Below average — CMS composite of the measures below.
The next survey window likely opens 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 Surge Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Failure to Investigate and Report Abuse Allegations: The facility did not thoroughly investigate two abuse allegations involving a resident and the resident’s roommate, and did not report the findings to the state within the required timeframe. An RN said a roommate reported seeing an aide hit a resident, while an LPN did not escalate the report to administration. The DON and Administrator later acknowledged they interviewed the resident and considered a CNA as a possible perpetrator, but they did not document the investigation or file the report. Care plans were not updated to reflect the allegations, and the resident involved had cognitive impairment and trauma-related needs.
A resident with ESRD, bladder cancer, and lung cancer had an order for a fentanyl patch for pain. MAR entries showed that on multiple occasions the same LPN signed as both the person removing and disposing of the patch and as the witness, and one disposal had no witness signature documented. Staff interviews confirmed that two nurses were required for fentanyl patch disposal and that both should sign the MAR, but several nurses could not recall the witnessing nurse.
An LPN left a resident’s electronic medical record open on a laptop in the hallway during med pass, making the resident’s personal and medical information visible to staff, residents, visitors, and a pharmacy vendor. The resident had cerebral infarction, dysphagia, and gastrostomy tube status, and could not complete the BIMS because the resident was rarely or never understood. The LPN said they forgot to turn off the screen, and the RN supervisor and DON stated the screen should have been closed to protect privacy.
Failure to Timely Report Abuse Allegations and Investigation Results: The facility did not promptly report abuse allegations involving two residents to the Administrator and NYSDOH, and did not submit investigation results within the required timeframe. One resident had Parkinson's disease, cognitive impairment, bipolar disorder, and PTSD history; the other had dementia, COPD, diabetes, and moderate cognitive impairment. A family member and another resident reported that an aide hit the resident on the head, but the allegation was not escalated through the chain of command as required, and the record lacked evidence of a completed investigation for one of the allegations.
Failure to Notify Ombudsman of Resident Transfer: A resident with severe cognitive impairment, dementia, and dependence for mobility and transfers sustained a fall, was found in pain, and was transferred to the hospital after x-rays showed a left hip fracture. The facility did not send the required transfer/discharge notice to the Office of the State LTC Ombudsman, and the DOSS and Administrator confirmed the notice was not sent.
Missing Care Plan for Long-Term UTI Prophylaxis: A resident with severe cognitive impairment and frequent incontinence had an order for Methenamine Hippurate for a history of UTI, but the current care plan did not document the long-term prophylactic use of the medication. The RN Supervisor stated the recurring UTI care plan had been resolved inadvertently, and the DON confirmed a care plan should have been in place for the long-term prophylactic medication.
A resident with a PEG tube, dysphagia, and a history of cerebral infarction received a bolus feeding and crushed Tylenol via the feeding tube without the ordered water flushes before and after the feeding and before and after the medication. An LPN stated the flushes were forgotten, and the RN supervisor and DON stated nurses must follow the physician’s orders and facility policy for tube patency and hydration.
A resident with a PEG tube, dysphagia, and a history of cerebral infarction did not receive ordered water flushes during bolus feeding and medication administration. An LPN completed the feeding and gave crushed Tylenol via the tube without the required pre- and post-medication flushes or the ordered pre- and post-feeding water flushes. The LPN said the flushes were forgotten, and the RN supervisor, physician, and DON stated staff must follow the physician’s orders, policy, and care plan to maintain tube patency and hydration.
A resident with COPD and dependence on supplemental oxygen had a physician order for oxygen at 2 L/min via nasal cannula as needed, but was observed on multiple occasions receiving oxygen at 3 L/min. The resident preferred to keep oxygen on continuously, and staff interviews showed the CNA, LPN, RN supervisor, physician, and DON all recognized that oxygen should be administered as ordered and that any increase in flow rate required physician notification and evaluation.
A facility employee obtained and cashed 16 checks from a resident with moderately impaired cognition, totaling between $27,000 and $40,000, despite facility policies prohibiting staff from accepting money or valuables from residents. The incident was discovered when the resident's next of kin reviewed financial records and reported the transactions to administration. The employee admitted to receiving the checks, and documentation showed the resident was at risk for abuse and victimization.
A facility failed to develop a comprehensive care plan for a resident receiving anticoagulant medication, as required by its policy. The resident, admitted with multiple fractures and Atrial Fibrillation, was prescribed Enoxaparin, but no care plan was documented. Interviews with the RN Supervisor and DON confirmed the oversight, as the admitting nurse and subsequent staff did not initiate the necessary care plan.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents and failed to report the results of the investigation to the New York State Department of Health within five working days. The report states that on 11/30/2025, an LPN received an allegation from a resident’s family member that the resident had been physically abused. The Administrator was not made aware of that incident until 12/01/2025. The resident involved had diagnoses including Parkinson’s disease, cognitive communication deficit, and bipolar disorder, and the admission MDS showed moderately impaired cognition. The resident also had a trauma-related care plan, but it was not revised to reflect the allegation. The report also states that after the first resident was discharged, the former roommate reported to an RN that they witnessed the resident being slapped by an unidentified staff member. The RN reported the allegation to the LPN charge nurse, but the LPN did not report it to facility administration. There was no documented evidence that an investigation was initiated for either allegation, and the facility did not document findings or report the incident to the state survey agency. The resident who made the second report had diagnoses including dementia, COPD, and type 2 diabetes mellitus, and the admission MDS showed moderately impaired cognition. The abuse care plan for that resident was also not revised to reflect the allegation. Interviews showed inconsistent handling of the allegations. The RN stated they reported the allegation to the LPN, while the LPN stated they were not informed of the roommate’s report and did not initiate an investigation. The family member stated the resident reported being hit on the head twice and treated unkindly by an aide, and that they reported this to the LPN. The Administrator and DON stated they were aware of the family allegation, interviewed the resident, and considered a specific CNA as the possible perpetrator, but they did not document the investigation, did not remove any staff member from assignment, and did not report the incident to the state because they did not view it as an abuse allegation. The DON also stated they did not document the assessment and did not conduct a staff re-enactment. The report cites 10 NYCRR 415.4(b)(3) and identifies the deficiency as Immediate Jeopardy.
Fentanyl Patch Disposal Documentation Not Properly Witnessed
Penalty
Summary
The facility did not maintain an established system of records for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation for Resident #12’s fentanyl patches. Resident #12 had diagnoses including end stage renal disease, bladder cancer, and lung cancer, and the admission MDS documented a BIMS score of 15, indicating intact cognition. The resident’s pain assessment showed pain intensity of 5 on a 0 to 10 scale, and the care plan included monitoring pain and administering medications per physician orders. A physician ordered fentanyl 50 microgram/hour transdermal patches to be applied to the chest wall every three days. The MAR for November and December 2025 documented repeated patch removal and disposal entries, but the same nurses signed both as the person removing and disposing of the patch and as the witness on multiple occasions. On 12/06/2025, there was no documented witness signature for disposal of the fentanyl patch. The facility policy required disposal in the presence of another licensed nurse, with both the signature and countersignature documented on the MAR. During interviews, multiple LPNs stated that two nurses were required for fentanyl patch disposal and that both nurses should sign the MAR, but several could not recall the witnessing nurse involved in the documented disposals. One LPN stated that the second nurse was supposed to sign under their own account, while another LPN acknowledged signing as both the remover/disposer and the witness. The DON stated that two nurses must be present for disposal and both must sign the MAR to indicate proper disposal of the fentanyl patch.
Unsecured Electronic Medical Record Left Visible in Hallway
Penalty
Summary
The facility did not ensure that each resident had secure and confidential medical records. During observation of medication administration, an LPN left Resident #112’s electronic medical record open on a laptop in the hallway, where the resident’s personal and medical information was visible to other staff, residents, and visitors, including a pharmacy delivery vendor present in the hallway. The facility’s Administration of Medication policy dated 04/28/2025 stated that the medication nurse would protect residents’ medical record privacy by lowering the laptop screen or locking the screen. Resident #112 had diagnoses including cerebral infarction, dysphagia, and gastrostomy tube status, and the annual MDS documented the resident could not complete the Brief Interview for Mental Status because the resident was rarely or never understood. During interviews, the LPN stated they were supposed to turn the computer screen off so the resident’s medical record would not be visible to others and said they forgot to do so. The RN supervisor stated the computer screen should have been closed to maintain privacy, and the DON stated the nurse should have turned the screen off or closed the laptop to maintain the privacy of the resident’s personal information.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported immediately to the Administrator and the New York State Department of Health, and failed to report the results of the investigation within five working days. The deficiency involved two residents reviewed for abuse. The facility policy stated that all allegations of abuse must be reported to the State Agency and law enforcement within two hours, regardless of injury, and that the facility would submit the initial report and the investigation results within the required timeframes. Resident #96 had diagnoses including Parkinson's disease, cognitive communication deficit, and bipolar disorder. The admission MDS documented a BIMS score of 8, indicating moderately impaired cognition. The resident's abuse care plan identified a potential for abuse, and the trauma-informed care plan documented PTSD related to past abuse. Neither care plan was revised to reflect the actual allegations that were later reported. On 11/30/2025, the resident's family member reported that the resident said someone hit them on the head twice and was unkind. LPN #1 was told of the allegation, but the Administrator was not made aware until 12/01/2025. The Administrator stated the incident did not present to them as an abuse allegation, and no report was made to the NYSDOH within two hours or with the investigation findings within five working days. Resident #98 had diagnoses including dementia, COPD, and type 2 diabetes mellitus. The admission MDS documented a BIMS score of 7, indicating moderately impaired cognition. The resident's abuse care plan identified a potential for abuse, but it was not revised to reflect the allegation. Resident #98 stated that an aide entered the room and hit Resident #96 on the head, and that the report was made to staff the same day. RN #1 stated the allegation was reported to LPN #1, but LPN #1 stated they were not informed by RN #1. The Administrator and DON stated they were not aware of this allegation, and the record lacked documented evidence that an investigation was completed related to the allegation made by Resident #98.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility did not ensure that a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long Term Care Ombudsman for Resident #118, who was transferred to the hospital after a fall and evaluation for a left hip fracture. The resident was admitted with diagnoses including left hip fracture and non-Alzheimer's dementia, and a Significant Change MDS documented a BIMS score of 3, indicating severely impaired cognition. The resident also had functional impairment to both lower extremities and was dependent on staff for all areas of mobility and transfers. After the resident sustained a fall in the dining room and was found on the floor in a left lateral position, nursing documented pain with touch to the right shoulder and right hip, and the physician ordered x-rays of both arms and legs. When the x-ray was positive for a left hip fracture, the resident was sent to the hospital via EMT per physician order. During interview, the Director of Social Services stated the ombudsman office was not notified when the resident was transferred, and that transfer and discharge notices had not been being sent to the Ombudsman office. The Administrator stated the social work team was responsible for sending the notices and confirmed the discharge notice for this resident should have been sent.
Missing Care Plan for Long-Term UTI Prophylaxis
Penalty
Summary
A comprehensive person-centered care plan was not developed for Resident #79 to address the long-term use of Methenamine Hippurate for a history of urinary tract infection. Record review showed the resident was admitted with diagnoses including bacterial infection unspecified, chronic obstructive pulmonary disorder, and Alzheimer's disease. The Quarterly MDS documented a BIMS score of 00, indicating severe cognitive impairment, and that the resident was frequently incontinent. A physician order dated 07/19/022 and last reviewed on 11/27/2025 documented Methenamine Hippurate 1 gram tablet twice a day for a personal history of UTI. Review of the current comprehensive care plans found no documentation for the resident's current use of prophylactic antibiotics for recurring UTIs. During interview, the RN Supervisor stated the resident had been on a prophylactic medication for UTIs since 2022 and that the care plan for recurring UTIs had been resolved inadvertently and should not have been resolved. The DON stated a care plan should be in place for the use of a long-term prophylactic medication, and that nursing supervisors, RNs, and LPNs were responsible for initiating and updating care plans.
Failure to Follow PEG Tube Flush Orders During Medication Administration
Penalty
Summary
The facility did not ensure that services provided or arranged met current professional standards of quality when a nurse administered medications and a bolus feeding to a resident with a gastrostomy tube without following the physician’s ordered water flushes. Resident #112 had diagnoses including cerebral infarction, dysphagia, and gastrostomy tube status, and the annual MDS documented the resident could not complete the BIMS because the resident was rarely or never understood and was receiving nutrition through a feeding tube. The physician’s orders required 30 mL of water via PEG tube before medication administration, 10 mL after each medication, 60 mL of water before and after each bolus feeding, and Jevity 1.5 bolus feedings five times daily. During observation of the medication pass, LPN #9 completed the resident’s bolus feeding but did not give the ordered 60 mL water flush before or after the feeding. The nurse also administered two Tylenol 325 mg tablets crushed via the feeding tube without giving the ordered 30 mL water before the medication or 10 mL after it. In interview, LPN #9 stated they forgot to give the ordered flushes because they were nervous and acknowledged that flushing the tube was important for patency and to maintain hydration. RN Supervisor #4 and the DON stated that nurses must follow physician orders and the facility policy to flush the feeding tube before and after bolus feedings and medication administration.
Failure to Follow PEG Tube Flush Orders
Penalty
Summary
The facility did not ensure that a resident receiving enteral feeding was provided the ordered treatment and services to support tube patency and hydration. Resident #112 had diagnoses including cerebral infarction, dysphagia, and gastrostomy tube status, and the annual MDS documented the resident could not complete the BIMS because the resident was rarely or never understood. The resident’s physician orders required 30 mL of water via PEG tube before medication administration, 10 mL after each medication, Jevity 1.5 bolus feedings five times daily, and 60 mL of water before and after each feeding. The resident’s care plan also directed staff to administer the prescribed formula with the required water flushes, check tube patency and position before each feeding, and monitor gastric residuals. During observation of medication administration, an LPN completed the resident’s bolus feeding without giving the ordered 60 mL water flush before and after the feeding. The same nurse administered two Tylenol tablets via the feeding tube without giving the ordered 30 mL water flush before the medication or the 10 mL flush after. In interview, the LPN stated they forgot to provide the ordered flushes because they were nervous and acknowledged that flushing was important to maintain tube patency and hydration. The RN supervisor, physician, and DON all stated that nurses must follow the physician’s orders, facility policy, and the care plan for tube feeding patency and hydration.
Oxygen Flow Rate Not Kept at Ordered Level
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD and dependence on supplemental oxygen. Resident #9 had a physician’s order for oxygen at 2 liters per minute via nasal cannula as needed, with orders to check oxygen saturation every shift and as needed and to administer oxygen at 2 liters per minute for comfort and when pulse oxygen saturation was less than 90%. The resident’s care plan also directed staff to administer oxygen therapy as ordered. The facility’s oxygen therapy policy stated oxygen must be ordered by a physician and the flow rate must be set at the prescribed liters per minute. On three separate observations, Resident #9 was found in bed receiving oxygen via nasal cannula at 3 liters per minute instead of the ordered 2 liters per minute. The resident’s record showed oxygen saturation levels were generally above 90%, except for one shift when the saturation was documented at 74%. During interviews, the resident stated a preference to always have oxygen because it made them feel better. A CNA stated nurses were responsible for oxygen administration and did not see the resident adjusting it, while an LPN stated they did not know the oxygen flow rate was set at 3 liters per minute. The RN supervisor, physician, and DON all stated the oxygen order should be followed and that any increase in flow rate required physician notification and evaluation.
Misappropriation of Resident Funds by Facility Employee
Penalty
Summary
A deficiency was identified when a facility employee, specifically a Certified Nurse's Aide, obtained 16 checks from a resident and cashed them for various amounts, totaling between $27,000 and $40,000. The resident, who had diagnoses including heart failure, circulatory problems, and anxiety, was assessed as having moderately impaired cognitive skills for decision making. The facility's admission packet, signed by the resident, explicitly stated that employees are not permitted to request or accept any form of remuneration, tip, or gratuity from residents. Facility policy also defined misappropriation of resident property as theft or unauthorized use of personal property, including money. Despite these policies, the aide received and cashed checks from the resident, with the aide's name appearing on the checks and the resident's signature present. The situation came to light when the resident's next of kin reviewed the resident's funds and reported the findings to facility administration, providing copies of the checks as evidence. Interviews with facility staff confirmed that employees are trained not to accept money or valuables from residents, and the aide admitted to receiving the checks. The resident acknowledged voluntarily giving the money to the aide, reportedly due to personal feelings. Documentation also indicated that the resident was considered at risk for abuse and victimization, with care plan interventions instructing staff to report any suspected abuse. The facility's investigation concluded there was reasonable cause to believe that abuse, neglect, or mistreatment had occurred.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident receiving anticoagulant medication, as identified during a recertification survey. The resident, who was admitted with multiple fractures and Atrial Fibrillation, was prescribed Enoxaparin, an anticoagulant, to be administered subcutaneously every 12 hours. Despite the physician's order for this medication, there was no documented evidence of a comprehensive care plan addressing the use of the anticoagulant, which is a requirement according to the facility's policy and procedure. Interviews with the Registered Nurse Supervisor and the Director of Nursing Services confirmed that a care plan should have been developed for the anticoagulant medication. The Registered Nurse Supervisor indicated that the admitting nurse is responsible for initiating care plans, and any additional required care plans should be initiated by another nurse the following day. However, upon review of the resident's electronic medical record, both the Registered Nurse Supervisor and the Director of Nursing Services found no care plan for the anticoagulant medication, highlighting a lapse in the facility's adherence to its own policies and regulatory requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Middle Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quantum Rehabilitation And Nursing Llc | 0 mi | ★★★★★ | 2 | 0 |
| Allegria Nursing & Rehab Center Of Port Jefferson | 4.3 mi | ★★★★★ | 0 | 0 |
| Medford Multicare Center For Living | 4.7 mi | ★★★★★ | 0 | 0 |
| John T Mather Memorial Hosp T C U | 5.2 mi | ★★★★★ | 0 | 0 |
| Island Nursing And Rehab Center | 5.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Surge Rehabilitation And Nursing Llc.
100% money-back within 48 hours.
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.