Inspection Reports for
Island Nursing and Rehab Center
5537 Expressway Drive North, Holtsville, NY, 11742
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
116% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 6, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in allowing residents to self-administer medications without proper physician orders or assessments, failure to implement a two-person care approach as required by care plans, improper handling and documentation of controlled substances including medication refusals, and failure to secure medications and narcotics in locked compartments.
Deficiencies (4)
F 0554: The facility allowed Resident #8 to self-administer medications without a physician's order or assessment, and medications were left unsecured at the bedside.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes, as Resident #8 requiring a two-person approach was cared for by one staff member.
F 0755: The facility did not ensure controlled drug records were reconciled after Resident #60 refused medications, and medications were left unsecured on an unattended medication cart.
F 0761: The facility failed to store all drugs and biologicals in locked compartments and allowed unauthorized access, including an unlocked medication cart and narcotic box on Unit 3.
Report Facts
Residents reviewed for accidents: 6
Residents reviewed for behavioral and emotional status: 2
Units reviewed for medication storage: 2
Medication refusal time: 21
Medication refusal time: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication self-administration finding for Resident #8. |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding medication self-administration and two-person care approach for Resident #8. |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding medication self-administration policies and medication security. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in medication refusal and medication cart security finding for Resident #60. |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Interviewed regarding medication cart security and controlled substance handling. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in two-person care approach finding for Resident #8. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Aug 6, 2025
Visit Reason
Multiple level 2 standard health citations related to care planning, medication labeling, pharmacy services, and resident self-administered medications were cited. All deficiencies were isolated and did not indicate systemic quality of care problems.
Findings
Multiple level 2 standard health citations related to care planning, medication labeling, pharmacy services, and resident self-administered medications were cited. All deficiencies were isolated and did not indicate systemic quality of care problems.
Deficiencies (4)
Develop/implement comprehensive care plan
Label/store drugs and biologicals
Pharmacy srvcs/procedures/pharmacist/records
Resident self-admin meds-clinically approp
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 2
Date: Jun 11, 2024
Visit Reason
The inspection was conducted as a Recertification and abbreviated Survey including Complaint #NY 00327627, initiated on 2024-06-05 and completed on 2024-06-11, to investigate staffing shortages and dental care concerns.
Complaint Details
Complaint #NY 00327627 triggered the investigation of nursing staffing shortages and dental care deficiencies. The complaint was substantiated with findings of insufficient staffing and failure to provide dental X-rays as ordered.
Findings
The facility was found to have insufficient nursing staff, especially Certified Nursing Assistants on weekends, causing delays in resident care. Additionally, the facility failed to ensure routine dental care for a resident, including timely dental X-rays as recommended.
Deficiencies (2)
F 0725: The facility did not provide enough nursing staff daily to meet resident needs and have a licensed nurse in charge on each shift, resulting in delays in care and insufficient Certified Nursing Assistants on Units 2 and 3 during weekends.
F 0791: The facility failed to provide routine dental care for Resident #37, including not completing recommended dental X-rays from March 2023 to September 2023 due to appointment cancellations and scheduling issues.
Report Facts
Residents: 120
Certified Nursing Assistants required: 5
Certified Nursing Assistants observed: 2
Brief Interview of Mental Status scores: 15
Inspection Report
Annual Inspection
Capacity: 120
Deficiencies: 6
Date: Jun 11, 2024
Visit Reason
The Recertification Survey was conducted to assess compliance with regulatory requirements for nursing home care, including resident assessments, care planning, medical supervision, staffing, and dental services.
Findings
The facility was found deficient in ensuring accurate resident assessments, comprehensive and updated care plans, physician supervision of medical devices, sufficient nursing staffing, and provision of routine dental care. Several residents lacked appropriate care plans for their conditions, physician orders were missing for medical devices, staffing shortages were noted especially on weekends, and dental X-rays were not completed as ordered.
Deficiencies (6)
F0641: The facility failed to ensure the Quarterly Minimum Data Set assessment accurately reflected that Resident #54 received Hospice care.
F0656: The facility did not develop comprehensive care plans with measurable objectives for residents' chronic skin conditions, use of assistive devices, and communication needs for non-English speakers.
F0657: The facility failed to review and revise comprehensive care plans timely to address residents' changing needs, including hydration and dental care.
F0710: The facility did not ensure physician supervision for residents' medical care, including monitoring of Resident #45's cardiac pacemaker and obtaining physician orders for Resident #73's Miami J Cervical Collar.
F0725: The facility failed to provide sufficient nursing staff to meet residents' needs, with documented low weekend staffing and resident complaints of delayed care.
F0791: The facility did not ensure Resident #37 received routine dental care, specifically dental X-rays ordered in March 2023 were never completed.
Report Facts
Facility total capacity: 120
Residents reviewed: 13
PBJ Staffing Data: 3
PBJ Staffing Data: 2
Pacemaker check interval: 3
Pacemaker check gap: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Primary Care Physician | Responsible for reviewing pacemaker checks and physician orders for medical devices |
| Registered Nurse #1 | Unit Manager | Interviewed regarding Resident #81's skin condition and care plan |
| Registered Nurse #2 | Minimum Data Set Assessment Nurse | Interviewed regarding inaccurate MDS assessment for Resident #54 |
| Director of Nursing Services | Interviewed multiple times regarding care plans, staffing, and dental services | |
| Certified Nursing Assistant #1 | Provided care for Resident #73 and described use of Miami J Cervical Collar | |
| Licensed Practical Nurse #1 | Interviewed about communication with Resident #90 and care provision | |
| Dentist #1 | Dentist | Provided dental care and recommended X-rays for Resident #37 |
| Dentist #2 | Dentist | Followed up on Resident #37's dental care and X-ray scheduling |
| Unit Secretary #1 | Responsible for scheduling outside appointments including dental X-rays | |
| Dental Service Vendor Representative | Interviewed about dental service approvals and scheduling |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jun 11, 2024
Visit Reason
Several level 2 standard health citations related to assessments accuracy, care plan timing, physician supervision, dental services, and nursing staff sufficiency. Most deficiencies were isolated and corrected by August 8, 2024.
Findings
Several level 2 standard health citations related to assessments accuracy, care plan timing, physician supervision, dental services, and nursing staff sufficiency. Most deficiencies were isolated and corrected by August 8, 2024.
Deficiencies (7)
Accuracy of assessments
Care plan timing and revision
Develop/implement comprehensive care plan
Resident's care supervised by a physician
Responsibilities of providers; required notif
Routine/emergency dental srvcs in nfs
Sufficient nursing staff
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
One level 2 standard health citation for reporting to the national health safety network with widespread scope and no indication of systemic quality of care problems.
Findings
One level 2 standard health citation for reporting to the national health safety network with widespread scope and no indication of systemic quality of care problems.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 13, 2022
Visit Reason
The inspection was a Recertification Survey conducted from 9/6/2022 to 9/13/2022 to assess compliance with regulatory standards for nursing care and facility operations.
Findings
The facility failed to ensure proper respiratory care, including continuous oxygen administration as ordered for Resident #64, and failed to ensure nurse aides demonstrated competency in reporting resident refusals of care. Additionally, the facility did not maintain an effective infection prevention and control program related to nebulizer equipment care for six residents, risking respiratory infections.
Deficiencies (3)
F 0695: The facility did not provide safe and appropriate respiratory care for Resident #64 by failing to administer oxygen therapy continuously as ordered by the physician.
F 0726: The facility failed to ensure nurse aides demonstrated competency by not reporting Resident #64's refusal to use prescribed oxygen therapy to the charge nurse.
F 0880: The facility failed to provide and implement an infection prevention and control program by not following policies for cleaning and changing nebulizer tubing, mouthpieces, and masks for six residents receiving nebulizer treatments.
Report Facts
Residents reviewed for respiratory care: 7
Residents affected by nebulizer care deficiencies: 6
Oxygen flow rate: 3
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Sep 13, 2022
Visit Reason
Multiple level 2 standard health citations related to nursing staff competency, infection control, respiratory care, and level 1 and 2 life safety code citations for fire drills, means of egress, and medical documentation. Most deficiencies were isolated or pattern scope and corrected by late 2022.
Findings
Multiple level 2 standard health citations related to nursing staff competency, infection control, respiratory care, and level 1 and 2 life safety code citations for fire drills, means of egress, and medical documentation. Most deficiencies were isolated or pattern scope and corrected by late 2022.
Deficiencies (6)
Competent nursing staff
Infection prevention & control
Respiratory/tracheostomy care and suctioning
Fire drills
Means of egress - general
Policies/procedures for medical documentation
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