Inspection Reports for
Central Island Healthcare
825 Old Country Rd, Plainview, NY 11803, United States, NY, 11803
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Inspection Report — Jun 16, 2025
Annual Inspection CMS
Date: Jun 16, 2025
Visit Reason
The Recertification Survey was initiated on 6/10/2025 and completed on 6/16/2025 to assess compliance with regulatory requirements for Central Island Healthcare.
Findings
The facility was found deficient in multiple areas including failure to develop and implement baseline and comprehensive care plans, inadequate pressure ulcer care, improper pharmaceutical services including expired insulin administration, incomplete medication documentation, improper medication storage and labeling, and failure to maintain infection prevention and control protocols.
Citations (7)
Failure to develop and implement a baseline care plan for Resident #305's Foley catheter use within 48 hours of admission.
Failure to develop and implement a comprehensive care plan for Resident #93's use of compression bandage wraps, including failure to document resident refusal and notify physician.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Residents #18, #354, and #142, including failure to provide air overlay as ordered and inconsistent wound care treatments.
Failure to provide pharmaceutical services to meet resident needs, including administration of expired Lantus insulin to Resident #128.
Failure to ensure drugs and biologicals were labeled and stored properly, including unauthorized medication storage in Resident #93 and Resident #134's rooms.
Failure to maintain complete and accurate medical records, specifically incomplete documentation of sliding scale insulin dosage and injection site for Resident #94.
Failure to maintain an infection prevention and control program, including failure of Registered Nurse #1 to wear required eye protection when entering Resident #303's room on Droplet Precautions.
Report Facts
Deficiencies cited: 7
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Insulin units: 10
Sliding scale insulin doses: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Unit Manager | Named in findings related to baseline care plan, wound care treatment, and infection control noncompliance |
| Registered Nurse #5 | Admission Nurse | Named in baseline care plan deficiency for Resident #305 |
| Director of Nursing Services | Provided statements regarding care plan responsibilities and medication administration | |
| Registered Nurse #3 | Medication Nurse | Named in compression bandage wrap refusal and medication storage findings |
| Registered Nurse #2 | Medication Nurse | Named in compression bandage wrap refusal and sliding scale insulin documentation findings |
| Registered Nurse #4 | Unit Manager | Named in compression bandage wrap refusal and medication storage findings |
| Wound Care Nurse | Named in wound care treatment deficiencies | |
| Licensed Practical Nurse #1 | Named in expired insulin administration finding | |
| Pharmacist | Provided statement on insulin expiration | |
| Registered Nurse #7 | Named in wound care treatment findings | |
| Registered Nurse #6 | Named in wound care treatment findings | |
| Licensed Practical Nurse #3 | Named in wound care treatment findings | |
| Infection Preventionist | Named in infection control findings | |
| Nurse Educator | Named in infection control findings |
Inspection Report — Jun 16, 2025
Original Licensing State
Date: Jun 16, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 25 complaints about this facility; 6 led to on-site inspections. Complaint surveys issued 3 citations in total.
Findings
Across 7 inspections, 40 citations were issued including 23 standard health and 17 Life Safety Code citations. The facility had 25 complaints with 6 on-site inspections and 1 enforcement action recorded.
Citations (25)
Baseline Care Plan: Standard Health Citation for quality of care related to baseline care planning deficiencies.
Develop/implement Comprehensive Care Plan: Standard Health Citation for quality of care related to care plan development and implementation.
Infection Prevention & Control: Standard Health Citation for quality of care related to infection prevention and control.
Label/store Drugs And Biologicals: Standard Health Citation for quality of care related to medication labeling and storage.
Pharmacy Srvcs/procedures/pharmacist/records: Standard Health Citation for quality of care related to pharmacy services and records.
Resident Records - Identifiable Information: Standard Health Citation for quality of care related to resident record confidentiality.
Treatment/svcs To Prevent/heal Pressure Ulcer: Standard Health Citation for quality of care related to pressure ulcer prevention and treatment.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation for NFPA requirements related to essential electrical systems.
Elevators: Life Safety Code Citation for NFPA requirements related to elevator safety.
Means Of Egress - General: Life Safety Code Citation for NFPA requirements related to means of egress.
Accuracy Of Assessments: Standard Health Citation for quality of care related to assessment accuracy.
Activities Daily Living (adls)/mntn Abilities: Standard Health Citation for quality of care related to activities of daily living maintenance.
Behavioral Health Services: Standard Health Citation for quality of care related to behavioral health services.
Develop/implement Comprehensive Care Plan: Standard Health Citation for quality of care related to care plan development and implementation.
Infection Prevention & Control: Standard Health Citation for quality of care related to infection prevention and control.
Investigate/prevent/correct Alleged Violation: Standard Health Citation for quality of care related to investigation and correction of alleged violations.
Pain Management: Standard Health Citation for quality of care related to pain management.
Quality Of Care: Standard Health Citation for quality of care deficiencies.
Egress Doors: Life Safety Code Citation for NFPA requirements related to egress doors.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation for NFPA requirements related to essential electrical systems.
Gas Equipment - Cylinder And Container Storag: Life Safety Code Citation for NFPA requirements related to gas equipment storage.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements related to sprinkler system maintenance and testing.
Stairways And Smokeproof Enclosures: Life Safety Code Citation for NFPA requirements related to stairways and smokeproof enclosures.
Building Construction Type And Height: Life Safety Code Citation for NFPA requirements related to building construction type and height.
Cardio-pulmonary Resuscitation (cpr): Standard Health Citation for quality of care related to CPR procedures.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 40
Inspections with violations: 5
Inspections without violations: 2
Plan of correction counts: Not explicitly stated
Total fines: 10000
Number of enforcement actions: 1
Inspection Report — Jun 9, 2025
Abbreviated Survey CMS
Date: Jun 9, 2025
Visit Reason
The abbreviated survey was conducted to assess the accuracy of resident assessments, specifically reviewing Minimum Data Set (MDS) accuracy for residents.
Findings
The facility failed to ensure that resident assessments were accurate and reflective of the resident's status, particularly regarding pressure injuries present on admission. The Minimum Data Set assessment did not align with nursing admission notes and wound care documentation.
Citations (1)
Failure to ensure each resident receives an accurate assessment reflective of the resident's status, specifically related to pressure injuries documented in the Minimum Data Set.
Report Facts
Residents Affected: 1
Look back period: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Wound Care RN | Documented nursing progress note regarding suspected Deep Tissue Injury |
| Minimum Data Set Coordinator | Interviewed regarding MDS completion and documentation |
Inspection Report — Jan 9, 2024
Annual Inspection CMS
Date: Jan 9, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 1/2/2024 to 1/9/2024 to evaluate compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate alleged violations such as skin tears, incomplete development and implementation of comprehensive care plans, inadequate provision of restorative nursing programs, failure to obtain physician orders for treatments, discrepancies in pain management medication orders, lack of psychological counseling services as ordered, and lapses in infection prevention and control practices.
Citations (7)
Failure to investigate skin tears and injuries of unknown origin for residents, including lack of incident reports and root cause analysis.
Incomplete development and implementation of comprehensive care plans for pressure ulcer prevention and skin condition management.
Failure to provide necessary restorative nursing services such as the Floor Ambulation Program as recommended by rehabilitation.
Failure to obtain physician orders and provide appropriate treatment for a resident with a wrist fracture, including non-use of prescribed wrist splint.
Inadequate pain management due to a discrepancy in physician's order for Oxycodone dosing, resulting in under-medication.
Failure to provide psychological counseling services as ordered for a resident with depression.
Non-compliance with infection prevention protocols, including failure to remove personal protective equipment before exiting a resident's room on Contact and Droplet precautions.
Report Facts
Medication doses per day: 4
Medication doses per day: 6
Physical therapy minutes: 420
Ambulation distance: 175
Ambulation distance: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Medical Director | Physician who wrote the Oxycodone order and provided progress notes regarding pain management. |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Responsible for incident reports and investigation related to skin tear for Resident #129. |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding oversight failures in care plans, incident reporting, and treatment orders. |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed failing to remove PPE before exiting room of resident on Contact and Droplet precautions. |
| Registered Nurse #1 | Wound Care Nurse | Interviewed about care for Resident #62's heel injury and refusal to wear heel booties. |
| Physical Therapist #2 | Physical Therapist | Provided therapy and discharge assessment for Resident #19. |
| Occupational Therapist | Occupational Therapist | Interviewed regarding care and referral process for Resident #152's wrist fracture and splint use. |
| Psychologist | Psychologist | Responsible for psychotherapy services; acknowledged not seeing Resident #138 since September 2023. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about responsibility for therapy referrals and safety concerns for Resident #152. |
Inspection Report — Jan 4, 2022
Abbreviated Survey CMS
Date: Jan 4, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and an Abbreviated Survey triggered by Complaint #NY 00262655 and Complaint #NY 00286283 to evaluate compliance with regulations related to abuse reporting, medication storage, and psychotropic medication administration.
Complaint Details
The abbreviated survey was complaint-related, triggered by Complaint #NY 00262655 regarding abuse reporting and Complaint #NY 00286283 regarding psychotropic medication use. The facility was found non-compliant in timely reporting injuries and documenting psychotropic medication use.
Findings
The facility failed to timely report injuries of unknown origin to the New York State Department of Health, did not discard an opened influenza vaccine vial within the manufacturer's recommended timeframe, and did not ensure documentation of non-pharmacological interventions prior to administering PRN psychotropic medication for one resident.
Citations (3)
Failure to timely report injuries of unknown origin to the New York State Department of Health for one resident.
Opened multidose vial of Influenza Vaccine was not discarded within the manufacturer's recommended 28 days after opening.
Non-pharmacological interventions were not implemented or documented prior to administering PRN psychotropic medication for one resident.
Report Facts
Medication vial volume remaining: 2
Medication vial expiration date: May 28, 2022
Medication vial opened date: Nov 24, 2021
PRN Alprazolam administration dates: 2
Physician order dosage: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Reviewed investigative statements and completed occurrence investigation summary for Resident #67 |
| Director of Nursing Services | Director of Nursing Services | Notified of Resident #67 incident and involved in decision not to report injury to NYSDOH |
| Medical Director | Medical Director | Attending physician for Resident #67, provided clinical information about injury and treatment |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Influenza Vaccine disposal practices |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Administered Alprazolam to Resident #401 and interviewed about documentation practices |
| Registered Nurse #2 | Registered Nurse | Administered Alprazolam to Resident #401 and interviewed about documentation practices |
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