Inspection Reports for
Our Lady of Consolation Nursing and Rehabilitative Care Center
111 Beach Drive, West Islip, NY, 11795
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
7.4 citations/year
Citations are regulatory findings recorded during state inspections.
45% worse than New York average
New York average: 5.1 citations/yearCitations per year
28
21
14
7
0
Inspection Report
Annual Inspection
Citations: 12
Date: Jul 2, 2025
Visit Reason
The facility underwent a recertification survey and abbreviated survey to assess compliance with regulatory requirements, including resident care, safety, and facility conditions.
Findings
The survey identified multiple deficiencies including failure to maintain comfortable environmental temperatures during an extreme heat event, late transmission and inaccuracies in Minimum Data Set assessments, incomplete care plans, inadequate treatment for bowel issues, significant unaddressed weight loss, delayed pain medication administration, insufficient nursing staffing on certain shifts, lack of documented pharmacist medication review responses, and improper food temperature monitoring.
Citations (12)
F 0584: The facility failed to maintain comfortable temperature levels during an extreme heat event, with HVAC and Package Terminal Air Conditioners malfunctioning, resulting in elevated temperatures up to 88 degrees Fahrenheit in resident rooms and common areas.
F 0640: The facility did not transmit Minimum Data Set assessments to the State within required timeframes, with some assessments transmitted up to 88 days late.
F 0641: The facility did not ensure accuracy of Minimum Data Set assessments, failing to document use of a chair alarm for a resident at high risk for falls.
F 0656: The facility failed to develop a comprehensive care plan addressing a resident's visual impairment, delaying the plan by 63 days after admission.
F 0684: The facility did not provide appropriate bowel care for a resident with constipation and diarrhea, failing to implement bowel protocol and notify the physician, resulting in hospitalization for fecalith removal.
F 0692: The facility did not ensure a resident maintained acceptable nutritional and hydration status, failing to implement interventions after significant weight loss and inadequate calorie intake.
F 0697: The facility did not provide timely pain management for a resident, delaying administration of pain medication and failing to assess pain level prior to medication.
F 0710: The facility did not ensure physician supervision of resident care related to significant weight loss, with no documented physician response to dietitian notifications.
F 0725: The facility failed to provide sufficient nursing staff on multiple units during evening shifts, staffing below par levels due to call-outs and scheduling challenges.
F 0756: The facility did not ensure pharmacist medication regimen review irregularities were addressed by medical providers, lacking documented assessment of risks for combined use of certain psychotropic medications.
F 0812: The facility failed to store, prepare, and serve food at safe temperatures, with cold food items such as sandwiches and milk served at temperatures above safe limits and no system to monitor cold food temperatures.
F 0908: The facility did not maintain cooling equipment properly during an extreme heat event, resulting in elevated temperatures in resident rooms and common areas, and delayed repairs of HVAC and air conditioning units.
Report Facts
Temperature: 88
Late transmission days: 88
Weight loss percentage: 5.3
Certified Nursing Assistants: 3
Certified Nursing Assistants: 3
Certified Nursing Assistants: 3
Certified Nursing Assistants: 3
Vendor quotes: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #2 | Nurse Practitioner | Signed medication regimen review but did not document assessment of medication risks |
| Registered Dietitian #1 | Registered Dietitian | Documented weight loss and calorie count but did not implement nutritional interventions |
| Director of Plant Operations | Reported HVAC system failure and repair status during heat wave | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Delayed pain medication administration and did not assess pain level |
| Registered Nurse #1 | Registered Nurse | Supervisory nurse who stated medication should be given within one hour of scheduled time |
| Staffing Coordinator | Reported staffing shortages and call-ins affecting par levels | |
| Administrator | Confirmed staffing expectations and nurse role flexibility | |
| Chief Clinical Dietitian #1 | Chief Clinical Dietitian | Stated nutritional interventions should have been offered after weight loss |
| Director of Nursing Services | Responsible for staffing levels and nursing services oversight | |
| Nurse Practitioner #2 | Nurse Practitioner | Agreed with pharmacist recommendations but failed to document response |
| Primary Physician #1 | Physician | Unaware of significant weight loss notifications and did not address resident's weight loss |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 16
Date: Jul 2, 2025
Visit Reason
Inspection revealed 12 standard health citations and 4 life safety code citations, mostly Level 2 severity, many corrected by August 2025.
Findings
Inspection revealed 12 standard health citations and 4 life safety code citations, mostly Level 2 severity, many corrected by August 2025.
Citations (16)
Accuracy of assessments
Develop/implement comprehensive care plan
Drug regimen review, report irregular, act on
Encoding/transmitting resident assessments
Essential equipment, safe operating condition
Food procurement,store/prepare/serve-sanitary
Nutrition/hydration status maintenance
Pain management
Quality of care
Resident's care supervised by a physician
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Electrical systems - essential electric syste
Fire drills
Means of egress - general
Portable fire extinguishers
Inspection Report
Annual Inspection
Citations: 5
Date: Apr 7, 2024
Visit Reason
The inspection was a Recertification Survey conducted from April 7, 2024 to April 12, 2024 to assess compliance with regulatory standards for the nursing home.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding assistance, improper labeling of enteral feeding supplies, inaccurate oxygen therapy administration and documentation, unsafe food storage and labeling practices, and inadequate policies and practices regarding food brought in by visitors.
Citations (5)
F 0550: The facility failed to ensure residents were treated with dignity during meal assistance; a nursing assistant was observed standing over a resident while feeding instead of sitting at eye level.
F 0693: The facility did not label enteral feeding and hydration bottles with resident name, flow rate, date, and time, risking complications from improper tube feeding care.
F 0695: Resident received 4 liters of oxygen via nasal cannula instead of the prescribed 3 liters, and there was no documentation of oxygen therapy administration in the medical record.
F 0812: Food items in the kitchen were stored without proper labeling and dating, including unlabeled desserts and leftover frozen foods kept beyond recommended timeframes.
F 0813: The facility's policy did not ensure safe storage, handling, or feeding assistance for food brought in by visitors; staff only assisted with facility-prepared food.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Few
Residents affected: Some
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Observed standing over Resident #77 while feeding and interviewed about feeding practices | |
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed regarding proper feeding assistance posture |
| Nurse Manager #1 | Interviewed about labeling requirements for tube feeding bottles | |
| Registered Nurse #2 | Admitted to forgetting to label tube feeding bottles while training new nurse | |
| Registered Nurse #4 | Interviewed about oxygen therapy documentation uncertainty | |
| Registered Nurse #1 | Nurse Manager | Interviewed about oxygen therapy documentation requirements |
| Director of Nursing Services | President of Clinical Services | Interviewed about feeding assistance and oxygen therapy documentation policies |
| Director of Culinary Services | Interviewed about food labeling, storage, and visitor food policies | |
| Culinary Ambassador | Interviewed about failure to label and date prepared desserts | |
| Kitchen Supervisor | Interviewed about food storage and leftover food discard practices | |
| Administrator | Interviewed about policies on food brought in by visitors and feeding assistance |
Inspection Report
Capacity: 60
Citations: 1
Date: Jul 13, 2023
Visit Reason
Covid-19 Survey with one Level 1 standard health citation related to emergency plan development and annual review, corrected by August 2023.
Findings
Covid-19 Survey with one Level 1 standard health citation related to emergency plan development and annual review, corrected by August 2023.
Citations (1)
Develop ep plan, review and update annually
Inspection Report
Annual Inspection
Citations: 2
Date: Mar 18, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey including a complaint investigation related to accidents and care planning for Resident #394.
Complaint Details
Complaint #NY00274868 triggered the investigation. The complaint involved concerns about the facility's handling of Resident #394's fall and failure to update care plans to reflect the resident's behavior of disarming alarms. The complaint was substantiated with findings of inadequate investigation and care planning.
Findings
The facility failed to thoroughly investigate an unwitnessed fall of Resident #394, specifically not addressing the resident's behavior of disarming bed and chair alarms. Additionally, the resident's comprehensive care plan was not updated to reflect this behavior, increasing risk for falls.
Citations (2)
F 0610: The facility did not ensure accidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. The investigation of Resident #394's fall did not address the resident's behavior of disarming bed and chair alarms.
F 0657: The facility did not ensure that Resident #394's comprehensive care plan was reviewed and revised to reflect the resident's behavior of turning off bed and chair alarms after an unwitnessed fall with no alarm sounding.
Report Facts
Residents reviewed for accidents: 3
Date of fall: Apr 21, 2021
Date survey completed: Mar 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Provided statement about resident disarming alarms and witnessed fall. |
| RN #1 | Registered Nurse | Responded to fall and documented resident condition. |
| RN #2 | Nursing Supervisor | Interviewed regarding knowledge of resident behavior and care plan updates. |
| RN #4 | Registered Nurse | Nurse assigned during fall shift; no longer employed. |
| RM | Risk Manager/Director of Nursing Operations | Conducted investigation and updated care plan after fall. |
| VPCS | President of Clinical Services | Interviewed about investigation conclusions and care plan revisions. |
Inspection Report
Capacity: 60
Citations: 1
Date: Nov 10, 2021
Visit Reason
Covid-19 Survey with one Level 1 standard health citation related to other laws, codes, rules and regulations, widespread scope, not corrected.
Findings
Covid-19 Survey with one Level 1 standard health citation related to other laws, codes, rules and regulations, widespread scope, not corrected.
Citations (1)
Other laws, codes, rules and regulations.
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