Inspection Reports for
Jefferson’s Ferry
500 Mather Drive, So Setauket, NY, 11720
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with resident abuse and neglect protections following an incident involving Resident #1 falling from a recliner chair and sustaining injuries.
Findings
The facility failed to ensure Resident #1's right to be free from abuse and neglect when Certified Nursing Assistant #4 improperly transferred the resident without required assistance, resulting in a fall causing injury. The facility's policies on abuse prevention and proper transfer procedures were not followed.
Deficiencies (1)
F 0600: The facility did not protect Resident #1 from abuse and neglect when the resident fell from a recliner chair during transfer, sustaining a skin tear and head injury. Certified Nursing Assistant #4 failed to follow the care plan requiring two-person mechanical lift assistance.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Named in the finding for improper transfer causing resident fall | |
| Director of Nursing Services | Interviewed regarding failure to follow care plan | |
| Registered Nurse #2 | Witnessed resident on floor after fall |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
One standard health citation for free from abuse and neglect, corrected as of July 31, 2025.
Findings
One standard health citation for free from abuse and neglect, corrected as of July 31, 2025.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 29, 2025
Visit Reason
Annual inspection survey of Jefferson's Ferry nursing home conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 29, 2025
Visit Reason
One standard life safety code citation for elevators, corrected as of July 15, 2025.
Findings
One standard life safety code citation for elevators, corrected as of July 15, 2025.
Deficiencies (1)
Elevators
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
The visit was an abbreviated survey to assess compliance with regulations regarding the use of physical restraints and alarms for fall prevention in the nursing home.
Findings
The facility did not ensure that all residents were free from physical restraints, specifically alarm devices used without documented medical necessity or physician orders for 17 residents. Staff and administration considered alarms as nursing interventions for safety, not restraints, but no assessments or orders were documented.
Deficiencies (1)
10NYCRR 483.10(e)(1) The facility failed to ensure that physical restraints, including alarms used for fall prevention, were only used when medically necessary. There was no documented assessment or physician's order for alarm use for 17 residents.
Report Facts
Residents affected: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Stated alarms were used for resident safety | |
| Certified Nursing Assistant #1 | Responsible for checking alarms and documented checks | |
| Certified Nursing Assistant #2 | Assigned to Resident #1 during fall incident and stated alarms are for safety | |
| Assistant Director of Nursing | Stated alarms are nursing interventions and not restraints, do not require physician orders | |
| Licensed Practical Nurse #3 | Stated alarms used for resident safety and fall concerns | |
| Registered Nurse #2 | Stated alarms are nursing interventions, not restraints, and do not require physician orders | |
| Administrator | Stated alarms are used for high fall risk residents and do not require physician orders | |
| Medical Director | Aware of alarm use for residents, stated alarms do not require physician orders and are not restraints | |
| Registered Nurse #3 | Documented putting alarms in place for Resident #2 due to safety concerns |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
One standard health citation for right to be free from physical restraints, corrected as of January 17, 2025.
Findings
One standard health citation for right to be free from physical restraints, corrected as of January 17, 2025.
Deficiencies (1)
Right to be free from physical restraints
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 31, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to evaluate compliance with food service safety standards, specifically monitoring food temperatures served to residents.
Findings
The facility failed to ensure cold foods were served at safe and appetizing temperatures, as cold food temperatures were not recorded and a key lime pie was found at 66.5 degrees Fahrenheit, exceeding safe temperature guidelines.
Deficiencies (1)
F 0804: The facility did not monitor or record cold food temperatures for the first two weeks of May 2024. A tray of key lime pie served to residents measured 66.5 degrees Fahrenheit, which is not compliant with temperature controls.
Report Facts
Food temperature: 66.5
Date of observation: May 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Culinary Services | Acknowledged that cold food temperatures were not recorded for the first two weeks of May 2024 | |
| Culinary Manager | Measured the key lime pie temperature at 66.5 degrees Fahrenheit | |
| Director of Culinary Operations | Acknowledged no cold food temperatures were recorded and that ice blankets were insufficient | |
| President of Culinary Operations | Stated temperature checks must be performed for cold food items and there is no excuse for not taking these temperatures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: May 31, 2024
Visit Reason
One standard health citation for nutritive value/appearance/palatability and one life safety code citation for fire drills, both corrected by mid-2024.
Findings
One standard health citation for nutritive value/appearance/palatability and one life safety code citation for fire drills, both corrected by mid-2024.
Deficiencies (2)
Nutritive value/appear, palatable/prefer temp
Fire drills
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 30, 2022
Visit Reason
The survey was a Recertification Survey initiated on 2022-08-24 and completed on 2022-08-30 to assess compliance with COVID-19 vaccination policies and procedures for staff.
Findings
The facility failed to develop and implement policies and procedures ensuring a contingency plan for staff who are not fully vaccinated against COVID-19. Specifically, the policy did not address additional precautions for medically exempt staff, and the exemption form lacked details on which COVID-19 vaccine was contraindicated for the exempted staff member.
Deficiencies (1)
F 0888: The facility failed to develop and implement policies and procedures to ensure a contingency plan for staff who are not fully vaccinated against COVID-19. The medical exemption form for one staff member did not specify which COVID-19 vaccine was clinically contraindicated.
Report Facts
COVID-19 positive residents: 2
Staff with medical exemption: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Staff member with medical exemption for COVID-19 vaccination |
| Director of Nursing Services (DNS) | Interviewed regarding COVID-19 positive residents and facility policies |
Inspection Report
Certification Survey
Capacity: 60
Deficiencies: 2
Date: Aug 30, 2022
Visit Reason
One standard health citation for Covid-19 vaccination of facility staff and one life safety code citation for electrical systems, both corrected by late 2022.
Findings
One standard health citation for Covid-19 vaccination of facility staff and one life safety code citation for electrical systems, both corrected by late 2022.
Deficiencies (2)
Covid-19 vaccination of facility staff
Electrical systems - essential electric syste
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