Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Edge At Port Jefferson For Rehab And Nrsg during CMS and state inspections, most recent first.
Failure to provide ordered oxygen therapy: A resident with COPD and respiratory failure was observed in respiratory distress with pale skin, gray lips, accessory muscle use, and an empty O2 tank while stating, “I need air.” An LPN dismissed the symptoms as a panic attack and did not check the tank or provide O2; the DON later found the saturation at 82% and replaced the tank. Another resident with CHF, COPD, and chronic respiratory failure with hypoxia was also found with an empty O2 tank, and a CNA changed the oxygen source even though the DON stated CNAs were not allowed to do so. Staff interviews showed inconsistent monitoring practices and no documented oxygen-care competency for the LPN.
Food storage and hot food holding were not maintained according to policy. Surveyors found opened, unlabeled, and undated food items in the freezer and on kitchen storage shelves, including pasta, flour, cornbread, hash brown patties, waffles, and another unidentified food package. During tray line observation, cooked chicken thighs were held at 110 to 120 degrees Fahrenheit, and the food temperature log documented 100 degrees Fahrenheit for the chicken, below the required 135 degrees Fahrenheit hot-holding standard.
Failure to Monitor Portable Oxygen Tanks: Two residents receiving oxygen therapy were found with portable oxygen tanks empty or in the red zone, and one resident showed signs of respiratory distress with low O2 saturation. An LPN did not check one resident’s tank during the shift and dismissed the resident’s complaint of needing air, while a housekeeper and a CNA were involved in changing oxygen tanks or sources. The facility’s oxygen policy addressed assessment and documentation but did not include guidance on how often to monitor portable oxygen tanks.
Failure to provide showers as planned. A resident with MS and intact cognition required extensive ADL assistance and had a care plan for 2-person assist to the shower twice weekly, but staff repeatedly gave bed baths instead and documented shower refusals. CNAs said staffing issues prevented showers, while staffing records showed no issues; the resident said they never refused showers and sometimes went more than 2 weeks without one.
Failure to Properly Monitor and Manage Oxygen Therapy: An LPN dismissed a resident’s complaint of shortness of breath while the resident’s portable O2 tank was empty and the resident showed signs of respiratory distress; the DON later found the resident’s O2 saturation was low and the tank was replaced. The report also described inconsistent staff practices, including CNAs and a housekeeper changing O2 tanks or sources for residents receiving oxygen, despite nursing leadership stating nurses were responsible for monitoring and changing oxygen equipment.
Failure to Assist Resident With Breakfast Meal: A resident with malnutrition, sepsis, and a right femur fracture required setup and clean-up help for eating, but was found awake in bed with an unopened, untouched breakfast tray on the overbed table. The resident said staff did not wake them or return to check whether they ate, and interviews confirmed the CNA was responsible for serving the tray, providing setup help, and checking intake, while the DON stated the tray should not have remained at the bedside unopened and untouched.
A resident with a history of a Stage IV pressure ulcer, moderate cognitive impairment, and risk for pressure ulcers was observed in bed on an air mattress set to 450 pounds despite weighing about 167 pounds. The chart included an order for nurses to check the mattress function and settings each shift, but staff interviews showed confusion over who set the weight and that the resident had no order for the mattress placement. The DON stated the mattress setting should match the resident’s weight to provide pressure relief.
Unlabeled and unattended medications were found during med pass and storage observations. An LPN retrieved Budesonide from an opened, undated foil packet for a resident with COPD, and a medication cup with three prepoured tablets was left in a med cart without a label. In another room, a resident with moderate cognitive impairment had two cups of unidentified meds left on the overbed table, and the RN later confirmed multiple ordered meds had been left at the bedside instead of being observed until swallowed.
Infection control was not maintained when two CNAs provided hygiene and clothing care to a resident with a Foley catheter without the proper PPE, and the EBP sign outside the room did not identify that resident as being on precautions. In a separate event, an LPN removed a vortioxetine tablet from a blister pack into a bare hand before placing it in a med cup for administration, contrary to the facility’s medication infection control procedure.
A resident with heart failure, acute kidney injury, and pneumonia exhibited critical symptoms and lab results, but was not sent to the hospital immediately as ordered. The resident was found unresponsive and later pronounced deceased. Interviews revealed communication failures and a lack of adherence to facility policy, resulting in Immediate Jeopardy.
Three residents at risk for aspiration were not provided with appropriate care. A resident with a PEG tube was given oral medications despite being NPO. Another resident on a puree diet ingested a dog biscuit, leading to coughing and stridor. A third resident, also NPO, received oral medications instead of through the feeding tube. Staff failed to notify the physician to change orders, and attempts to contact the Physician Assistant were unsuccessful.
Two residents in a facility were administered oral medications despite having orders for nothing by mouth (NPO) and feeding tubes. The physician failed to review and document the residents' care appropriately, leading to inappropriate medication orders and administration. Attempts to contact the responsible Physician Assistant were unsuccessful, and a Nurse Practitioner failed to discontinue a medication as recommended by a pharmacy review.
A resident experienced significant health changes, including fever, tachycardia, hypotension, and critical lab results, but the facility failed to notify the resident's representative as required by policy. Despite the initiation of a sepsis protocol and administration of antibiotics, the representative was not informed until after the resident's passing. Interviews with staff confirmed the lack of communication, and the Director of Nursing Services acknowledged the oversight.
The facility failed to initiate the bowel protocol for several residents who experienced extended periods without documented bowel movements, despite having care plans that required monitoring for constipation. Interviews revealed a lack of adherence to the protocol and awareness of the residents' bowel records among staff.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy, including failure to follow the comprehensive care plan and physician orders. The deficiency involved two residents reviewed for respiratory care, including one resident with COPD and respiratory failure who had an order for supplemental oxygen to maintain oxygen saturation above 90% every shift, and another resident with CHF, COPD, and chronic respiratory failure with hypoxia who also had an oxygen order. The report states that the facility did not ensure oxygen was available and provided as ordered, and that staff did not consistently monitor oxygen equipment or resident respiratory status. For the resident with COPD, the record showed that the resident used oxygen therapy and had a care plan directing staff to monitor respiratory status, oxygen saturation, lung sounds, shortness of breath, accessory muscle use, cyanosis, and to provide oxygen as ordered. On 07/25/2025, the resident was observed in respiratory distress, using accessory muscles, appearing pale with gray lips, and stating, “I need air.” The resident’s portable oxygen tank gauge was in the red zone, and the LPN told the resident they were having a panic attack and exaggerating while waiting for Xanax. The LPN did not check the oxygen tank or provide oxygen at that time. The DON later confirmed the tank was empty, obtained an oxygen saturation of 82%, and replaced the tank, after which the saturation increased to 94% and the resident stated they felt better. The report also states that the same resident was later observed again with an oxygen tank in the red zone and no air flow coming through the tubing. The resident said they had difficulty breathing and did not report it because staff usually would not do anything. A housekeeper replaced the oxygen tank after being told to do so by recreational staff. Interviews showed conflicting understanding among staff about who should monitor and replace oxygen tanks, with the LPN stating the tank should have been checked every two hours but was not because of medication pass duties, while other staff stated tanks were monitored at different intervals and could be changed by non-nursing staff. For the second resident, an observation showed the resident holding the nasal cannula while the oxygen tank was empty, and a CNA changed the oxygen source from the tank to the concentrator. The DON stated CNAs were not allowed to change the oxygen source. The report also noted that the LPN had no in-service education related to oxygen therapy and that the inservice coordinator stated there was no competency completed for nurses related to oxygen or respiratory care except tracheostomy care.
Food Storage and Hot Food Holding Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen observation with the Food Service Director and Assistant Food Service Director, surveyors found opened and undated food items in the walk-in freezer, including bags of hash brown patties and a tray of waffles, as well as multiple open packages of pasta and pastina on a storage shelf that were not labeled or dated. The observation also identified an undated canister of flour, another unlabeled and undated powdered food product, and an opened, undated package of cornbread plus an unlabeled and unidentified food package in the two-door reach-in freezer. During the same survey, the Assistant Food Service Director stated that the hash brown patties and waffles should not be used because of potential freezer burn and reduced quality, and stated that opened food packages should be properly labeled and dated. The facility’s food storage policy required foods to be covered, labeled, dated, and stored to prevent contamination or cross-contamination, and required opened packages and storage containers to be legible and accurately labeled and dated. Surveyors also observed the lunch tray line and found cooked chicken thighs at 110 degrees Fahrenheit and 120 degrees Fahrenheit. The Assistant Food Service Director stated that the chicken temperatures did not meet the food safety standard and that hot foods should be held at at least 135 degrees Fahrenheit. A review of the food temperature log for the meal documented temperatures of 100 degrees Fahrenheit for the cooked chicken, and the Food Service Director and Assistant Food Service Director stated that this was not an appropriate temperature for holding and service. A cook stated they had taken the internal temperature about 15 minutes before service and measured 165 degrees Fahrenheit, but did not recheck the holding temperature before service.
Failure to Monitor Portable Oxygen Tanks
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain residents’ highest practicable well-being, based on failures to monitor residents receiving oxygen therapy. The facility’s Oxygen Administration policy, last reviewed in 01/2025, addressed assessment and documentation of oxygen therapy but did not provide guidance for monitoring or handling portable oxygen tanks to ensure residents were not left without supplemental oxygen. Resident #74 had diagnoses including COPD and respiratory failure, a BIMS score of 12 indicating moderately impaired cognition, and required assistance with personal hygiene, transfers, and dressing. The resident received oxygen therapy and had an order for supplemental oxygen at 2-4 liters per minute to maintain oxygen saturation above 90% every shift. On 07/25/2025, the resident was observed in a wheelchair with a nasal cannula connected to a portable oxygen tank, but the tank gauge was in the red area and the resident was having difficulty breathing, using accessory muscles, with pale color and gray lips. The resident told an LPN, “I need air,” and the LPN said the resident was having a panic attack and was exaggerating. The DON intervened, confirmed the tank was empty, obtained an oxygen saturation of 82%, and replaced the tank, after which the saturation increased to 94%. On 07/28/2025, the resident was again observed with a portable oxygen tank in the red area and no air flow through the tubing; a housekeeper replaced the tank after being told to do so by a recreational assistant. Resident #119 had diagnoses including CHF, COPD, and chronic respiratory failure with hypoxia, and had a BIMS score of 6 indicating severely impaired cognition. The resident was on oxygen at 2 liters per minute. On 08/08/2025, the resident was observed in the room holding the nasal cannula in hand while the oxygen tank was empty with the gauge at zero. A CNA changed the oxygen source from the tank to the oxygen concentrator and removed the tank from the room, while the DON stated CNAs were not allowed to change the oxygen source. The Administrator later stated that nonclinical staff should not be handling oxygen, and both the DON and Administrator stated the facility’s policy did not include how often to monitor a resident’s portable oxygen tank.
Failure to Provide Showers as Planned
Penalty
Summary
The facility did not reasonably accommodate a resident’s bathing needs and preferences by failing to provide showers as outlined in the care plan. The resident had diagnoses including Multiple Sclerosis, a BIMS score of 15 indicating intact cognition, and required extensive assistance with personal hygiene, transfers, dressing, and bathing. The care plan documented that the resident needed two-person assistance for transfers to the shower on Wednesdays and Saturdays, and the resident stated during the Resident Council meeting that they were not receiving showers as preferred and that staff were documenting shower refusals even though the resident said they never refused showers. Record review showed that during July 2025 the resident received bed baths on multiple days and showers only four times in 24 days. Certified Nursing Assistants stated they were usually assigned to the resident but did not give showers because of staffing issues, while staffing sheets for the month showed no staffing issues. The resident also stated they sometimes went without a shower for more than two weeks and reported not receiving a bed bath on one date, only having their back cleansed. The RN stated all residents should receive showers per the plan of care and was not aware the resident had not been receiving them, and the DON stated staff had reported the resident refused showers, although the resident wanted showers and the facility was not aware of staffing concerns.
Failure to Properly Monitor and Manage Oxygen Therapy
Penalty
Summary
The facility did not ensure that respiratory services were provided in accordance with professional standards of quality for residents receiving oxygen therapy. The deficiency involved two residents with significant respiratory diagnoses and oxygen orders. One resident had chronic obstructive pulmonary disease, respiratory failure, and moderately impaired cognition, and the other resident had congestive heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and severely impaired cognition. Both residents were receiving oxygen therapy under physician orders. For one resident, a surveyor observed the resident self-propelling to the nursing station while wearing a nasal cannula connected to a portable oxygen tank that was in the red zone. The resident was having difficulty breathing, using accessory muscles, and appeared pale with gray lips. When the resident told an LPN, “I need air,” the LPN dismissed the complaint as a panic attack and said the resident was exaggerating while continuing medication administration to other residents. The resident was not evaluated until the DON intervened, at which time the oxygen saturation was found to be 82% and the oxygen tank was replaced, after which the saturation increased to 94%. The LPN stated they had not connected the resident to the oxygen tank and had not checked the tank since starting the shift. The report also described repeated issues with staff changing and monitoring oxygen tanks. A housekeeper changed the resident’s oxygen tank after being told to do so by recreational staff, and nursing staff stated it was acceptable for CNAs or housekeepers to replace oxygen tanks. However, the DON and respiratory RN stated nurses were responsible for monitoring and changing oxygen tanks, and the respiratory RN stated the LPN should check the tank every three hours. For the second resident, a CNA observed the resident holding the nasal cannula while the oxygen tank was empty, then changed the oxygen source from the tank to the concentrator and removed the tank, stating they were allowed to do that. The DON stated CNAs were not allowed to change the oxygen source.
Failure to Assist Resident With Breakfast Meal
Penalty
Summary
The facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary assistance to maintain good nutrition. During an observation on 07/22/2025 at 11:20 AM, Resident #7 was found in bed awake and alert with an unopened and untouched breakfast tray on the overbed table. The resident stated they had been asleep, were not aware the tray was there, and that staff did not wake them to tell them breakfast had arrived or return to check whether they had eaten. Resident #7 was admitted with diagnoses including malnutrition, sepsis, and a right femur fracture. The admission MDS documented a BIMS score of 13, indicating intact cognition, no behavior problems, no rejection of care, and impairment of one upper extremity with a need for setup and clean-up help for eating. The care plan documented assistance with ADLs related to fractures, pain, and trauma, with interventions to encourage participation to the fullest extent possible. Staff interviews confirmed that CNAs were responsible for serving meal trays, providing setup help, and checking whether the resident ate, but the assigned CNA did not recall serving the breakfast tray or checking on the resident, and the DON stated the tray should not have remained at the bedside unopened and untouched.
Air Mattress Weight Setting Not Matched to Resident Weight
Penalty
Summary
The facility did not ensure that a resident with a history of a Stage IV pressure ulcer received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Resident #112 was admitted with diagnoses including chronic kidney disease, urinary tract infection, and congestive heart failure, and the Quarterly MDS documented moderate cognitive impairment and risk for pressure ulcers. A Skin/Wound Care Evaluation dated 7/24/2025 documented a Stage IV pressure ulcer on the right gluteus that was present on admission and resolved on 7/24/2025. A physician order dated 7/24/2025 directed staff to check the function and settings of the air mattress every shift and as needed, and the care plan included checking the function and settings of the air mattress every shift. During observations on 7/21/2025 and 7/22/2025, the resident was in bed on an air mattress that was set to 450 pounds, while the resident’s documented weight was 167.4 pounds on 7/17/2025 and 175.0 pounds on 6/24/2025. Staff interviews showed CNA staff did not adjust weight settings, an LPN was unsure who entered the settings, and the RN supervisor stated nurses were responsible for checking the settings each shift and should notify the supervisor if the setting was inaccurate. The DON stated nurses were responsible for obtaining a physician order for the air mattress and monitoring the weight setting, and that the setting should be adjusted to match the resident’s weight to provide pressure relief. The record also noted there was no physician order for the placement of the air mattress.
Unlabeled and Unattended Medications
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled in accordance with accepted professional principles, including expiration dating. During medication pass observation, a nurse retrieved Budesonide Inhalation for a resident with COPD, type 2 diabetes mellitus, and pulmonary embolism from an opened foil packet that was not dated, even though the packet instructions stated the ampules should be used within two weeks after opening and provided a place to write the open date. The resident’s quarterly MDS documented intact cognition. The nurse stated the package had been forgotten and should have been dated, and the DON and pharmacist confirmed the packet should be dated when opened and discarded after the manufacturer’s time frame. The facility also had unlabeled medications stored in a medication cart. On the 2 North medication cart, a soufflé cup containing three prepoured tablets was observed without any label. The medications had been prepared for a resident with cerebral infarction, major depressive disorder, and chronic kidney disease, but the nurse stopped before administering them and left the unlabeled cup in the cart. The nurse acknowledged the medications should not have been stored that way, and the RN supervisor and DON stated that medications poured but not promptly administered should be discarded and not kept in a medication cup in the cart. A third event involved a resident with hypertension and chronic kidney disease who had moderate cognitive impairment. The resident was observed sitting in a wheelchair with two medication cups containing unidentified medications on the overbed table, and no staff were nearby. The resident stated the nurse had given the medications without fluids. The RN later confirmed the medications had been left at the bedside, and the MAR showed multiple medications were left there, including alprazolam, carvedilol, dapagliflozin, ferrous sulfate, hydralazine, senna, sodium bicarbonate, venlafaxine, and TUMS. The RN stated the medications should not have been left unattended and should have been observed until swallowed.
Infection Control Failures During Enhanced Barrier Precautions and Medication Administration
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. One resident had a physician’s order for Enhanced Barrier Precautions because of an indwelling Foley catheter, and the care plan included gown and glove use for high-contact care such as dressing, bathing, hygiene, and transferring. During observation, two CNAs provided clothing change and hygiene care to the resident without the proper PPE, and the Enhanced Barrier Precautions sign outside the room did not identify that resident as being on precautions; instead, it indicated the roommate was on Enhanced Barrier Precautions. The resident involved had diagnoses including chronic kidney disease, UTI, and CHF, and the MDS documented moderate cognitive impairment, use of an indwelling catheter, and risk for pressure ulcers. The RN supervisor observed the care and stopped the CNAs so they could remove gloves, wash hands, and put on the proper PPE. Interviews confirmed that the CNAs did not realize the resident was on Enhanced Barrier Precautions because the sign outside the room did not indicate that status, and one CNA stated the sign only showed the roommate’s precautions. Facility leadership stated that staff should have used appropriate PPE even without the sign and acknowledged that the precaution sign was not displayed for the resident. During medication administration, an LPN removed a vortioxetine tablet from a blister pack into a bare hand and then placed it into a medication cup for administration to another resident. The resident receiving the medication had diagnoses including Parkinson’s disease, seizures, and depression, and the order was for vortioxetine 10 mg daily. The LPN stated they had used hand sanitizer before removing the medication but should not have touched the tablet with a bare hand; the tablet was discarded and replaced. The facility’s infection control medication administration policy required staff to follow established infection control procedures, including handwashing and aseptic technique.
Failure to Provide Timely Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident, leading to a critical situation. The resident, who had been readmitted with heart failure, acute kidney injury, and pneumonia, exhibited symptoms of fever and tachycardia. Despite critical lab results indicating a dangerously low hemoglobin level and other concerning signs, the resident was not sent to the hospital immediately as ordered by the Nurse Practitioner. Instead, the Registered Nurse Supervisor documented that the resident would be sent to the hospital the following morning. The resident's condition deteriorated, and they were found unresponsive, pulseless, and without respirations in the early hours of the morning. Despite efforts to resuscitate, the resident was pronounced deceased shortly after. Interviews with facility staff revealed a breakdown in communication and a failure to act on critical lab results and vital signs, which were not indicative of stable conditions. The Nurse Practitioner and Physician both indicated that the resident should have been sent to the hospital immediately given the critical lab results and unstable vital signs. The facility's policy required timely medical assessments and appropriate responses to acute changes in a resident's condition. However, the failure to adhere to these standards resulted in Immediate Jeopardy, with the likelihood of serious harm or death for the resident. The Director of Nursing confirmed that the resident's condition was not stable, contradicting the decision to delay the transfer to the hospital.
Failure to Prevent Aspiration Risks in Residents
Penalty
Summary
The facility failed to provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three residents reviewed for accidents. Resident #2, identified as high risk for aspiration, was supposed to be fed via a PEG tube, yet physician orders documented medications to be administered by mouth. Despite the speech therapy evaluation recommending nothing by mouth (NPO), the physician orders did not reflect this, and medications were administered orally. Multiple attempts to contact the Physician Assistant regarding this issue were unsuccessful. Resident #3, who was at risk for aspiration and had a physician's order for a puree diet, was given a dog biscuit during pet therapy, which the resident ingested. This led to coughing and abnormal lung sounds (stridor). The incident was documented, and the Registered Nurse Supervisor was notified, but the resident refused vital signs at the time. The Speech Language Pathologist confirmed that the resident could not tolerate solid foods, indicating a risk for aspiration. Resident #5, also at risk for aspiration, was evaluated with recommendations for nothing by mouth (NPO) and was on a tube feed diet. However, the medication administration records indicated multiple medications were given orally. The Director of Nursing and Medical Doctor confirmed that residents assessed as NPO should have medications administered through the feeding tube, and staff should have notified the physician to change the order. Multiple attempts to reach the Physician Assistant regarding this issue were also unsuccessful.
Failure to Review and Document Resident Care Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, including treatments, at each visit, leading to inappropriate medication orders and administration for two residents. Resident #2, who was admitted with orders for nothing by mouth (NPO) and a feeding tube, did not have an NPO order included in the admission orders. Despite recommendations from a speech therapist, the resident was prescribed and administered oral medications such as Tylenol and Tamiflu, which contradicted the NPO status. Attempts to contact the responsible Physician Assistant were unsuccessful. Resident #5 was also admitted with orders for nothing by mouth and a feeding tube. However, the resident was evaluated by a Physician Assistant who ordered oral medications, including Amoxicillin, Prednisone, and Tamiflu, which were administered despite the NPO status. Additionally, a pharmacy review recommended discontinuing Proscar and starting Rapaflo, but the Nurse Practitioner failed to discontinue Proscar, resulting in the resident receiving both medications for 30 days. The facility's Physician's Visit policy requires the attending physician to review the resident's total program of care and document appropriately at each visit. However, this was not adhered to, as evidenced by the inappropriate medication orders and administration for Residents #2 and #5. The Medical Director acknowledged the oversight and emphasized the need for physician orders to reflect the residents' intake status, particularly for those deemed NPO.
Failure to Notify Resident's Representative of Significant Health Changes
Penalty
Summary
The facility failed to ensure that a resident's representative was immediately informed of significant changes in the resident's condition, as required by their policy. This deficiency was identified during an Abbreviated Survey for one resident who experienced a decline in health status. The resident presented with fever, tachycardia, hypotension, and critical lab results, including a hemoglobin level of 4.9g/dL, which is significantly below the normal range. Despite these critical changes, the resident's representative was not notified of the condition or the interventions provided. The facility's policy mandates prompt notification of the resident, their attending physician, and representative in the event of a significant change in condition. However, documentation and interviews revealed that the facility staff did not adhere to this policy. The resident's representative was not informed of the initiation of a sepsis protocol or the administration of antibiotics. Additionally, the representative was unaware of the resident's symptoms and critical lab results until after the resident's passing. Interviews with facility staff, including nurses and the Director of Nursing Services, confirmed the lack of communication with the resident's representative. Staff members acknowledged the failure to notify the representative and could not provide a reason for this oversight. The Director of Nursing Services stated that the facility staff should have informed the resident's representative about the changes in the resident's medical condition and the new interventions.
Failure to Initiate Bowel Protocol for Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. This deficiency was identified during an abbreviated survey for six residents, focusing on the lack of documented bowel movements over several consecutive days. Specifically, three residents were noted to have no documented bowel movements for periods ranging from five to eight days, despite having care plans that required monitoring and intervention for constipation. Resident #1, who had a history of Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Iron Deficiency Anemia, was admitted with a care plan that included interventions for constipation. However, there was no documented evidence of bowel movements for eight days, and the facility's bowel protocol was not initiated. Similarly, Resident #2 and Resident #3 also experienced five consecutive days without documented bowel movements, and the bowel protocol was not initiated in a timely manner for these residents either. Interviews with facility staff revealed a lack of awareness and adherence to the bowel protocol, with several staff members unaware of the full extent of the residents' bowel records. The Director of Nursing Services and the Medical Director both acknowledged that the bowel protocol should have been initiated after two to three days without a bowel movement, but this was not done. The facility's policy did not clearly outline the steps to be taken in the event of constipation, contributing to the oversight and resulting in the deficiency.
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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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Illustrative
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Nursing homes near Port Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| John T Mather Memorial Hosp T C U | 1.2 mi | ★★★★★ | 0 | 0 |
| Allegria Nursing & Rehab Center Of Port Jefferson | 2.2 mi | ★★★★★ | 0 | 0 |
| Jefferson's Ferry | 2.7 mi | ★★★★★ | 0 | 0 |
| Long Island State Veterans Home | 3 mi | ★★★★★ | 0 | 0 |
| St James Rehabilitation & Healthcare Center | 5.5 mi | ★★★★★ | 10 | 0 |
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