the LPN did not document the administration of Ventolin. The DON acknowledged that the facility could have obtained the medications from a local pharmacy if they were not in stock and that it was the responsibility of the RN Supervisor to ensure timely administration of ordered medications. The physician stated that the resident should have received the inhalers as ordered.
Delayed Administration of Prescribed Inhalers Due to Pharmacy Authorization Issues
Penalty
Summary
A deficiency was identified when a resident with a history of chronic respiratory conditions, including Chronic Obstructive Pulmonary Disease (COPD), Bronchiectasis, and lung cancer in remission, did not receive all prescribed inhaler medications in a timely manner upon admission. The resident was admitted with physician orders for Symbicort, Ventolin, and Tudorza Pressair inhalers to manage their respiratory conditions. However, the Symbicort and Tudorza Pressair inhalers were not available in the facility until three days after admission, and the initial doses were not administered as ordered. The delay occurred because the pharmacy required authorization from the facility to dispense the high-cost medications, and this authorization process was not completed promptly. The pharmacy received the physician's orders on the evening of admission and contacted the facility for authorization, but the necessary approvals for Tudorza Pressair and Symbicort were not provided until the following days. As a result, the resident only received Ventolin initially, which was available, while the other inhalers were delayed. Nursing staff notified the pharmacy and physician about the missing medications, but the documentation of medication administration was incomplete. Interviews with staff confirmed that the facility did not have the required inhalers on hand and that the process for obtaining and authorizing the medications was not completed in a timely manner. The Director of Nursing acknowledged that the medications could have been sourced from a local pharmacy if not available from the contracted pharmacy, and that it was the responsibility of the nursing supervisor to ensure timely administration of ordered medications. The resident, who was alert and oriented, experienced worsening breathing difficulties during this period and expressed a need for their inhalers.
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What surveyors actually found near you
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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 Smithtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St James Rehabilitation & Healthcare Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Luxor Nursing & Rehabilitation At Mills Pond | 1.6 mi | ★★★★★ | 0 | 0 |
| Brookside Multicare Nursing Center | 1.7 mi | ★★★★★ | 3 | 0 |
| The Hamlet Rehabilitation And Healthcare Center At | 1.7 mi | ★★★★★ | 0 | 0 |
| St Catherine Of Siena Nrsg And Rehab Care Center | 1.8 mi | ★★★★★ | 5 | 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.