Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Hamptons Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. One resident’s quarterly MDS had no completion date, while three others were completed well beyond the 14-day ARD window. The MDS Assessor said other duties interfered with timely completion, and the MDS Coordinator cited increased admissions and a change in the MDS submission system. The DON, former DON, and Administrator were aware of the late assessments.
Delayed MDS Transmission: The facility failed to transmit completed MDS assessments to CMS within the required timeframe for three residents. One resident's annual MDS, one resident's admission MDS, and one resident's quarterly MDS were all submitted late, with one assessment also rejected due to a Section X mismatch. The residents had diagnoses including osteoporosis, DM2, seizures, postlaminectomy syndrome, HTN, Guillain-Barre syndrome, discitis, and COPD, and their BIMS scores indicated intact cognition.
Unsecured Oxygen Tank in Nurse's Station: An unsecured full E-cylinder oxygen tank was observed freely standing in the Unit G nurse's station instead of being secured in a rack, caddy, or chained to the wall. Staff interviews showed the LPN, RN, Unit G manager, housekeeping director, and DON all acknowledged that oxygen tanks must be secured, and the facility policy required tanks to be chained or otherwise secured and separated as full or empty.
A resident with severe cognitive impairment and multiple medical conditions was transferred to the hospital, and staff boxed the resident’s belongings for storage. Due to confusion with another resident who had the same last name and was later admitted to the same room, the boxed items were mistakenly given to the wrong resident and were not returned when the original resident came back from the hospital. The family later reported missing clothing with sentimental value, and staff interviews confirmed that the belongings had been misidentified and were no longer in the facility.
Two residents with intact cognition reported allegations of sexual abuse by a CNA, including inappropriate comments and unwanted touching during care. Despite these reports, the facility did not conduct thorough investigations, failed to assess the residents physically or psychosocially, and allowed the CNA to return to work with access to all residents. Leadership did not report the incidents or inform the medical director in a timely manner.
Two residents with intact cognition reported inappropriate and potentially abusive contact by a CNA, including unwanted touching and inappropriate comments. Facility leadership did not report these allegations to law enforcement or the state health department, nor did they conduct required investigations, as they did not believe the incidents constituted abuse. The facility's policy lacked guidance on reporting to law enforcement, and no physical or psychosocial assessments were completed for the affected residents.
Two residents with intact cognition reported inappropriate and distressing care by a CNA, including intimate care against their wishes and inappropriate comments. Despite facility policy requiring immediate reporting and investigation of abuse allegations, leadership dismissed the concerns without thorough inquiry or documentation, and no comprehensive investigation was conducted.
Three residents in a facility were found with fall prevention mats improperly placed on their sides against the beds, restricting their movement. The facility's policy requires these mats to be laid flat on the floor to prevent falls, not to act as restraints. Interviews with CNAs, LPNs, and the DON confirmed the incorrect placement of the mats, which was not in line with the facility's guidelines.
A survey found that call systems were not accessible to residents in their rooms, affecting three residents with conditions like Parkinson's, Dementia, and Aphasia. Observations showed call bells out of reach, despite facility policy and care plans requiring accessibility. Staff, including CNAs and LPNs, failed to ensure call bells were within reach, as confirmed by the DON.
A resident's dignity was compromised due to a failure to maintain cleanliness in their room. Despite the resident's preference for urinals on the floor for easy access, staff did not ensure the area was clean and odor-free. The resident, who required substantial assistance for toileting, expressed a desire for cleanliness, but staff failed to promptly address the issue, leaving a full urinal and soiled bed mat in place.
A resident with severe cognitive impairments fell from their bed, sustaining facial bruising. The facility failed to notify the resident's primary contact, the family member, as required by policy, and instead informed the group home. Staff interviews confirmed the oversight, acknowledging the family should have been the first contact.
A facility failed to maintain a safe and clean environment for residents, with issues including a broken bathroom door for a resident with dementia and stained privacy curtains and soiled bathroom floors for another resident. Despite maintenance and cleaning protocols, these issues persisted, indicating lapses in timely response and adherence to cleaning policies.
A resident with severe cognitive impairment and a history of falls was found on the floor with a laceration and bruising. The facility failed to obtain a statement from the Kitchen transporter, who first found the resident, as required by policy. This oversight was acknowledged by the RN Supervisor and DON, highlighting an incomplete investigation.
A facility failed to complete a Minimum Data Set (MDS) assessment within the required timeframe for a resident admitted with Congestive Heart Failure and Diabetes Mellitus. The assessment was completed six days late, and the MDS Coordinator acknowledged the delay but was unsure of the reason. The Administrator was unaware of the issue.
A resident with a tracheostomy did not receive proper respiratory care as a nurse failed to change the inner cannula as per physician orders, instead attempting to clean and reuse it. The facility's policy lacked specific directions for changing the cannulas, and there was no evidence of physician orders for outer cannula changes for several months. Interviews with staff confirmed the improper practice and highlighted the risk of infection due to these deficiencies.
A resident with severe cognitive impairment and cellulitis did not receive prescribed doses of Ampicillin at two scheduled times. The medication was not documented as administered, and the setup lacked proper labeling. Nursing staff interviews confirmed the oversight, highlighting a breach in the facility's medication administration policy.
The facility failed to adhere to food safety standards, as observed when a dietary aide handled food with contaminated gloves and cold food items were served above the required temperature. The aide did not change gloves after exiting the refrigerator, and cold food temperatures were not routinely checked, leading to potential contamination risks.
A non-verbal resident with severe communication impairments was sent to a Neurology appointment unaccompanied, resulting in the appointment's cancellation. The facility failed to document the cancellation or reschedule the appointment, and the resident's family was not informed. The LPN responsible did not follow the facility's policy requiring accompaniment for such residents, and the Director of Nursing acknowledged the lack of documentation and follow-up.
The facility failed to transmit MDS assessments to CMS within the required timeframe for six residents, with delays ranging from 46 to 65 days. The MDS Coordinator believed the assessments were submitted on time but did not receive validation reports, leading to a resubmission. The Administrator was unaware of the delays, highlighting a lapse in the facility's compliance with timely MDS submissions.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents sampled from the resident assessment task. Resident #184 had a Quarterly MDS with an ARD of 02/06/2026 that was not completed and did not include a completion date in item Z0500B. Resident #35’s Quarterly MDS with the same ARD was not completed until 77 days after the ARD, Resident #25’s Quarterly MDS with an ARD of 01/21/2026 was not completed until 71 days after the ARD, and Resident #36’s Quarterly MDS with an ARD of 11/28/2025 was not completed until 22 days after the ARD. The facility policy titled Minimum Data Set (MDS 3.0) Completion stated that all MDS assessments are to be completed, signed, and transmitted in accordance with federal requirements and the RAI Manual, and that required assessments are to be scheduled based on the ARD and completed within 14 days. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.20.1 also stated that the completion date for quarterly assessments must be no later than 14 days after the ARD. The report identified that these quarterly assessments were not completed within that required period. Resident #184 had diagnoses including dementia, hypertension, and hyperlipidemia, and the Quarterly MDS documented a BIMS score of 10, indicating moderately impaired cognition. Resident #35 had diagnoses including nontraumatic subarachnoid hemorrhage, dysphagia, and aphasia, and the Quarterly MDS noted the BIMS was not completed because the resident was unable to understand others. Resident #25 had diagnoses including multiple sclerosis, tremor, and ulcerative colitis, and the Quarterly MDS documented a BIMS score of 15, indicating intact cognition. During interviews, the MDS Assessor stated they were responsible for completing all MDS assessments and said they were unable to complete them on time because of other duties such as care plan meetings. The MDS Coordinator stated quarterly assessments should be completed within 14 days but reported delays related to a sudden influx of admissions and a change in the MDS submission system. The former DON, current DON, and Administrator were aware of the late completion of MDS assessments.
Delayed MDS Transmission
Penalty
Summary
The facility failed to ensure that completed MDS assessments were electronically transmitted to CMS within 14 days of assessment completion for three sampled residents. Resident #178 had an annual MDS completed on 02/10/2026, but it was not transmitted until 04/07/2026, 56 days later; the validation report also noted the assessment was rejected because Section X did not match the corresponding items of an existing record in the database. Resident #43 had an admission MDS completed on 11/26/2025, but it was not transmitted until 01/07/2026, 42 days later. Resident #36 had a quarterly MDS completed on 12/20/2025, but it was not transmitted until 01/16/2026, 27 days later. Resident #178 was admitted with osteoporosis, type 2 diabetes mellitus, and urinary retention, and the annual MDS documented a BIMS score of 13, indicating intact cognition. Resident #43 was admitted with seizures, postlaminectomy syndrome, and hypertension, and the admission MDS documented a BIMS score of 13, indicating intact cognition. Resident #36 was admitted with Guillain-Barre syndrome, thoracic discitis, and COPD, and the quarterly MDS documented a BIMS score of 15, indicating intact cognition. During interviews, the MDS Assessor stated that the MDS Coordinator and they were responsible for transmitting assessments and that other duties, including care plan meetings, interfered with timely completion and transmission. The MDS Coordinator stated the facility had been affected by a sudden influx of new admissions and a change in the MDS submission system, and the DON and Administrator stated they expected all MDS assessments to be completed and transmitted timely.
Unsecured Oxygen Tank in Nurse's Station
Penalty
Summary
An unsecured free-standing E-Cylinder oxygen tank was observed in the Unit G nursing station during an initial tour. The tank was full, not in use, and was not secured in a safety stand, rolling caddy, or metal rack. The facility policy titled "Oxygen Tank Storage and Handling" stated that all oxygen tanks must be secured to a wall with a chain or heavy cable, that no oxygen tanks are to be left unattended on a transport dolly, and that full oxygen tanks must be separated from empty oxygen tanks and identified as such. During interviews, an LPN stated the tank had not been noticed while medication administration was being completed and stated oxygen tanks must be secured with a chain against the wall and on a dolly. An RN stated nurses on all shifts were responsible for ensuring oxygen tanks were secured properly and that they should not be freely standing. The Unit G Manager stated they were not aware of the unsecured tank in the nurse's station and did not know who placed it there, while the Director of Housekeeping stated they transported oxygen tanks to the unit and had seen the tanks secured earlier that morning. The DON stated all staff should monitor oxygen tanks in the unit and resident rooms and ensure they are secure in a dolly and chained against the wall.
Failure to Safeguard and Return a Resident’s Personal Belongings After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity and to retain personal possessions when transferred to the hospital. The facility’s policy on personal belongings stated that upon discharge to a hospital, valuables would be sent to the basement for storage and other belongings could remain in the room if security could be ensured, with property left more than 30 days after discharge subject to disposal. Resident #266, who had diagnoses including type 2 diabetes, cerebral infarction, and essential hypertension, and who had a Brief Interview of Mental Status score of 3 indicating severely impaired cognition and required assistance with all ADLs and was always incontinent, was transferred to the hospital for evaluation. During this transfer, the resident’s belongings were boxed and stored in the basement. After the resident’s return from the hospital, the belongings were not returned to the resident or family. A grievance filed by the resident’s family reported missing clothing that could not be located. The family stated that the belongings were never returned after the hospital transfer and that they were not informed what happened to the items until months later, when they were told by the Director of Housekeeping and the Administrator that the possessions had been accidentally given to another resident with the same last name. Interviews with staff revealed that CNAs typically pack belongings in a labeled box stored in the resident’s closet until removed, and that nurses and CNAs are responsible for packing belongings while housekeeping staff clean rooms and the Director of Housekeeping moves boxes to the basement. The Director of Housekeeping acknowledged that the boxed belongings of Resident #266 were mistakenly assumed to belong to a newly admitted resident with the same last name and were given to that resident, who later left the facility, and the items were no longer in the facility.
Failure to Protect Residents from Alleged Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from alleged sexual abuse, resulting in Immediate Jeopardy for two residents with intact cognition. Both residents reported inappropriate actions by a Certified Nursing Assistant (CNA), including sexually inappropriate comments and unwanted touching during personal care. Despite these allegations, there was no documented evidence that a thorough investigation was initiated, nor were the residents assessed by a registered nurse or provided with a psychosocial evaluation after expressing fear and discomfort. One resident, diagnosed with multiple sclerosis, protein calorie malnutrition, and pseudobulbar affect, reported that a male CNA made a sexually inappropriate comment and applied cream to intimate areas without proper consent. The resident had previously requested female caregivers, but this preference was not documented or honored. The incident was reported to facility leadership, but the CNA was only suspended for three days without a comprehensive investigation and was later allowed to return to work with access to all residents. There was no documentation of a physical or psychosocial assessment for the resident following the incident. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same CNA took an unusually long time wiping their genital area, making them feel unsafe. This concern was reported to another CNA and a registered nurse supervisor, but no formal investigation or assessment was conducted. The resident was transferred to another room, but there was no evidence of a registered nurse assessment or psychosocial evaluation. Facility leadership decided not to report or investigate the allegation, citing a lack of perceived sexual abuse, and the medical director was not informed until much later.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. This deficiency was identified for two residents who reported allegations of inappropriate and potentially abusive behavior by a certified nursing assistant. The facility did not document evidence that these allegations were reported to local law enforcement or the New York State Department of Health as required by regulation. One resident, with a history of multiple sclerosis, protein-calorie malnutrition, and pseudobulbar affect, reported that a male certified nursing assistant made inappropriate comments about their shaved vaginal area and applied cream to their buttocks despite the resident's request to self-apply. The resident delayed reporting the incident due to embarrassment, and the family member subsequently informed facility leadership. Despite the resident and family expressing concerns about safety, the facility leadership determined within two hours that there was no evidence of abuse and did not report the incident to authorities. The facility's policy did not include guidance on reporting to law enforcement, and the staff involved did not consider the incident to be sexual abuse. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same certified nursing assistant rubbed their genital area in a manner that made them feel violated. The resident was visibly upset and reported the incident to another staff member, who escalated it to a supervisor. However, the facility did not document any report to authorities or conduct a formal investigation, as leadership did not believe the incident constituted abuse. Interviews with facility leadership and the medical director revealed a lack of awareness and appropriate response to the allegations, and no physical or psychosocial assessments were completed for the residents involved.
Failure to Investigate Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to thoroughly and promptly investigate allegations of sexual abuse involving two residents, resulting in a deficiency identified during an abbreviated survey. According to the facility's abuse prevention policy, all allegations of abuse must be immediately reported and investigated, including obtaining statements from staff, witnesses, and residents, as well as reviewing medical and employee records. However, in both cases, there was no documented evidence that a comprehensive investigation was initiated to rule out abuse, neglect, or mistreatment. One resident, with a history of multiple sclerosis and intact cognition, reported that a male CNA provided intimate care despite their request for a female caregiver and made inappropriate comments regarding the resident's body. The resident delayed reporting the incident due to embarrassment, but when the family member informed facility leadership, the Assistant Director of Nursing dismissed the allegation, believing the resident was fabricating the story, and did not pursue further investigation. The administrator also concluded within two hours that there was no evidence of abuse based on family input, without conducting a thorough inquiry. A second resident, also with intact cognition and a care plan identifying risk for psychosocial distress, reported discomfort and distress after a CNA allegedly took an unusually long time providing care to their genital area. The resident was visibly upset and requested a room change to avoid further contact with the CNA. Although the concern was reported to nursing and social work staff, no further questions were asked, and the Director of Nursing decided not to report or investigate the allegation, concluding it did not constitute sexual abuse. The administrator similarly determined no investigation was necessary. The medical director later stated that all allegations of abuse should be reported and investigated immediately.
Improper Use of Fall Prevention Mats as Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required for medical treatment. During an abbreviated survey, it was observed that three residents were subjected to improper use of fall prevention mats, which were placed on their sides against the beds, restricting the residents' freedom of movement. This setup was contrary to the facility's policy, which mandates that such mats should be laid flat on the floor next to the bed to prevent injuries from falls. Resident #1, diagnosed with Parkinson's Disease, Dementia, and Dysphagia, was observed in bed with fall prevention mats placed on their sides, restricting movement. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse Manager revealed that the mats were intended to be flat on the floor, not on their sides, as this would restrict the resident's ability to move freely. The Director of Nursing Services confirmed that the mats should not be placed on their sides as it could restrict movement. Similarly, Resident #2, with diagnoses including Cerebral Infarction and Dementia, and Resident #3, diagnosed with Dementia and Alzheimer's Disease, were also observed with fall prevention mats improperly placed on their sides. Interviews with CNAs and nursing staff confirmed that the mats were not positioned according to the facility's policy, which led to the restriction of the residents' freedom of movement. The Director of Nursing Services reiterated that the mats should be laid flat to be effective and not act as restraints.
Inaccessible Call Systems for Residents
Penalty
Summary
The facility failed to ensure that call systems were accessible to residents while they were in their rooms, as observed during an abbreviated survey. This deficiency was identified for three residents who were unable to reach their call bells, preventing them from calling for assistance. The facility's policy on call bell and alarm response, effective since October 2019, did not specify the placement of call bells, contributing to the oversight. Resident #1, diagnosed with Parkinson's Disease, Dementia, and Dysphagia, was observed multiple times with the call bell out of reach, hanging on the nightstand knob. Despite the care plan intervention to keep the call bell within reach, staff failed to ensure its accessibility. Certified Nursing Assistant #1, responsible for Resident #1, was unaware of the call bell's location and did not rectify the situation. Similarly, Resident #2, with Cerebral Infarction, Hemiplegia, and Dementia, had their call bell on the floor behind the headboard, out of reach. Staff, including Certified Nursing Assistant #2 and Licensed Practical Nurse #1, acknowledged the call bell should be within reach but did not ensure it was. Resident #3, with Dementia, Alzheimer's Disease, and Aphasia, also had their call bell out of reach, despite staff observations. The Director of Nursing Services confirmed that call bells should be clipped to the bed sheet and within reach, but this was not consistently practiced.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the conditions observed in the resident's room. On the initial observation, a strong urine odor was present, and a disposable bed pad with a large urine stain was found on the floor next to the resident's bed, along with three urinals, one of which was full. The resident, who was cognitively intact and required substantial assistance for toileting due to functional limitations, expressed a desire for the area to be clean. Despite the resident's preference for having urinals on the floor for easy access, the staff did not maintain a clean and odor-free environment. Certified Nursing Assistant #1 was informed of the situation but did not take immediate action to address the issue, leaving the full urinal and soiled bed mat in place. An hour later, the Licensed Practical Nurse (unit manager) acknowledged that the urinal should have been emptied and the bed mat removed. The Director of Nursing Services confirmed the resident's preference for urinals on the floor but emphasized the need for cleanliness. The resident reiterated their difficulty in getting out of bed and the aides' busyness, underscoring their wish for a clean area.
Failure to Notify Primary Contact of Resident's Fall
Penalty
Summary
The facility failed to ensure that a resident's primary representative was immediately informed of an accident resulting in injury, which had the potential for requiring physician intervention. This deficiency was identified during a recertification survey for a resident who fell from their bed and sustained bruising to their face. Despite the facility's policy requiring immediate notification of the resident's family or next of kin in such incidents, the family member, who was listed as the primary contact, was not informed of the fall. Instead, the group home, listed as a secondary contact, was notified. The resident involved had severe cognitive impairments and was non-verbal, with diagnoses including cerebral palsy, quadriplegia, and seizure disorder. The incident report documented that the resident was found on the floor by a housekeeper, and the physician and group home manager were notified. However, the family member only learned of the fall the following day through another organization. Interviews with facility staff, including the Assistant Director of Nursing Services and the Director of Nursing Services, confirmed that the family should have been notified first, as per the resident's medical record contact list.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in Unit E, as observed during a recertification survey. Specifically, Resident #144's bathroom door had broken hinges, preventing it from closing, a condition that had persisted for months despite being reported in the maintenance log. The maintenance worker acknowledged the issue, noting that the door had supposedly been fixed earlier in the month, but the problem recurred. The unit manager confirmed the long-standing nature of the issue, indicating a lapse in timely maintenance response. Additionally, Resident #56's room was found to have stained privacy curtains and a soiled bathroom floor. Despite daily cleaning protocols, the curtains remained stained, and the bathroom floor was not adequately cleaned. Interviews with staff revealed that the housekeeping team was responsible for these tasks, yet the issues persisted. The housekeeper claimed the curtain was recently changed but acknowledged the need for further cleaning. The Director of Housekeeping and the Director of Nursing Services both recognized the unacceptability of the conditions, highlighting a failure to adhere to the facility's cleaning policies.
Incomplete Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an accident involving a resident, which resulted in a deficiency. The incident occurred when a resident with severe cognitive impairment and a history of falls was found on the floor with a six-centimeter laceration and bruising on the left side of their face. The facility's policy required statements from all staff involved, but the investigation did not include a statement from the Kitchen transporter, who was the first to find the resident on the floor. This omission was due to the Certified Nursing Assistant not reporting the Kitchen transporter's involvement to the Nursing Supervisor, and the Registered Nurse Supervisor not obtaining the necessary statement. The resident had a history of falls and required moderate assistance for transfers and ambulation. Despite the facility's policy mandating comprehensive collection of statements from all relevant personnel, including those who interacted with the resident within the last 24 hours, the investigation was incomplete. Interviews with staff revealed that the Registered Nurse Supervisor and the Director of Nursing Services acknowledged the oversight in not obtaining the Kitchen transporter's statement, which was crucial for a thorough investigation of the incident.
Delayed Completion of MDS Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within the required timeframe for a resident, leading to a deficiency during a recertification survey. Resident #486, who was admitted with diagnoses of Congestive Heart Failure and Diabetes Mellitus, had their admission MDS assessment initiated on July 7, 2024, but it was not completed until July 25, 2024, which was six days beyond the required 14-day period. The MDS Coordinator acknowledged the delay and admitted responsibility for ensuring timely completion of assessments but was unsure why this particular assessment was late. The Administrator was unaware of the delay in completing MDS assessments on time.
Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as observed during a survey. Specifically, a registered nurse did not change the inner tracheostomy tube (cannula) as ordered by the physician. Instead, the nurse attempted to clean and reuse the disposable inner cannula, which is against the manufacturer's guidelines and the physician's orders. This action was observed during a tracheostomy care session for the resident, who has severe cognitive impairment and is dependent on staff for all care. The facility's policy on tracheostomy care, revised in May 2023, requires aseptic cleaning of the tracheostomy cannula, stomas, and surrounding areas, with nurses authorized to change the inner cannula. However, the policy did not specify a timeframe for changing the outer cannula. The resident's comprehensive care plan also lacked specific directions for changing the inner or outer cannula. The manufacturer's brochure for the tracheostomy tube used by the resident specifies that the inner cannula is for single use and the outer cannula should be changed every 28 days, but there was no documented evidence of physician orders to change the outer cannula from March 2023 to October 2023. Interviews with facility staff, including a nurse practitioner, the medical director, the director of nursing services, and a respiratory therapist, confirmed that the inner cannula should not have been reused and that the outer cannula should have been changed every three months. The respiratory therapist, who took over the resident's care in January 2024, stated that they have been changing the tracheostomy tube every 90 days since then. The failure to follow proper procedures for tracheostomy care placed the resident at risk for infections, as noted by the staff during interviews.
Significant Medication Error: Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that all residents were free from significant medication errors, as observed during a recertification survey. Specifically, a resident with severe cognitive impairment and diagnosed with acute osteomyelitis and cellulitis did not receive their prescribed doses of Ampicillin, an antibiotic, at 12:00 AM and 6:00 AM on a specific date. The Medication Administration Record lacked documentation of these doses being administered, which is a violation of the facility's medication administration policy. During the survey, it was observed that the intravenous medication setup by the resident's bedside was not labeled with the time of reconstitution or administration. Interviews with nursing staff revealed that the 6:00 AM dose was prepared but not administered, and the 12:00 AM dose was administered but not documented. The Director of Nursing Services and a medical doctor emphasized the importance of adhering to physician orders for antibiotic administration to maintain medication effectiveness.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was prepared and served in accordance with professional standards for food service safety. During a kitchen observation, Dietary Aide #1 was seen handling peeled, hard-cooked eggs with the same gloves used to enter and exit the walk-in refrigerator, which is against the facility's handwashing and glove use policies. Dietary Aide #1 acknowledged the mistake, recognizing the increased risk of food contamination due to not changing gloves. Additionally, the facility's policy requires hands to be washed frequently and gloves to be changed when switching tasks, which was not adhered to in this instance. Furthermore, during a lunch meal tray line observation, cold food temperatures were found to be above the safety zone. The egg salad sandwich was measured at 60 degrees Fahrenheit, and the health shake at 45 degrees Fahrenheit, both exceeding the facility's policy requirement of maintaining cold food at or below 40 degrees Fahrenheit. The Food Service Supervisor admitted that they did not routinely check the temperatures of cold food items before meal services, relying instead on the refrigerator's temperature. This oversight could potentially lead to bacterial growth and illness among residents, as acknowledged by the Food Service Director.
Failure to Ensure Accompaniment for Non-Verbal Resident's Medical Appointment
Penalty
Summary
The facility failed to ensure that timely arrangements were made for outside services that met professional standards, as evidenced by the case of a resident with severely impaired communication who was transferred to a Neurologist's office for a medical appointment. The resident, who had diagnoses including Cerebral Palsy, Quadriplegia, and Seizure Disorder, was not accompanied by facility staff or a representative who could communicate on their behalf, leading to the cancellation of the appointment. There was no documentation in the resident's medical record regarding the cancellation of the appointment, coordination of future appointments, or communication with the resident's primary care provider about the missed appointment. The facility's Transport Policy for Medical Appointments required that a qualified staff member or family member accompany residents during transport to ensure their comfort and safety, and that all transport-related activities be documented in the resident's medical record. However, the Licensed Practical Nurse (LPN) responsible for the resident's care did not document discussions with the resident's family or group home staff, nor did they document the appointment cancellation or reschedule the appointment. The LPN was unaware of the facility's policy for sending a non-verbal resident to an appointment unaccompanied. Interviews revealed that the resident's family was not informed of the appointment and would not have agreed to it due to concerns about the resident's comfort during transport. The Director of Nursing Services acknowledged that all communications should have been documented and that there should have been follow-up regarding rescheduling the appointment. The Nurse Practitioner was aware of the appointment cancellation but did not recall documenting their communication with the resident's family in the medical record.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe. This deficiency was identified during a Recertification Survey conducted from September 23 to September 30, 2024. Specifically, six residents' MDS assessments were not transmitted within 14 days of completion, as required. The assessments for these residents were transmitted between 46 to 65 days late. The facility's policy, last reviewed in March 2024, mandates timely transmission of MDS assessments, but this was not adhered to in these cases. The Minimum Data Set Coordinator, responsible for submitting these assessments, stated during an interview that they believed the assessments had been submitted on time but did not receive the validation report, indicating otherwise. Consequently, the assessments were resubmitted on September 26, 2024. The Administrator, during a separate interview, acknowledged that the MDS Coordinator is responsible for timely submissions and was unaware of the delays. This oversight resulted in the facility's non-compliance with the regulatory requirement to transmit MDS assessments within the specified timeframe.
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Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Hampton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Simeon By The Sound Center For Nursing & Rehab | 11.3 mi | ★★★★★ | 1 | 1 |
| Acadia Center For Nursing And Rehabilitation | 14.3 mi | ★★★★★ | 0 | 0 |
| Peconic Landing At Southhold | 14.8 mi | ★★★★★ | 0 | 0 |
| Westhampton Care Center | 15 mi | ★★★★★ | 0 | 0 |
| Oasis Rehabilitation And Nursing, Llc | 20.2 mi | ★★★★★ | 1 | 0 |
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