Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nans Pointe Rehabilitation And Nursing during CMS and state inspections, most recent first.
Facility staff failed to maintain the fire alarm system in fully operational condition and did not implement Fire Watch according to policy, leading to an Immediate Jeopardy finding. Surveyors observed non‑working exit lights, a fire alarm panel in trouble mode, and no credible evidence of required annual testing, while the facility had been on Fire Watch for months without a dedicated, trained Fire Watch person. Multiple CNAs, LPNs, and other staff could not clearly explain why the facility was on Fire Watch, who was responsible, or the full scope of required surveillance, and Fire Watch rounds were largely limited to hallways and the building exterior rather than all risk areas. The Administrator and maintenance staff were unable to produce timely documentation of inspections, testing, or risk assessments for the fire alarm system, and the facility continued to accept new admissions while on Fire Watch, contrary to expectations outlined during the survey.
Facility leadership failed to ensure proper oversight of the fire alarm system and Fire Watch, with no evidence of fire alarm panel testing or inspections for several months while the facility remained on Fire Watch. The Administrator, newly in the role, confirmed that nursing staff primarily performed Fire Watch rounds and later identified a receptionist as the dedicated Fire Watch person but could not provide her full identification or documentation of vendor verification that the fire panel was functioning. There were no records of fire alarm functionality audits, system inspections, or maintenance program records, and the facility lacked a full-time maintenance director and a policy on administrative duties. The ongoing fire panel and smoke detector malfunctions and extended Fire Watch status were not reported to the QAPI committee, despite QAPI materials listing maintenance and fire safety items for review.
The governing body failed to ensure effective oversight and implementation of policies related to the fire alarm system and Fire Watch, resulting in prolonged Fire Watch across all units without clear documentation or monitoring. The Administrator, who was newly appointed, could not initially explain the exact fire panel issue, provide vendor service reports, or show evidence of fire alarm testing, inspections, or maintenance records, and the fire alarm panel was observed in trouble mode for multiple units. The facility lacked a full‑time maintenance director, and the ongoing fire alarm and smoke detector problems, as well as the extended Fire Watch status, were not brought to the QAPI committee despite maintenance and life safety items being listed on the QAPI agenda. There was no documented process or evidence of communication between the Administrator and the governing body regarding these life safety issues or of the governing body’s involvement in QAPI oversight as required by facility policy.
Staff failed to involve the QAPI committee in identifying and overseeing serious life safety deficiencies related to a malfunctioning fire alarm system and prolonged Fire Watch on all units. The facility had been on Fire Watch for months, with staff making frequent rounds to look for smoke or fire, yet the Administrator could not clearly explain the long-standing issue, provide maintenance or vendor documentation, or show that the fire panel, smoke detectors, and exit signage problems were evaluated through QAPI. Although monthly QAPI meetings were reportedly held, there was no evidence that these fire safety issues were discussed, monitored, or tracked, and the Administrator acknowledged they should have been reported to QAPI but were not.
Facility staff did not post the most recent survey results in an accessible location, instead keeping the report in a drawer by the receptionist and only providing a sign stating it was available upon request. This deficiency was confirmed through observation and staff interviews.
A resident with an infected diabetic foot ulcer did not receive any doses of a prescribed IV antibiotic despite the medication and IV access being available. The initial dose was missed without explanation, and subsequent doses were not given due to a dislodged IV that was not promptly replaced. The antibiotic was discontinued before administration, and facility leadership did not comment on the incident.
A resident with an infected diabetic foot ulcer had abnormal wound culture results indicating multiple pathogens, but staff did not promptly notify the NP as required. The results were available in the electronic system and should have been identified during routine chart checks, but the oversight was not recognized for several days, delaying practitioner notification and subsequent medical intervention.
A resident with significant neurological impairments and dependence in daily activities did not receive timely OT, PT, and ST evaluations as ordered by a physician. Facility staff failed to initiate therapy evaluations within the required timeframe due to miscommunication about therapy orders and insurance coverage, resulting in delayed treatment and increased risk for decline.
Staff did not follow infection prevention protocols by failing to post Enhanced Barrier Precautions signage for a resident with a PEG tube who was sharing a room with another resident on Contact Precautions for an infected diabetic foot ulcer. The required precautions and cohorting practices were not implemented until after the issue was identified during a survey.
Failure to Maintain Functional Fire Alarm System and Proper Fire Watch Implementation
Penalty
Summary
The deficiency involves the facility’s failure to maintain the fire alarm system in fully operational condition and to implement Fire Watch in accordance with its own policy and Life Safety Code requirements. During a Life Safety Inspection, surveyors observed three non‑operational exit lights, a fire alarm panel in trouble mode, and no credible evidence of annual fire alarm system testing. The acting maintenance director reported that the alarm trouble condition had been ongoing for about a week. The facility had been on Fire Watch since at least late January, but there was no dedicated Fire Watch person assigned at the time of the Life Safety Inspection; instead, nursing staff were informally making rounds. The Administrator later acknowledged that the facility had been on Fire Watch for months and that the fire alarm system had been “touch and go” since the end of the prior year. Staff interviews from multiple departments showed inconsistent understanding of Fire Watch, its purpose, and who was responsible for it. Several CNAs, LPNs, and other staff members stated that Fire Watch meant someone walked around every 15 minutes or so to look for smoke or fire, but many did not know who was currently on Fire Watch or why the facility was on Fire Watch. Staff reported they had not received formal training specific to Fire Watch, and some said they were only told to be more alert and to walk the halls and outside the building. The Director of Social Services and the MDS RN also confirmed that nursing staff had been performing Fire Watch because they were present 24/7, but they did not know the exact reason for Fire Watch. The Maintenance Assistant stated that the fire panel was malfunctioning and beeping frequently, that the facility had been on Fire Watch for a long time, and that replacement of the fire panel would not occur until mid‑summer. The Administrator, who had recently started in his role, confirmed that the facility was on Fire Watch and that nursing staff had been performing the rounds while also carrying out their regular duties. He was unsure of the exact issue with the fire alarm system and could not initially provide credible evidence of fire alarm inspections, testing, or maintenance records when requested. Review of the fire maintenance binder showed Fire Watch logs dating back to late January, but the Administrator could not explain why Fire Watch had been in place that long. He also stated that the facility did not have a full‑time maintenance director and that he was not aware of any risk assessment being completed on the malfunctioning fire panel, despite a facility policy requiring risk assessments for building systems. During observation with the Maintenance Assistant, the fire panel was seen in trouble mode for multiple units, and the Maintenance Assistant silenced the beeping without taking further action or indicating any steps to investigate the trouble conditions. The facility’s written Fire Watch policy required continuous and systematic surveillance by trained personnel, with duties including searching diligently for fires, controlling ignition sources, ensuring egress routes and fire protection features were available and functioning, and documenting patrols. However, interviews and observations showed that Fire Watch activities were limited mainly to walking hallways and the building exterior, without consistent attention to areas such as laundry, kitchen, resident rooms, cook surfaces, dryers, smoking materials, and janitor closets with flammable liquids. Staff were often unaware of the full scope of Fire Watch responsibilities described in the policy. The facility continued to accept new admissions while on Fire Watch, and there was no evidence that the malfunctioning fire panel or prolonged Fire Watch status had been brought to the facility’s QAPI committee. The surveyors determined that failure to maintain a functional fire alarm system and to conduct Fire Watch according to policy created a hazardous environment and resulted in an Immediate Jeopardy determination, later reduced in scope and severity after immediacy was addressed. Further review showed that the facility had remained on Fire Watch for approximately three months without evidence of re‑inspection or testing of the fire panel until a fire alarm system inspection and test were performed near the end of the survey period. A third‑party event history record later provided by corporate plant operations leadership showed ongoing communication between the fire panel and the monitoring company, but this information, along with earlier vendor service reports and Fire Watch notices from local fire authorities, had not been available or presented to surveyors during the initial investigations. The lack of a full‑time maintenance director and the newness of the Administrator were cited by corporate representatives as reasons why these documents were not produced when first requested. Throughout this period, interviews and document review demonstrated that Fire Watch was not consistently implemented in accordance with the facility’s own ASHE Fire Watch Procedure, and not all staff had been educated on Fire Watch procedures, emergency procedures, and response expectations at the time of the initial Immediate Jeopardy determination.
Failure of Administrative Oversight for Fire Alarm System and Fire Watch
Penalty
Summary
Facility leadership failed to ensure effective systems were in place to maintain a safe, hazard-free environment and to integrate these issues into QAPI activities across all three units. During a complaint investigation and extended survey, staff could not provide evidence that fire alarm panel testing and inspections had been conducted since 1/30/26. The Administrator, who had been in the role since 3/30/26, confirmed the facility was on Fire Watch but was unsure of the exact reason, stating only that a Life Safety inspector had identified a malfunctioning fire panel during an inspection on 4/15/26. Fire Watch logs dating back to 1/30/26 showed the facility had been on Fire Watch for several months, yet the Administrator could not explain why it had been in place since January or provide documentation that the fire alarm system had been tested or inspected during that period. The Administrator reported that Fire Watch duties were primarily performed by nursing staff, who were already in the building 24/7, and that a Life Safety inspector had later instructed the facility to assign a dedicated person to Fire Watch who could not perform other tasks. At the time of the survey, the Administrator identified the receptionist by first name as the person currently on Fire Watch but could not recall her last name. He stated that the fire alarm vendor had recently verified the panel was functioning but could not provide any visit report or other credible evidence of this verification, and he had no records of fire alarm functionality audits, system inspections, or maintenance program records. The facility did not have a full-time maintenance director, and the Administrator acknowledged that the ongoing fire panel and smoke detector malfunctions and prolonged Fire Watch status had not been brought to the QAPI committee, despite the QAPI agenda including maintenance items such as fire drill logs, disaster drill logs, monthly fire alarm tests, and maintenance tracking. The facility also lacked a policy addressing administrative duties, and no additional information was provided at the exit meeting.
Governing Body Failed to Ensure Oversight of Fire Alarm System and Fire Watch
Penalty
Summary
The deficiency involves the governing body’s failure to ensure effective leadership, policy implementation, and operational systems to maintain a safe, hazard‑free environment on all three units while the facility was on Fire Watch. Surveyors found that the facility had been on Fire Watch since 1/30/26 due to issues with the fire alarm system, yet the Administrator, who started on 3/30/26, could not clearly explain the exact problem with the fire panel or provide contemporaneous documentation of the malfunction or its monitoring. During an interview, the Administrator stated that Fire Watch consisted of someone making rounds every 15 minutes, primarily nursing staff, and acknowledged that the facility did not have a full‑time maintenance director. When surveyors requested evidence on 4/24/26 of the fire panel’s functionality, fire alarm system inspections, testing, or maintenance records, the Administrator was unable to produce any such documentation, including vendor service reports or audit records. He also could not initially provide documentation from the fire safety vendor verifying that the panel was functioning, and he did not present any evidence of communication from the local Fire Marshal or Fire and Rescue Department regarding Fire Watch. The fire alarm panel was observed in trouble mode for specific units, and the explanation given by regional leadership later was that the issue related to sensitivity and the age of the system, but this information and supporting documents were not available or presented at the time of the initial surveyor request. The governing body’s policies required it to be legally responsible for establishing and implementing policies for management and operation of the facility, including appointment and oversight of the Administrator and accountability for QAPI. However, there was no evidence that the governing body was involved in QAPI activities related to the ongoing fire panel and smoke detector issues or the prolonged Fire Watch status since January. The Administrator confirmed that the fire alarm and Fire Watch issues had not been brought to the QAPI committee, despite the QAPI agenda format including maintenance items such as fire drills, disaster drills, monthly fire alarm tests, and use of the TELS system. No evidence was provided to show a defined process of communication between the Administrator and the governing body regarding these life safety problems or that the Administrator was being held accountable for reporting and managing these operational issues.
Failure to Use QAPI to Address Prolonged Fire Alarm Malfunction and Fire Watch
Penalty
Summary
Facility staff failed to use the Quality Assurance and Performance Improvement (QAPI) committee to identify and oversee serious safety deficiencies related to a malfunctioning fire alarm system and prolonged Fire Watch on all three units. During a complaint investigation and extended survey, surveyors determined that the facility had been on Fire Watch since 1/30/26 due to fire alarm panel and related system malfunctions, yet there was no credible evidence that these issues were reported to or addressed by the QAPI committee. The Administrator, who began in the role at the end of March, confirmed the facility was on Fire Watch but was unsure of the exact cause, stating only that a Life Safety inspector had identified a malfunctioning fire panel during a mid-April inspection. Interviews and document reviews showed that Fire Watch rounds had been documented since 1/30/26, with staff making rounds approximately every 15 minutes to look for signs of smoke or fire. Initially, nursing staff performed Fire Watch duties while also carrying out their regular responsibilities, and only later was a dedicated person assigned to Fire Watch per the Life Safety inspector’s directive. The Administrator could not clearly explain why Fire Watch had been in place since January, reported that the fire alarm system had been “touch and go” since late 2025, and stated that the vendor had recently verified the panel was functioning, but he was unable to provide any visit reports, audit records, or maintenance program documentation to substantiate this. Further review of QAPI activities revealed that, although monthly QAPI meetings were reportedly held and attendance sheets existed for several recent meetings, there was no evidence that the malfunctioning fire panel, nonfunctioning smoke detectors, exit signage issues, or the ongoing Fire Watch had been discussed or monitored by the QAPI committee. The Administrator produced a QAPI action plan for a broken exit door and a blank agenda/minutes form listing maintenance-related items such as fire drill logs and fire alarm tests, but he had no supporting documentation showing that identified tasks were completed or that the fire alarm deficiencies were addressed. He also lacked evidence of quarterly QAPI meetings or medical director participation, and he acknowledged that the fire panel and Fire Watch issues should have been reported to QAPI but were not.
Failure to Publicly Post Survey Results
Penalty
Summary
Facility staff failed to post the most recent survey results in a location that was readily accessible to residents, family members, and legal representatives. During observations, a sign in the lobby indicated that the inspection report was available upon request, but no actual posting of the survey results was observed. Staff interviews revealed that the survey results book was kept in a drawer by the receptionist rather than being publicly displayed. These findings were confirmed during the survey and shared with facility leadership, with no additional information provided by staff.
Failure to Administer Ordered IV Antibiotic for Infected Foot Ulcer
Penalty
Summary
Facility staff failed to administer a prescribed intravenous (IV) antibiotic to a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with activities of daily living, had a deteriorating foot wound with increased edema and purulent drainage. After laboratory results identified multiple organisms in the wound, a wound care nurse practitioner ordered IV Linezolid to begin on a specific date, with the medication and IV access available at the scheduled start time. Despite these preparations, the resident did not receive any doses of the antibiotic as ordered. The initial dose was missed even though the IV access and medication were ready, and subsequent doses were not administered due to the IV being dislodged and not promptly replaced. Nursing notes indicated ongoing delays, and the antibiotic was ultimately discontinued on the recommendation of a consulting physician before any doses were given. Facility leadership was informed of these findings and did not provide comments or express concerns during the final interview.
Failure to Promptly Notify Practitioner of Abnormal Lab Results
Penalty
Summary
Facility staff failed to promptly notify the ordering practitioner of abnormal laboratory results for a resident with an infected diabetic ulcer of the right foot. The resident, who was cognitively intact and required significant assistance with daily activities, had a wound specimen collected due to increased edema and purulent drainage. The laboratory results, which identified the presence of Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis in the wound, were sent to the facility but were not communicated to the nurse practitioner until several days later. The delay in notification occurred despite the facility's process for lab result review, which includes making results viewable on the Point-Click-Care system dashboard and requiring the overnight shift to conduct a 24-hour chart check to identify any oversights. The oversight was not recognized until several days after the results were received, at which point the practitioner was notified and appropriate medical interventions were ordered. The facility's policy requires prompt reporting of positive culture results to the practitioner, but this was not followed in this instance.
Delayed Therapy Evaluation Due to Missed Orders and Miscommunication
Penalty
Summary
Facility staff failed to provide a timely specialized therapy evaluation for a resident who was admitted with significant neurological impairments, including cerebral infarction and hemiplegia. The resident was dependent in multiple activities of daily living and had a physician's order for Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) evaluations upon admission. Despite this standing order, the initial therapy evaluations were not initiated until several weeks after admission, contrary to facility policy which required evaluations to be completed within two days of a referral. Interviews with staff revealed confusion and miscommunication regarding the resident's therapy orders and insurance status. The Director of Rehabilitation stated that no therapy orders were present initially, and therapy evaluations did not begin until nearly a month after admission. The Business Office Manager clarified that the resident had Medicare Part B as a therapy payor source, but there was a misunderstanding at admission regarding insurance coverage, which contributed to the delay in therapy services. The resident and her spouse reported that therapy services were not provided as expected, with the spouse stating that the facility social worker informed them that therapy could not be initiated due to insurance issues. The resident experienced significant pain and required assistance with mobility, as observed during the survey. Facility policy and staff interviews confirmed that the therapy evaluation order was missed, resulting in delayed treatment and placing the resident at higher risk for decline.
Failure to Implement Enhanced Barrier Precautions and Proper Cohorting
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper implementation of Enhanced Barrier Precautions (EBP) and cohorting practices. A resident with an infected diabetic foot ulcer, confirmed to be colonized with multiple organisms including Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis, was placed under Contact Precautions. However, the resident's roommate, who had a PEG tube and therefore met criteria for EBP, did not have appropriate EBP signage posted. This omission was observed during a facility tour, and staff interviews confirmed that the required precautions were not in place for the roommate. The Unit Manager acknowledged the error, stating that after consultation with the Infection Preventionist, it was determined that the two residents should not have been cohorted together. The roommate was subsequently moved, and EBP signage was posted, but these actions occurred only after the deficiency was identified. The facility's own infection prevention and control policy required all staff to follow established procedures, which was not adhered to in this instance, resulting in a lapse in infection control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Suffolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Care Of Suffolk | 2.1 mi | ★★★★★ | 0 | 0 |
| Lake Prince Woods, Inc | 4 mi | ★★★★★ | 3 | 0 |
| Windsor Grove Health And Rehabilitation | 10.7 mi | ★★★★★ | 0 | 0 |
| Northern Cardinal Rehabilitation And Nursing | 12.5 mi | ★★★★★ | 0 | 0 |
| Portside Health & Rehab Center | 12.9 mi | ★★★★★ | 0 | 0 |
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