Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Swan Lake Nursing & Rehabilitation during CMS and state inspections, most recent first.
Hot Water Exposed Resident to Accident Hazard: A resident with schizophrenia, schizoaffective disorder, PTSD, and moderately impaired cognition had a behavior of washing clothes in the bathroom sink and flushing items in the toilet. Staff reported the resident requested hotter water, and the sink water in the resident’s room was measured at 136.2°F, 123°F, and 127°F, above the 110°F limit for residents not trained to regulate water temperature. The care plan did not include this behavior, and facility water temperature logs were incomplete.
Unsanitary shower rooms and a resident bathroom were observed with urine, feces, broken privacy curtain clips, and strong foul odors. Two residents complained in council about dirty shower rooms, and staff interviews confirmed the areas were supposed to be cleaned regularly, but the observed conditions showed they were not maintained as required. A resident’s toilet flushing mechanism had been disabled after prior flooding, yet the toilet and commode still contained waste and the room remained foul-smelling.
Failure to Maintain Resident Privacy, Cleanliness, and Dignity: A resident with schizophrenia, PTSD, and moderately impaired cognition had a history of putting items in the toilet and causing flooding. After the toilet flush was disabled and a commode was placed in the bathroom, the room and bathroom were observed with a strong feces and urine odor, and the toilet and commode were filled with waste. Staff also entered the bathroom without knocking while the resident was using it, and interviews showed the resident continued using the disabled toilet without staff awareness.
Care Plan Not Updated to Reflect Floor Mat Intervention: A resident with COPD, CVA, bipolar disorder, and severe cognitive impairment had a history of falls and a behavior of rolling onto a floor mat when refusing care. Although staff observed and used a floor mat at the bedside as a fall precaution, the behavior and fall care plans and CNA instructions did not document the floor mat as an intervention, and an LPN manager acknowledged the care plan had not been updated to include it.
A resident with COPD, hemiplegia, heart failure, and moderate cognitive impairment had an order for continuous O2 at 2 L/min via NC, but staff observed the resident receiving 4 L/min and later 3 L/min instead. The TAR documented 2 L/min and shift oxygen saturation monitoring, and an LPN UM stated the nurse on duty was responsible for checking oxygen settings. The resident was not able to change the oxygen flow rate themself, and the ADON stated the RN should assess the resident and notify the MD if oxygen needed to be increased.
A resident's clothing was lost after being sent to the laundry, and the facility failed to maintain an inventory list of the resident's belongings, violating their policy. The resident, with diagnoses including Cerebral Palsy and Morbid Obesity, reported the loss, and staff confirmed the absence of an inventory sheet. The facility acknowledged the deficiency.
A resident with a history of anxiety and depression was verbally abused by a CNA, who threatened them with physical harm. Despite facility policies requiring immediate suspension of staff suspected of abuse, the CNA continued working their shift. The incident was witnessed by a Registered Nurse Supervisor and reported to authorities, leading to the CNA's termination.
A facility failed to provide a resident with an ongoing activities program based on their comprehensive assessment and care plan. The resident, with moderate cognitive impairment and specific activity preferences, was often found without meaningful engagement. Despite the care plan's interventions, the resident received limited one-to-one visits and group activities. Staff interviews revealed a lack of evening activities due to staffing shortages, contributing to the deficiency.
A resident with a history of aggressive behavior was not adequately supervised, leading to a physical altercation with another resident. Despite the care plan requiring close monitoring, staff failed to maintain supervision, resulting in the resident wandering into another's room and initiating a fight. The incident highlights a lapse in supervision protocols within the facility.
A resident with COPD, Schizophrenia, and Asthma was observed receiving oxygen therapy without a physician's order during a survey. Despite facility policy requiring such orders, none were documented in the resident's medical records. Interviews with staff confirmed the absence of a written order, highlighting a failure to maintain medical records according to professional standards.
Hot Water Exposed Resident to Accident Hazard
Penalty
Summary
The facility failed to ensure that a resident’s environment remained free of accident hazards. Resident #39 had diagnoses of schizophrenia, schizoaffective disorder, and post-traumatic stress disorder, with moderately impaired cognition on the Quarterly MDS. The resident required substantial assistance with toileting and toilet transfers, supervision or touching assistance for personal hygiene, and had documented behaviors including refusing care, screaming, talking very loudly, putting inappropriate items in the toilet, and flooding the room. The psychiatric note also documented paranoia, auditory hallucinations, poor impulse control, and erratic, unpredictable triggers. During the survey, staff and observations showed that Resident #39 routinely washed clothing in the bathroom sink and flushed items in the toilet. The Director of Social Work stated the resident had a behavior of washing clothes in the bathroom sink and flushing clothes in the toilet bowl, and the Director of Environmental Services stated the resident requested the water be set to 125 degrees Fahrenheit to wash clothing. Staff reported that if the water temperature was not to the resident’s liking, the resident would yell, scream, and throw themself on the floor, and the facility accommodated the request by increasing the water temperature. The comprehensive care plan did not include the behavior of washing clothes in the sink or requesting hotter water. On multiple observations, the bathroom sink water temperature in Resident #39’s room was measured at 136.2 degrees Fahrenheit, 123 degrees Fahrenheit, and 127 degrees Fahrenheit. The surveyor also observed that the water felt hot enough that a hand had to be quickly removed. The Director of Environmental Services acknowledged that 136.2 degrees Fahrenheit was too hot and above the regulatory requirement, and the Medical Doctor stated that 136.2 degrees Fahrenheit could cause significant burns. The facility was unable to provide September 2025 water temperature logs when requested, and the log later provided for Resident #39’s room had multiple missing dates and noted the automatic faucet was not working properly on 09/27/2025.
Unsanitary shower rooms and resident bathroom conditions
Penalty
Summary
The facility did not ensure that residents had a clean, comfortable, and homelike environment. During the Resident Council meeting, two residents complained about dirty shower rooms on the second floor, and prior council minutes also documented complaints that the shower rooms were not being cleaned. Survey observations found the second-floor shower room unsanitary, with a dirty floor, dirty gloves on the floor, a hairbrush in the sink, an incontinent brief on the sink counter, an unlined garbage can, two toilet bowls containing urine, broken privacy curtain rod clips, and a strong foul odor. Resident #39’s room and bathroom were also observed multiple times to have a strong feces and urine odor. The toilet bowl and portable commode contained feces and urine, and the toilet flushing mechanism was non-functional. The Director of Environmental Services stated the flushing mechanism had been disabled because the resident had previously flushed clothes and caused flooding, and also stated the condition of the bathroom was disgusting and should have been cleaned. A CNA stated the resident was still using the disabled toilet, that the feces and urine caused a strong foul odor, and that environmental services staff knew the resident was using the toilet but did nothing about it. Staff interviews showed that shower rooms were supposed to be cleaned three times daily and resident rooms and bathrooms daily, but the observed conditions did not reflect that standard. The LPN Unit Manager stated CNAs were responsible for ensuring shower rooms were clean after showers, and the Administrator stated maintenance should ensure shower curtains were working properly and that housekeepers should flush and clean the resident’s toilet regularly every day and as needed to maintain dignity. The report also noted that the second-floor shower room privacy curtains were in disrepair and that the resident bathroom had a strong foul odor during multiple observations.
Failure to Maintain Resident Privacy, Cleanliness, and Dignity
Penalty
Summary
The facility failed to ensure that Resident #39 was treated with respect, privacy, and dignity. The resident had diagnoses of Schizophrenia, Schizoaffective disorder, and Post-Traumatic Stress Disorder, with moderately impaired cognition on the Quarterly MDS. The resident required substantial assistance with toileting and toilet transfers, supervision or touching assistance for personal hygiene, and was always continent of bowel and bladder. The behavior care plan documented that the resident put inappropriate items in the toilet, which had resulted in flooding in the room, and also screamed, talked very loudly, and refused care. During the survey, the resident's room and bathroom were observed to have a strong foul feces and urine odor. The portable commode and the toilet were filled with feces and urine, and the resident was sitting on the bed wearing pants that were long and soiled with brownish material. The Psychiatric Nurse Practitioner note documented paranoia, auditory hallucinations, poor impulse control, and a history of erratic and unpredictable triggers. Facility staff reported the resident had been using other residents' toilets to wash clothes and attempting to flush items in the toilet. The flushing mechanism in the resident's bathroom toilet had been disabled after the resident caused flooding by flushing clothing, and a portable commode was placed in the bathroom. Staff interviews showed that the resident continued to use the disabled toilet, but this was not known to the unit manager, administrator, or housekeeper. The Director of Environmental Services observed the bathroom condition as disgusting and stated the toilet should have been cleaned. The Director of Environmental Services also entered the resident's bathroom without knocking while the resident was using the bathroom, and the resident shouted at the staff member.
Care Plan Not Updated to Reflect Floor Mat Intervention
Penalty
Summary
The facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect a resident’s preferences and status after assessment. For Resident #24, who had diagnoses including COPD, cerebral infarction, and bipolar disorder, the MDS documented a BIMS score of 5, indicating severe cognitive impairment, and also noted one fall since admission/reentry without injury. The resident was identified as having a behavior of rolling out of bed onto the floor mat when needing care and refusing staff assistance, but the comprehensive care plan titled Behavior did not document the use of floor mats as an intervention, and the Fall/Injury care plan also did not include floor mats despite the resident being assessed as high risk for falls. Record review showed that the CNA Accountability Record/Kardex did not document floor mats as part of the resident’s care. During observations, the resident was seen in bed with a floor mat placed by the bedside, and at another time a floor mat was observed lying against the wall when the resident was not in the room. During interviews, a CNA stated the resident was on fall precautions and used a floor mat, while an LPN manager stated the resident had a behavior of throwing themselves on the floor when they did not want care and acknowledged there was no intervention added to the care plan for the floor mat. The Assistant DON stated floor mats are a nursing intervention and should have been documented in the fall or injury care plan.
Improper Oxygen Flow Rate for Resident with COPD
Penalty
Summary
The facility did not ensure safe and appropriate respiratory care for a resident who had an order for supplemental oxygen. Resident #10 had diagnoses including Chronic Obstructive Pulmonary Disease, right-sided hemiplegia, and heart failure, and the MDS documented moderate cognitive impairment and oxygen therapy use. A care plan for respiratory status directed staff to administer supplemental oxygen as ordered, and a physician's order renewed on 09/15/2025 specified oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath and dyspnea on exertion. However, during an observation on 09/25/2025, the resident was receiving oxygen at 4 liters per minute via nasal cannula while sleeping in bed. The Treatment Administration Record for September 2025 documented daily use of oxygen at 2 liters per minute and continuous oxygen saturation monitoring each shift. During interview, the LPN Unit Manager stated the nurse on duty was responsible for checking oxygen settings for residents using supplemental oxygen. Later observations showed the resident receiving oxygen at 3 liters per minute via nasal cannula while sleeping in a geri chair in the hallway. During re-interview, the LPN Unit Manager stated they should have been made aware that the resident required an increase in oxygen, and that the resident was not able to change the oxygen flow rate themself. The ADON stated the resident should have received oxygen as ordered by the physician and that the RN on duty should assess the resident and notify the physician if oxygen needed to be increased.
Failure to Safeguard Resident's Personal Belongings
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's property, specifically clothing, from loss or theft. This deficiency was identified during a recertification survey when it was discovered that a resident's clothes were lost after being sent to the laundry. The facility did not maintain an inventory list of the resident's belongings, which made it impossible to determine the lost items. The facility's policy required that all resident property be inventoried and documented on a Resident's Personal Possessions Sheet, but this was not done for the resident in question. The resident, who had diagnoses including Cerebral Palsy and Morbid Obesity, reported the loss of clothing through a grievance form. The social worker noted the absence of an inventory list and indicated that the facility would reimburse the resident for the lost items. Interviews with facility staff, including the social worker, Director of Guest Services, and the Administrator, confirmed that no inventory sheet was found in the resident's record, despite the resident being admitted in 2018. The facility acknowledged the lack of an inventory list and the need to implement one to ensure accuracy.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nurse Assistant (CNA). The incident involved a verbal altercation where the CNA threatened the resident with physical harm, causing the resident to feel scared and upset. The facility's policy on abuse prevention, which was last reviewed in March 2024, clearly states that residents have the right to be free from abuse, including verbal abuse. Despite this policy, the CNA engaged in behavior that was deemed verbally abusive, as witnessed by a Registered Nurse Supervisor. The resident involved in the incident had a history of morbid severe obesity, anxiety disorder, and major depressive disorder, with a documented intact cognition score. The resident's comprehensive care plan identified them as being at risk of abuse, neglect, and mistreatment. On the night of the incident, the CNA was reported to have used threatening language towards the resident, which was corroborated by the resident and a Registered Nurse Supervisor who witnessed the event. Despite the facility's policy requiring immediate suspension of staff suspected of abuse, the CNA continued to work their shift until the following morning. Interviews with staff revealed that the CNA was not immediately removed from the unit, and the resident was left feeling afraid throughout the night. The Director of Nursing Services confirmed that the CNA was eventually terminated due to the verbal abuse incident. The incident was reported to the New York State Department of Health and the local police department, indicating that the facility recognized the severity of the situation but failed to act promptly in accordance with their own policies.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the comprehensive assessment and care plan of each resident, specifically for one resident who was observed without meaningful activities. The resident, who has diagnoses of cancer, arthritis, and cataracts/glaucoma or macular degeneration, was found in their room on multiple occasions without engagement in activities that matched their preferences, such as conversation, crafts, or music. The resident expressed that recreation staff did not visit them due to enhanced barrier precautions, and there were no scheduled activities after 3:00 PM on weekdays or in the evenings. The facility's policy on recreation programming requires that activities be based on the comprehensive assessment and preferences of each resident, yet the resident's care plan was not followed. The resident's care plan included interventions like escorting to activities and offering one-to-one visits, but these were not consistently provided. The resident's attendance record showed limited participation in programs, with only a few one-to-one visits and group activities over several months, and there was no documented evidence of the resident being offered or refusing activities. Interviews with staff revealed that there were no evening activities due to staffing shortages, and the recreation aide could not provide attendance or refusal records for the resident. The Assistant Director of Recreation confirmed the lack of evening activities and limited weekend offerings, and the Administrator acknowledged the absence of evening recreation staff. Despite the resident's preference for group activities and going outside, the facility did not adequately support these interests, leading to the deficiency.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents, specifically involving a resident with a history of physical altercations and behaviors that disturb others. This resident, diagnosed with Vascular Dementia and Anxiety Disorder, was supposed to be kept in a supervised area when out of bed, as per their Comprehensive Care Plan. However, on the day of the incident, the resident was not adequately supervised and wandered into another resident's room, leading to a physical altercation. The incident involved the resident entering another resident's room and throwing a water bottle at them, which escalated into a physical fight. The resident who was attacked had intact cognition but was at risk of being a victim of abuse due to their medical conditions, including lack of coordination and essential tremors. The altercation was witnessed by a Certified Nursing Assistant who intervened after hearing calls for help. Interviews with staff revealed a lack of consistent supervision for the resident with aggressive behavior. Staff members, including CNAs, LPNs, and a Resident Assistant, acknowledged the need for close monitoring of the resident but failed to maintain the required supervision. The Director of Nursing Services admitted that the facility should have prevented the altercation by ensuring the resident was kept within the line of sight at all times.
Resident Received Oxygen Therapy Without Physician's Order
Penalty
Summary
The facility failed to maintain medical records for each resident in accordance with accepted professional standards and practices, as evidenced by the case of a resident receiving oxygen therapy without a physician's order. This deficiency was identified during a recertification survey conducted from July 24 to July 31, 2024. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease, Schizophrenia, and Mild Intermittent Asthma, was observed receiving oxygen therapy on multiple occasions without a documented physician's order. The facility's policy required verification of a physician's order for oxygen administration, but no such order was found in the resident's medical records for July 2024. Interviews with facility staff, including a Licensed Practical Nurse Manager, a Nurse Practitioner, the Director of Nursing Services, and a physician, revealed that the resident was receiving oxygen therapy daily, yet there was no written order for this treatment. The physician indicated that a verbal order had been given, but it was not documented in the resident's records. This lack of documentation and adherence to the facility's policy resulted in the deficiency noted during the survey.
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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 Patchogue
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookhaven Health Care Facility, Llc | 1.4 mi | ★★★★★ | 3 | 0 |
| Bellhaven Center For Rehab And Nursing Care | 3.2 mi | ★★★★★ | 3 | 1 |
| Sayville Nursing And Rehabilitation Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Medford Multicare Center For Living | 3.9 mi | ★★★★★ | 0 | 0 |
| Island Nursing And Rehab Center | 4 mi | ★★★★★ | 0 | 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.