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 Sunharbor Manor during CMS and state inspections, most recent first.
A resident with a physician's order for a Lidocaine patch received a Menthol patch instead during a medication pass. The nurse did not re-check the physician's order and signed off as if the correct medication had been administered. The resident had moderate cognitive impairment and was receiving pain medications for a lumbar vertebra fracture and low back pain.
A resident with multiple diagnoses lost their left hearing aid over a year ago and experienced delays in obtaining an Audiology Consult despite multiple physician orders. The delay was attributed to a change in the unit clerk responsible for scheduling the appointment, resulting in the resident struggling with hearing difficulties.
The facility failed to provide adequate supervision for two residents, leading to one resident being unsupervised outside in a smoking area and another resident having access to multiple medications without proper assessment. The facility's policies for resident supervision and medication administration were not followed.
A resident's tube feeding and hydration bags were found without required labels, including the resident's name and start time, contrary to facility policy. The deficiency was confirmed through staff interviews, revealing oversight by the nursing staff.
A resident was observed with a Peripheral Intravenous Catheter in their left hand without a physician's order for its placement and care. Despite having a care plan for intravenous therapy, there was no documentation of the catheter's assessment or care. Interviews revealed no awareness of who placed the catheter or why it was still in place. The physician confirmed that the catheter should have been removed after the fluids finished infusing.
A resident was prescribed Ambien as needed for insomnia without a 14-day limit or documented rationale for continued use, contrary to CMS guidelines. The primary care physician was unaware of the requirement, and the resident received the medication nightly until the survey date. The Medical Director later provided education on the regulation.
The facility failed to ensure proper labeling and storage of medications, including insulin pens, leading to deficiencies in three of twelve medication carts reviewed. Staff interviews revealed a lack of adherence to medication storage policies.
A resident with Type 2 Diabetes Mellitus and Peripheral Vascular Disease had a Physician's Order for a dental consult that was delayed for several months. Despite a Dentist's recommendation for six tooth extractions to facilitate dentures, the facility did not address these recommendations until prompted by a Surveyor. Interviews revealed lapses in communication and follow-up among nursing staff.
A facility failed to post the correct Contact Precaution signage for a resident with a Clostridium Difficile infection, leading to potential lapses in infection control practices. Staff acknowledged the oversight and the need for appropriate signage to alert staff and visitors.
A resident with severe cognitive impairment and multiple diagnoses was discharged without confirmed home care services, leading to an eight-day delay in receiving necessary home healthcare. The facility failed to ensure an effective discharge planning process, as required by their policy.
Failure to Implement Comprehensive Pain Management Care Plan
Penalty
Summary
The facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident, specifically for pain management. Resident #246, who had a physician's order for a Lidocaine patch to be applied to the lumbar area, received a Menthol patch instead during a medication pass. The nurse administering the medication did not re-check the physician's order in the electronic medical record and applied the incorrect patch. This discrepancy was observed during the survey, and the nurse signed off on the Medication Administration Record as if the correct medication had been administered. Resident #246 was admitted with diagnoses including a wedge compression fracture of the fourth lumbar vertebra, low back pain, and anxiety. The resident had moderate cognitive impairment and was receiving scheduled and as-needed pain medications. The error was identified during a medication pass observation, and it was confirmed that the nurse should have applied the Lidocaine patch as per the physician's order. The Director of Nursing Services acknowledged the error and stated that the nurse should have followed the physician's order.
Delay in Audiology Consult for Resident
Penalty
Summary
The facility did not ensure that Resident #155 received proper treatment and assistive devices to maintain hearing abilities. Resident #155, who has diagnoses including Type 2 Diabetes, Hypertension, and Congestive Heart Failure, lost their left hearing aid over a year ago while in the hospital. Despite multiple physician orders for an Audiology Consult from January 2024 through March 2024, the appointment was not confirmed until two months after the first order. The resident, who has intact cognition, reported the loss and malfunction of their hearing aids to the nursing staff on several occasions, but no timely action was taken to address the issue. Interviews with the Registered Nurse Supervisor and the Director of Nursing Services revealed that the delay in obtaining the Audiology consult was due to a change in the unit clerk responsible for making the appointment. The Director of Nursing Services acknowledged that it was unacceptable for the resident to wait this long for an Audiology appointment. The resident was observed struggling to hear with their remaining hearing aid, indicating a significant lapse in the facility's responsibility to provide necessary hearing assistive devices and timely medical consultations.
Inadequate Supervision and Medication Management
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents. Resident #240 was observed unsupervised outside the building in the designated smoking area, despite not being assessed as a safe smoker. The facility was unaware that the resident had exited the building. The resident had a physician's order to go out on pass with a responsible party but did not have an order to go outside independently. The facility's policies and staff interviews confirmed that residents require an assessment and a physician's order to go outside independently, which Resident #240 did not have. The receptionist/security guard, responsible for monitoring the front entrance and the smoking area, did not see Resident #240 exit the building due to being overwhelmed with other tasks. Resident #101 was observed with multiple medication tablets in a medication cup and an inhaler on their overbed table on two separate occasions. There were no staff members present in the vicinity, and the resident was not assessed to safely self-administer medications. The facility's policy requires medications to be administered by staff unless there is a physician's order for self-administration. Interviews with nursing staff revealed that Resident #101 often did not adhere to the medication schedule and preferred to take medications at their own pace. Despite this, the resident did not have an order to self-administer medications, and staff were aware that medications should not be left in the resident's room. The facility's policies and procedures for medication administration and resident supervision were not followed, leading to these deficiencies. The Director of Nursing Services and other staff acknowledged that residents should not have medications in their rooms without a physician's order and that residents should be monitored when going outside. The failure to adhere to these policies resulted in Resident #240 being unsupervised outside and Resident #101 having access to medications without proper assessment or supervision.
Failure to Label Tube Feeding and Hydration Bags
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 #161's tube feeding and hydration bags were observed hanging without labels, including the resident's name and the time the tube feeding was initiated. This observation was made on 3/15/2024 at 12:03 PM. The facility's policy requires that feeding bags be labeled with the resident's name, feed volume, date, start time, and flow rate, but this was not followed in this instance. Resident #161, who has diagnoses of Cerebral Infarction, Aphasia, and Hemiplegia, relies on tube feeding for more than 51% of their total caloric intake and receives significant hydration through the tube. The deficiency was confirmed through interviews with Licensed Practical Nurses and the Director of Nursing Services, who acknowledged that the labeling was not done as required. The failure to label the feeding and hydration bags was attributed to oversight by the nursing staff responsible for hanging the bags.
Failure to Ensure Proper Administration and Documentation of IV Fluids
Penalty
Summary
The facility did not ensure that Resident #216 received care and services for the provision of parenteral fluids consistent with professional standards of practice and in accordance with physician orders and the comprehensive person-centered care plan. On three separate occasions, the resident was observed with a Peripheral Intravenous Catheter in their left hand without a physician's order for its placement and care. The resident had diagnoses including Heart Failure, Type 2 Diabetes Mellitus, and Vascular Dementia, and was cognitively intact. Despite having a care plan for intravenous therapy, there was no documentation of the catheter's assessment or care in the medical record or Treatment Administration Record. The resident was observed with the catheter in place on multiple dates, with no fluids infusing and no date on the dressing. Interviews with the resident, nursing staff, and the Director of Nursing Services revealed that there was no awareness of who placed the catheter or why it was still in place. The physician confirmed that intravenous fluids were ordered to maintain hydration but stated that the catheter should have been removed after the fluids finished infusing. The lack of assessment and documentation could lead to complications such as phlebitis, infection, and skin breakdown.
Non-Compliance with 14-Day Limit for As-Needed Psychotropic Medication
Penalty
Summary
The facility did not ensure that as-needed orders for psychotropic drugs were limited to 14 days and that there was a rationale and indication for the duration of the medication. This deficiency was identified for a resident who was prescribed Ambien 10 milligrams to be taken as needed for insomnia. The order was not limited to 14 days, and there was no documented rationale or indication for the continued use of the medication in the physician's notes. The resident received Ambien every night from the date of the prescription until the survey date, without a specified stop date, contrary to CMS guidelines. The primary care physician, who was new to the nursing home role, was unaware of the 14-day limit requirement for as-needed psychotropics and the need to provide a rationale for continued use. The physician documented that the resident wanted the medication ordered as needed to have the option to refuse it. The Medical Director later provided education to the physician and the resident about the regulation. A comprehensive care plan for the resident's insomnia was initiated, noting that the insomnia was due to anxiety and obsessive-compulsive disorder, with interventions including medication as per the physician's order and environmental adjustments to promote sleep.
Improper Medication Storage and Labeling
Penalty
Summary
The facility did not ensure that all drugs used were labeled in accordance with professional standards, including expiration dates, and that the medications were stored at proper temperatures. This deficiency was identified for three of twelve medication carts reviewed during the Medication Storage task. Specifically, an open Lantus Solostar insulin pen for Resident #194 was observed in the medication cart with an open date of 2/23/2024, which was more than 28 days old. Additionally, Resident #518's unopened Admelog insulin pen and Resident #3's unopened Humalog insulin pen were found stored in the medication cart instead of the refrigerator, which is required for maintaining their efficacy. Interviews with the nursing staff revealed a lack of awareness and adherence to the facility's medication storage policies. Licensed Practical Nurse #2 and Licensed Practical Nurse #3 were unsure why the insulin pens were not stored correctly. The Registered Nurse Manager and the Pharmacist confirmed that medications must be stored according to the manufacturer's guidelines to ensure their effectiveness. The Director of Nursing Services also acknowledged that medications should be checked for proper labeling and stored at appropriate temperatures as per the guidelines. The facility's failure to comply with these standards resulted in the identified deficiencies.
Failure to Ensure Timely Dental Care for Resident
Penalty
Summary
The facility did not ensure that residents were assisted in obtaining routine dental care, as evidenced by the case of a resident with Type 2 Diabetes Mellitus and Peripheral Vascular Disease. The resident had a Physician's Order for a dental consult dated 7/6/2023, but was not seen by the Dentist until 2/4/2024. Despite the Dentist's recommendation on 2/16/2024 for six tooth extractions to facilitate the creation of full upper and lower dentures, these recommendations were not addressed by the facility until brought to their attention by the Surveyor on 3/19/2024. The resident expressed concerns about waiting for dentures and not knowing when they would receive them. The facility's policy stated that residents would be assisted in obtaining regular and emergency dental care, but this was not followed. The resident's medical record showed multiple renewals of the Physician's Order for a dental consult, but no documented evidence that the recommendations made by the Dentist on 2/16/2024 were ever addressed. Interviews with various nursing staff revealed lapses in communication and follow-up. Registered Nurse #2 could not recall if they filled out the consult form for the resident, while Registered Nurse #3 discovered the oversight during an audit and issued a new Physician's Order on 2/1/2024. The Registered Nurse Minimum Data Set Assessor updated the resident's Dental Comprehensive Care Plan but did not confirm if the Dentist's recommendations were carried out. The Dentist and the Director of Nursing Services acknowledged that the recommendations should have been communicated and followed up on, but this did not occur.
Failure to Post Correct Infection Control Signage
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Specifically, a resident with a physician's order for Contact Precautions due to a Clostridium Difficile (C-Diff) infection did not have the appropriate signage posted outside their room. Instead, a Droplet Precaution sign was stored in a caddy outside the resident's door, which was not visible to staff and visitors. This oversight was identified during an observation on 3/14/2024, where it was noted that the required Contact Precaution signage was missing, and the wrong precaution sign was later posted by staff members after the surveyor's observation. The resident involved had diagnoses including Osteomyelitis, Enterocolitis due to C-Diff infection, and Malignant Neoplasm of the Breast. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14. The resident's care plan included maintaining Contact Precautions and providing a private room due to the C-Diff infection. Despite these documented precautions, the appropriate signage was not displayed, leading to potential lapses in infection control practices. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Assistant Director of Nursing Services, and the Director of Nursing Services, revealed that the failure to post the correct signage was an oversight. The staff acknowledged that the appropriate Contact Precaution sign should have been posted outside the resident's room to alert staff and visitors of the necessary precautions. The Assistant Director of Nursing Services, who is also the facility's Infection Control Preventionist, confirmed that the correct signage was not posted and could not explain why the error occurred.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to ensure an effective discharge planning process for Resident #466, who was discharged without confirmation of acceptance from a Home Care Agency. The resident, who had diagnoses including Symptomatic Epilepsy, Cerebral Palsy, and Major Depressive Disorder, was discharged on 7/17/2023. However, the referred Home Care Agency denied services on 7/18/2023 due to a lack of skilled needs, resulting in the resident not receiving home healthcare services until 7/25/2023, eight days post-discharge. The facility's policy required that the post-discharge plan include necessary arrangements for home care and equipment. Despite this, the discharge planning process for Resident #466 was inadequately executed. The social worker documented that a referral for home care would be made, but there was no confirmation of acceptance from the Home Care Agency before the resident's discharge. The Case Manager/Discharge Coordinator admitted that confirmation was not obtained, and the necessary documentation was not always completed due to time constraints. Interviews with the Case Manager/Discharge Coordinator and the Director of Social Work revealed that the facility did not ensure the provision of home care services before discharging Resident #466. The Director of Social Work acknowledged that the facility should have confirmed the home care services prior to discharge. This lapse in the discharge planning process led to a delay in the resident receiving the required home healthcare services, highlighting a significant deficiency in the facility's discharge procedures.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roslyn Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Amsterdam At Harborside | 2.6 mi | — | 0 | 0 |
| Northwell Health Stern Family Center For Rehabilit | 3.2 mi | ★★★★★ | 0 | 0 |
| Highfield Gardens Care Center Of Great Neck | 3.3 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Great Neck | 4 mi | ★★★★★ | 0 | 0 |
| Sands Point Center For Health And Rehabilitation | 4 mi | ★★★★★ | 8 | 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.