Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 South Shore Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
An effective pest control program was not maintained when the kitchen exit door used for refuse removal had an approximate half-inch gap at the bottom. The FSD was unaware of the gap, and the DES noted the facility had been cited for the same issue during the prior survey and that a door sweep installed to deter water and pest entry may have been dislodged by delivery staff.
Medication Regimen Review responses were not properly carried out for three residents. Pharmacy consultant recommendations for a resident receiving Flomax via G-tube, a resident receiving Ferrous Sulfate via PEG tube, and a resident with anemia on Retacrit were documented by the DON, but physician signatures and clear medical record evidence of review and implementation were missing. One resident remained on a capsule that should not have been opened, another continued receiving a tablet via feeding tube instead of liquid form, and a third never received the recommended Ferrous Sulfate.
The facility failed to develop comprehensive care plans for two residents with significant medical needs. One resident with MRSA chest wounds had no documented care plan for the wound infection or contact precautions, despite wound treatment orders and staff using PPE at the room entrance. Another resident receiving Midodrine, Metoprolol, and Enoxaparin for hypotension, hypertension, and DVT prevention had no documented care plan for cardiovascular status or anticoagulant therapy, even though monitoring and bleeding precautions were ordered.
An RN failed to follow the five rights of medication administration for a resident with CVA, seizure disorder, and G-tube status by pouring Keppra from another resident’s labeled bottle without checking the label first. The RN also administered meds through the G-tube without verifying tube placement, despite facility policy requiring label checks and placement verification before tube medication administration.
A resident with HTN and idiopathic hypotension had an active order for PRN Midodrine via PEG tube when systolic BP was below 120 mmHg, but the MAR showed the medication was not given for all opportunities reviewed in early August and most opportunities in July. The MAR also lacked BP documentation on multiple occasions and did not show BP monitoring every 8 hours to determine need for the medication. An LPN stated the medication was withheld because the resident was asymptomatic, while the physician stated it should have been administered when BP was below the ordered parameter.
Two residents with significant pressure ulcers did not receive proper pressure-relief mattress management. One resident with severe cognitive impairment and Stage 3 ulcers was repeatedly observed on an air mattress set at 350 lbs despite weighing 84.7 lbs, and staff were unsure how the setting should be adjusted. Another resident with a Stage 4 sacral ulcer and multiple additional wounds had a low-pressure warning light illuminated on the mattress for several days, the pump was later found damaged, and after replacement the new mattress was still set at 350 lbs despite the resident weighing 115.5 lbs.
A resident with CVA, seizure disorder, and gastrostomy status received multiple meds via the feeding tube, including supplements, furosemide, glycopyrrolate, and Keppra. During observation, an RN disconnected the tube feeding and flushed the tube but did not verify G-tube placement before administering the meds, despite the physician order and facility policy requiring placement checks before tube medication administration.
Failure to Follow Contact Precautions and Hand Hygiene: Staff did not follow contact precaution signage for two residents with CRE/VIM and MRSA-related orders. An LPN entered the room without PPE to adjust a feeding tube pump and did not perform hand hygiene on exit, and a CNA was observed in the room without PPE while opening drawers and closets and also did not clean hands when leaving.
Facility Assessment did not identify unit-specific nursing staffing needs for the first and second floor resident units. During the survey, the Admin Assistant stated the facility had two resident units and handled the nursing staffing schedule for both floors, while the Administrator said they were responsible for developing and reviewing the Facility Assessment but did not know unit-specific staffing was required. The DON stated they did not directly participate in developing the assessment and agreed it did not consider the nursing staffing needs for each unit.
The facility failed to provide a homelike environment and adequate maintenance in three of its four units, with unrepaired water damage, peeling wallpaper, and holes in the walls. A resident's room had unrepaired holes from a removed soap dispenser for three months. Interviews revealed a lack of communication and follow-through on maintenance issues, and work order records showed no requests for repairs in the affected rooms.
The facility failed to follow professional standards for food safety by allowing a carton of frozen egg product to thaw at room temperature instead of in the refrigerator, as required by their policy. The First Cook and Food Service Director both confirmed this improper practice.
A resident with a history of Seizure Disorder, Respiratory Failure, and Anoxic Brain Damage was found with a fractured wrist. The facility failed to report the injury of unknown origin to the Department of Health within the required 24-hour timeframe, attributing the delay to the incident occurring over the weekend.
The facility failed to ensure a comprehensive care plan for a resident with limited mobility, resulting in the resident not wearing a prescribed hand roll. Staff were either unaware of the requirement or did not check care instructions, and refusals to wear the hand roll were not reported for further assessment.
A resident with multiple Stage 4 pressure ulcers did not receive necessary treatment due to a malfunctioning air mattress set at an incorrect weight. Despite staff reporting the issue, the mattress was not repaired or replaced, leading to inadequate pressure relief and wound care.
The facility failed to ensure that enteral feeding bags were properly labeled for a resident with a feeding tube. The bags lacked labels with the resident's name, start time, and feeding directions, contrary to the facility's policy. Nursing staff on different shifts did not check the labels, leading to this deficiency.
A resident receiving dialysis treatment three times a week returned with swelling in their left upper arm and recommendations for warm compresses. The facility staff failed to check the Dialysis Communication Notebook and did not apply the warm compresses as indicated, resulting in the resident not receiving the necessary care.
The facility allowed an unlicensed graduate nurse to work as an RN for almost four months beyond the expiration of the COVID-19 PHE waiver. The issue was discovered during an audit by the current DON, leading to the nurse's termination. The Administrative Assistant had informed the prior DON about the unlicensed status, but no action was taken.
The facility failed to maintain accurate medical records for a resident self-administering insulin. The resident's blood glucose reading and insulin dosage were incorrectly documented, and nursing staff inconsistently followed the facility's policy for verifying self-medication.
A facility failed to maintain an infection prevention and control program when the Director of Maintenance entered a resident's room on contact precautions for Candida Auris without wearing the required PPE. The resident had severe cognitive impairment and was on contact isolation due to a multidrug-resistant organism. The Director of Nursing Services confirmed that proper PPE should have been used.
The facility failed to ensure effective pest control in the kitchen due to a half-inch gap at the bottom of the exit door, allowing vermin to enter. Despite regular pest control services, the gap was not addressed, leading to sightings of mice and dead mice found in glue traps.
Pest Control Program Not Maintained at Kitchen Exit Door
Penalty
Summary
An effective pest control program was not maintained because the kitchen exit door used to remove refuse and leading to the parking lot and garbage disposal bins had an approximate half-inch gap at the bottom. During the initial kitchen tour, the Food Service Director observed the gap but stated they were unaware of it. The facility policy titled Pest Control stated that the facility maintains an ongoing pest control program to keep the building free of insects and rodents. The Director of Environmental Services stated the facility had been cited for the same issue during the previous survey in 2024 and that a door sweep had been installed at that time. The Director stated they had seen the sweep in place the prior week but believed delivery staff may have dislodged it, and that they found the door sweep on the floor near the area and reinstalled it. The Administrator also stated the door had been fixed after the previous survey and that a door sweep had been installed to prevent water and pest entry.
Medication Regimen Review Responses Not Carried Out
Penalty
Summary
The facility failed to ensure that physician responses documented on Monthly Medication Regimen Reviews were carried out for identified medication irregularities. The deficiency involved three residents reviewed for unnecessary medications, and the record showed that pharmacy consultant recommendations were documented on the Medication Regimen Review forms, but the related physician review, documentation, and implementation were not consistently present in the medical record. One resident had diagnoses including respiratory failure, cerebrovascular accident, and benign prostatic hyperplasia, and had severe cognitive impairment. The resident received Flomax via G-tube even though the pharmacy noted that the capsule should not be opened and suggested changing to Rapaflo. The DON documented responses on the review forms, but the record did not show physician review or documented action in the medical record. The pharmacy provider stated Rapaflo had not been ordered at the time of review, and the DON acknowledged that the medication change had not been ordered even though the review response indicated it should be changed. A second resident had iron deficiency anemia and severe cognitive impairment, with a feeding tube in place. The pharmacy recommended changing Ferrous Sulfate tablet administration via PEG tube to liquid form on two separate Medication Regimen Reviews, and responses indicated physician agreement. However, the forms were signed by the DON rather than the attending physician or Medical Director, and the MAR showed the resident continued to receive Ferrous Sulfate in tablet form via PEG tube with no documented change to liquid form. A third resident with Crohn's disease and anemia had a physician order for Retacrit, and the pharmacy recommended adding Ferrous Sulfate. The DON documented that the physician was consulted, but the review was not signed by the resident's primary care physician, and the resident was not receiving and had never received Ferrous Sulfate.
Missing Comprehensive Care Plans for Infection Control and Cardiovascular Management
Penalty
Summary
The facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for all of the resident’s medical, nursing, mental, and psychosocial needs. During the recertification survey, surveyors identified that one resident with a diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) infection in chest wounds and septicemia had no care plan addressing the wound infection or the required contact precautions. The resident also had moderate cognitive impairment, and a contact precaution sign was posted outside the room while staff were observed using gowns and gloves before entering. Record review showed physician orders for contact precautions and wound treatment for the bilateral chest wounds, including cleansing with normal saline, collagen powder, calcium alginate packing, and silicone super absorbent dressings. Despite these orders and the resident’s MRSA diagnosis, the comprehensive care plan did not reflect the infection or the precautions in place. Nursing staff stated that care plans should have been developed, and the DON, who was also the Infection Preventionist, stated that a Registered Nurse was expected to develop a care plan for the MRSA infection and contact precautions. A second resident with diagnoses including essential hypertension and idiopathic hypotension also had no documented comprehensive care plan for cardiovascular status or anticoagulant therapy. The resident was receiving Midodrine for low blood pressure, Metoprolol for hypertension, and Enoxaparin for DVT prevention, with orders for orthostatic blood pressure monitoring and cardiology follow-up noting daily blood pressure monitoring, continued medications, and bleeding precautions. Nursing staff and the DON stated that a comprehensive care plan should have been developed to reflect the resident’s cardiovascular status and anticoagulation therapy, but no such plan was documented.
Medication Administration Errors With Wrong Bottle Use and G-Tube Placement Check Omitted
Penalty
Summary
The facility did not ensure medication administration met professional standards of quality for one resident who had diagnoses including cerebrovascular accident, seizure disorder, and gastrostomy status, and whose MDS documented severely impaired cognitive skills for daily decision making. During a medication administration observation, the RN prepared multiple medications for the resident, including Keppra oral solution, and poured the Keppra into a souffle cup without reading the bottle label first. The bottle used had another resident’s name on it, and the RN only realized this after the surveyor asked to see the bottle. The RN stated she was unsure what to do with the medication already poured, then discarded it and re-poured the medication from the correct bottle. The same RN then administered the medications through the resident’s gastrostomy tube after disconnecting the tube feeding and flushing the tube, but did not check tube placement before giving the medications. The RN later stated she did not check placement and should have. Facility leadership confirmed that nurses are expected to follow the five rights of medication administration and to verify gastrostomy tube placement before administering medications through the tube, and the facility policy required reading medication labels and checking tube placement before administration.
Failure to Administer PRN Midodrine and Monitor BP per Order
Penalty
Summary
The facility did not ensure Resident #32 received treatment and care in accordance with the physician’s orders and professional standards. Resident #32 had diagnoses including Essential Hypertension and Idiopathic Hypotension, and had an active order for Midodrine 10 mg via PEG tube every 8 hours as needed when systolic blood pressure was below 120 mmHg. Review of the Medication Administration Record showed the resident did not receive Midodrine for 16 of 16 opportunities from 08/01/2025 through 08/13/2025, and for 26 of 29 opportunities in July 2025. In July 2025, there were nine instances when blood pressure was not documented on the MAR, and there was no documented evidence that blood pressure was monitored every 8 hours to determine whether Midodrine should be given as ordered. During interview, the LPN stated the resident’s blood pressure was checked before administering blood pressure medications, but Midodrine was not given on 08/12/2025 because the resident was not lethargic, not in distress, and was asymptomatic, despite a systolic blood pressure of 112 mmHg. The nursing supervisor stated the ordered blood pressure parameters for Midodrine were higher than typically ordered and would need clarification with the physician. The physician stated nursing staff must administer medication as ordered, including following ordered parameters, and that Midodrine should have been administered if the blood pressure was below 120 mmHg. The DON also stated nurses should have administered Midodrine according to the ordered blood pressure parameters. The record also noted no comprehensive care plan related to the resident’s cardiovascular status.
Pressure Ulcer Care and Air Mattress Settings Not Properly Managed
Penalty
Summary
The facility did not ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote wound healing, prevent infection, and prevent new ulcers from developing. This deficiency involved two residents reviewed for pressure ulcers: one resident with severe cognitive impairment, adult failure to thrive, chronic kidney disease, and two unhealed Stage 3 pressure ulcers; and another resident with diabetes, cerebrovascular accident, anoxic brain damage, and multiple pressure ulcers including a Stage 4 sacral ulcer, unstageable ulcers, and deep tissue injuries. For the first resident, the record showed an air pressure mattress was ordered for wound care, and the wound care consultation noted a low air loss mattress per facility protocol with verification of inflation and settings. The resident weighed 84.7 pounds, but during observations the resident was lying in bed on an air mattress set at 350 pounds on two separate occasions. The resident stated the bed felt hard and uncomfortable. Staff interviews showed the CNA was responsible for checking whether the mattress was deflated or leaking, while the RN stated they were not sure how the weight setting should be set. The nursing supervisor and wound care staff stated the mattress setting should correspond to the resident’s actual weight, and the setting of 350 pounds was not appropriate. For the second resident, the wound care consult documented use of a low air loss mattress per facility protocol and verification of the mattress inflation and settings, but the care plan did not include the use of an air mattress. The resident weighed 115.5 pounds, yet the mattress was observed with the low-pressure warning light illuminated on multiple days and the weight setting was documented at 180 pounds and then 170 pounds. Staff stated the low-pressure light indicated a problem or malfunction, and the environmental services director later stated the pump was damaged and the mattress and pump were replaced. After replacement, the new mattress was observed set at 350 pounds, and an RN supervisor stated the mattress should be set according to the resident’s weight but did not adjust it. Multiple staff interviews confirmed that nursing staff were responsible for monitoring and adjusting the mattress settings and notifying maintenance when there was a malfunction.
Gastrostomy Tube Placement Not Checked Before Medication Administration
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident because the facility did not ensure accurate administration of medications through a gastrostomy tube. During the medication administration observation for Resident #75, who had diagnoses including cerebrovascular accident, seizure disorder, and gastrostomy status, Registered Nurse #6 prepared multiple medications for administration through the feeding tube, including vitamin supplements, furosemide, glycopyrrolate, and Keppra oral solution. The resident’s quarterly MDS documented severely impaired cognitive skills for daily decision making, and the physician’s order required tube patency to be checked before medication administration every shift. During the observation, the nurse disconnected the tube feeding and flushed the tube but did not check for placement of the gastrostomy tube before giving the medications. In an immediate interview, the nurse stated the tube placement was not checked and should have been. The Assistant Director of Nursing/Educator and the DON later stated that nurses are supposed to check gastrostomy tube placement before administering medications through the tube, consistent with the facility policy titled Medication Administration via Feeding Tube.
Failure to Follow Contact Precautions and Hand Hygiene
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved one nursing unit on the second floor and centered on staff not using appropriate PPE and not performing hand hygiene while caring for residents on contact precautions. The facility policy required PPE use and hand hygiene, and the contact precaution signage at the room entrance directed staff to clean hands before entering and leaving, wear gloves and a gown before room entry, and discard them before room exit. Resident #27 had diagnoses including CVA, seizure disorder, and non-Alzheimer’s dementia, with severe cognitive impairment documented on the 07/02/2025 MDS. Resident #4 had diagnoses including DM, seizure disorder, and respiratory failure, and was in a persistent vegetative state on the 05/17/2025 MDS. Both residents had physician orders for contact precautions related to CRE/VIM, and Resident #4 also had contact precautions for MRSA in sputum. During observation, an LPN entered the room of both residents without PPE and adjusted Resident #27’s feeding tube pump, then stated they were not sure whether the residents were actually on contact precautions and did not wash hands when exiting. On another observation, a CNA was in the room without PPE and was opening and closing drawers and closets; the CNA stated they had removed the gown too early and did not wash hands when leaving the room.
Facility Assessment Did Not Address Unit-Specific Nursing Staffing Needs
Penalty
Summary
The facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit. During the recertification survey, record review and interviews identified that the Facility Assessment, last reviewed in July 2025, did not indicate nursing staffing needs for each resident unit, including Certified Nursing Aides, Licensed Practical Nurses, and Registered Nurses. The undated Facility Assessment policy stated the facility would evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services, including a detailed review of census data, resident capacity, factors affecting resident acuity, physical characteristics of the facility, and services currently provided. Review of the Facility Assessment dated [DATE] showed it did not identify the resident units in the facility and did not indicate specific nursing staffing needs for each resident unit. During interviews, the Administrative Assistant stated the facility had two resident units, the first and second floors, and that they were responsible for the nursing staffing schedule for both floors. The Administrator stated they were responsible for developing and reviewing the Facility Assessment and said it did not consider specific nursing staffing needs per resident unit because they were not aware that it was a requirement. The DON stated they did not directly participate in developing the Facility Assessment, did not know that nursing staffing needs must be considered per resident unit, and agreed the Facility Assessment did not and should have considered the nursing staffing needs for each unit.
Failure to Maintain Homelike Environment and Adequate Maintenance
Penalty
Summary
The facility failed to provide a homelike environment and adequate maintenance services in three of its four units, specifically in rooms 217, 117, 115, and 111. Observations revealed unrepaired water damage, peeling wallpaper, crumbling sheetrock, and holes in the walls. Resident #60's room had holes from a removed soap dispenser that were left unrepaired for approximately three months despite multiple requests for repair. The facility's policy dated April 2024 emphasized providing a comfortable and homelike environment, but this was not upheld in the observed rooms. The Resident Council Meeting minutes from February 2024 documented a resident's complaint about water leaking from the walls, and the Administrator had stated that a plumber was scheduled to address the issue. However, the plumbing estimate from February 2024 indicated that while the leaking sanitary piping was repaired, the contractor excluded carpentry, sheetrock, spackling, painting, tile, and flooring repairs. During the initial facility tour in April 2024, multiple rooms were found with significant water damage and unrepaired walls, indicating that the necessary follow-up repairs were not completed. Interviews with the Director of Maintenance, Licensed Practical Nurse, Certified Nurse Aide, and the Administrator revealed a lack of communication and follow-through on maintenance issues. The Director of Maintenance was unaware of the damaged walls in several rooms and stated that repairs were incomplete due to a lack of materials and pending mold testing. The nursing staff and aides did not report the damages, and the Administrator acknowledged the need for improvement in the facility's aesthetics and maintenance tracking. The facility's work order records showed no requests for repairs in the affected rooms, highlighting a systemic issue in addressing and documenting maintenance needs.
Improper Thawing of Frozen Egg Product
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 the initial kitchen tour, a carton of frozen egg product intended for the next day's breakfast was observed thawing at room temperature on a table. The facility's policy on thawing frozen raw food requires that food be thawed in the refrigerator and not left out at room temperature for extended periods. However, the First Cook admitted to removing the carton from the freezer and leaving it out at room temperature for several hours before planning to place it in the refrigerator. The Food Service Director confirmed this practice, stating that they allow the product to sit at room temperature to get the initial frost thawed out before refrigerating it. The First Cook later admitted to placing the frozen egg product outside to thaw because they were in a rush. This practice is contrary to the facility's policy and professional standards for food safety, which require proper temperature control during thawing to prevent potential foodborne illnesses.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility did not ensure that it reported an injury of unknown origin to the New York State Department of Health within the required 24-hour timeframe. This deficiency was identified for a resident who was found with discoloration and swelling in the right arm, which was later confirmed to be an acute oblique fracture of the distal radius. The incident occurred on 8/5/2023, but it was not reported to the Department of Health until 8/7/2023, exceeding the 24-hour reporting requirement. The resident involved had a medical history that included Seizure Disorder, Respiratory Failure, and Anoxic Brain Damage, and was documented as comatose. The facility's policy required the Director of Nursing Services or Administrator to notify the Department of Health within five working days for incidents involving alleged abuse. However, the Director of Nursing Services acknowledged that injuries of unknown origin should be reported within 24 hours. The delay in reporting was attributed to the incident occurring over the weekend, and the Director of Nursing Services not being informed until the following Monday morning.
Failure to Implement Comprehensive Care Plan for Resident with Limited Mobility
Penalty
Summary
The facility did not ensure that a comprehensive person-centered care plan was developed or implemented for Resident #47, who had a physician's order for a hand roll to be worn on the right hand at all times due to limited mobility. Despite the physician's order and the facility's policy, Resident #47 was observed multiple times without the hand roll. Certified Nursing Assistants (CNAs) assigned to Resident #47 either did not check the care instructions or were unaware of the requirement, leading to the resident not wearing the hand roll as prescribed. Additionally, there were instances where the resident refused to wear the hand roll, but these refusals were not consistently reported to the nursing staff or the rehabilitation department for further assessment and intervention. Interviews with various staff members, including CNAs, the Assistant Occupational Therapist, the Unit Supervisor, the Director of Rehabilitation Services, and the Director of Nursing Services, revealed a lack of communication and follow-through regarding the resident's care plan. The CNAs were responsible for applying the hand roll, but they did not always do so, and the nurses were not adequately monitoring compliance with the physician's order. The Director of Rehabilitation Services and the Director of Nursing Services were not aware of the resident's refusals to use the hand roll, indicating a breakdown in the reporting and evaluation process necessary to address the resident's needs effectively.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #55, who had multiple Stage 4 pressure ulcers, received necessary treatment and services consistent with professional standards of practice. The resident's air mattress, which was supposed to provide pressure relief, was set at an incorrect weight setting of 240 pounds, while the resident's actual weight was 123 pounds. This discrepancy was due to a malfunction in the air mattress that required it to be set at a higher weight to prevent deflation. Despite the nursing staff reporting the issue to the maintenance department, the mattress was not repaired or replaced in a timely manner. The facility's policy on impaired skin integrity emphasized a multidisciplinary approach for the prevention and treatment of wounds, including the use of specialty mattresses for Stage 4 pressure ulcers. However, the maintenance request for the malfunctioning air mattress was not properly documented or addressed. Interviews with various staff members, including the wound care nurse, maintenance director, and assistant housekeeping director, revealed a lack of communication and follow-up regarding the maintenance issue. The maintenance director was unaware of the problem until the surveyors brought it to their attention. During the survey, it was observed that the resident's sacral wound dressing was saturated with drainage, indicating inadequate pressure relief and wound care. The Director of Nursing Services acknowledged that the air mattress should have been replaced when the problem was first identified and that the weight setting should correspond with the resident's weight to promote optimal healing. The wound care nurse practitioner also confirmed that an inappropriate weight setting could adversely affect wound healing.
Failure to Label Enteral Feeding Bags
Penalty
Summary
The facility did not ensure that the staff implemented and provided care and services according to the resident's needs and professional standards of practice for each resident with a feeding tube. This deficiency was identified for one resident who was observed receiving enteral tube feeding on two separate occasions. During these observations, the enteral tube feeding bag and the water bag were found hanging on a feeding tube stand without labels that included the resident's name, the time the feeding was started, and the feeding directions as prescribed by the physician. The facility's policy and procedure for enteral feeding, which requires such labeling, was not followed. The resident involved had diagnoses including respiratory failure, gastrostomy status, and type II diabetes, and required assistance with all activities of daily living. The nursing staff on different shifts failed to ensure that the enteral feeding bags were properly labeled, as confirmed through interviews. The Director of Nursing Services acknowledged that it was the responsibility of all nurses to check and ensure that the enteral tube feeding bags were labeled correctly. This lack of adherence to the facility's policy and procedure for enteral feeding led to the identified deficiency.
Failure to Follow Dialysis Care Recommendations
Penalty
Summary
The facility did not ensure that a resident requiring dialysis services received care consistent with professional standards of practice. Specifically, a resident who receives dialysis treatment three times a week was observed with swelling in their left upper arm. The resident returned from dialysis with recommendations to apply warm compresses to the left upper arm, which were communicated via a Dialysis Communication Notebook. However, the facility staff did not address or apply the warm compresses as indicated by the dialysis center. The resident, who has diagnoses including End-Stage Renal Disease and Type II Diabetes, was admitted with a care plan that included checking the dialysis access dressing and communicating with the dialysis center. Despite these interventions, the resident reported that the nurses did not check the Communication Notebook after their return from dialysis. The resident informed a Licensed Practical Nurse about the swelling, but the nurse failed to check the notebook and did not follow the dialysis center's recommendations. Interviews with facility staff revealed that the nurse responsible for the resident's care did not notice the swelling and failed to review the Communication Notebook. The Director of Nursing Services confirmed that the nurse should have assessed the resident and checked the notebook for any recommendations. The failure to follow these procedures resulted in the resident not receiving the necessary care to address the swelling in their left arm.
Unlicensed Nurse Employed Beyond Waiver Expiration
Penalty
Summary
The facility was found to be deficient in its administration, as it allowed an unlicensed graduate nurse to work in the capacity of a Registered Nurse for almost four months beyond the expiration of the Public Health Emergency (PHE) waiver. The unlicensed nurse was hired in February 2023 by the previous administration and had a nursing diploma dated May 2021 but never obtained their license. This oversight was discovered during an employee audit conducted by the current Director of Nursing Services in October 2023, leading to the immediate termination of the unlicensed nurse and a report to the Office of Professions. Interviews revealed that the Administrative Assistant had informed the prior Director of Nursing Services about the unlicensed status of the graduate nurse, but no action was taken. The Administrative Assistant believed that the prior Director of Nursing Services would follow up on the issue. Additionally, the Administrative Assistant was unaware that the COVID-19 PHE waiver, which allowed unlicensed nurses to practice, had expired in June 2023. The facility's current Director of Nursing Services and Administrator both acknowledged that the unlicensed nurse should not have been allowed to work as a Registered Nurse after the waiver expired.
Inaccurate Documentation of Self-Administered Insulin
Penalty
Summary
The facility did not maintain medical records for Resident #39 in accordance with accepted professional standards and practices. Resident #39, who has diagnoses including Diabetes Mellitus, Morbid Obesity, and Depression, had a physician's order to self-administer insulin and perform blood glucose checks. On 4/9/2024, the surveyor observed the resident checking their blood glucose and administering insulin, but the medication administration record inaccurately documented the blood sugar reading and insulin dosage. Specifically, the record showed a blood sugar reading of 210 milligrams per deciliter and six units of insulin administered, while the actual reading was 255 milligrams per deciliter and eight units of insulin were administered. Interviews with the nursing staff revealed inconsistencies in following the facility's policy for self-medication. Licensed Practical Nurse #2 admitted to relying on the resident's verbal report rather than verifying the blood glucose reading and insulin dosage. In contrast, Licensed Practical Nurse #3 stated they always observed the resident to ensure accurate documentation. The second-floor supervisor and the Director of Nursing Services confirmed that nurses should verify the blood glucose readings and insulin dosages to ensure accurate documentation, as per the facility's policy.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility did not maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections. This deficiency was identified for a resident who was on contact precautions for Candida Auris, a multidrug-resistant organism. On the day of the survey, the Director of Maintenance entered the resident's room without wearing the required personal protective equipment (PPE) despite a sign indicating the need for contact precautions. The Director of Maintenance came into substantial contact with the resident's environment, including the bed sheets, privacy curtain, and air pump, without wearing gloves or a gown and without performing hand hygiene before or after the interaction. The resident involved had severe cognitive impairment and was on contact isolation due to a Candida Auris infection. The facility's policy required staff to wear appropriate PPE and perform proper hand hygiene to prevent the spread of infections. Despite this, the Director of Maintenance failed to adhere to these protocols, citing an air mattress malfunction as an emergency. The Director of Nursing Services confirmed that the situation was not an emergency and that the proper PPE should have been used to prevent the spread of the infection.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure effective pest control measures in the kitchen, as observed during the Recertification Survey. Specifically, the exit door from the kitchen, which leads to the parking lot and garbage disposal bins, had an approximate half-inch gap at the bottom. This gap was large enough to allow vermin to enter the kitchen. Kitchen staff reported sightings of mice, and the Food Service Director confirmed finding dead mice in glue traps. The Maintenance Director acknowledged that the gap also allowed water to enter during heavy rain, causing puddles in the kitchen. Despite having a pest control company that visits twice a month, the facility did not address the gap in the door, which is a critical entry point for pests. The facility's undated policy on pest control documented the need to maintain an effective pest control system to keep the building free of insects and rodents. However, the gap at the bottom of the kitchen exit door was not corrected, leading to a pest control concern. The Maintenance Director and Food Service Director both acknowledged the issue and the need for correction. A recent pest control service ticket indicated treatments for water bugs, roaches, and mice, but the physical barrier to pest entry was not addressed, resulting in the deficiency.
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Freeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Care Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Mount Sinai South Nassau T C U | 2 mi | ★★★★★ | 1 | 0 |
| Oceanside Care Center Inc | 2.8 mi | ★★★★★ | 5 | 0 |
| A Holly Patterson Extended Care Facility | 3.1 mi | ★★★★★ | 18 | 0 |
| Rockville Skilled Nursing & Rehabilitation Center, | 3.1 mi | ★★★★★ | 0 | 0 |
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