Inspection Reports for
San Simeon by the Sound Center for Nursing & Rehabilitation
61700 Route 48, Po Box 2122, Greenport, NY, 11944
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
171% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Sep 5, 2024
Visit Reason
Multiple standard health and life safety code citations including immediate jeopardy level 4 deficiencies related to accident hazards and abuse reporting, all corrected by late 2024.
Findings
Multiple standard health and life safety code citations including immediate jeopardy level 4 deficiencies related to accident hazards and abuse reporting, all corrected by late 2024.
Deficiencies (16)
Develop/implement comprehensive care plan
Food procurement, store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Label/store drugs and biologicals
Nutrition/hydration status maintenance
Quality of care
Safe/clean/comfortable/homelike environment
Building construction type and height
Electrical systems - essential electric syste
Electrical systems - other
Elevators
Fire alarm system - testing and maintenance
Fire drills
Hvac
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Sep 5, 2024
Visit Reason
The survey was a Recertification Survey initiated on 2024-08-26 and completed on 2024-09-05 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, care planning, treatment administration, medication management, food safety, infection control, and safety hazards related to hot water temperatures. Immediate Jeopardy was identified due to unsafe hot water temperatures but was removed after corrective actions.
Deficiencies (8)
F 0584: The facility failed to provide a safe, clean, and homelike environment. Observations included dirty suction equipment, soiled privacy curtains, and feces-like substance on toilet seats in resident bathrooms.
F 0656: The facility did not develop and implement comprehensive care plans reflecting residents' advanced directives and failed to consistently provide wound care as ordered.
F 0684: The facility failed to ensure residents received treatment and care according to orders and professional standards. A transcription error led to an x-ray being ordered for the wrong hand and results not reviewed.
F 0689: The facility failed to maintain safe water temperatures, exposing 114 residents to immediate jeopardy of burns from excessively hot water up to 129 degrees Fahrenheit.
F 0692: The facility did not ensure residents maintained acceptable nutritional status. Resident #79's weight was not obtained or monitored as ordered.
F 0761: The facility failed to ensure all drugs and biologicals were labeled and stored properly. Loose medications and non-medication items were found in medication carts.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Issues included undated food packages, improper hand hygiene by dietary staff, and unsafe food temperatures.
F 0880: The facility failed to maintain an infection control program. Dirty linens were transported without sealed bags and suction equipment was not cleaned or replaced as required.
Report Facts
Residents affected: 114
Water temperature: 129
Water temperature: 127.9
Water temperature: 124.7
Water temperature: 124.5
Water temperature: 122
Water temperature: 121.8
Water temperature: 115
Tube feeding volume: 1350
Staff in-service education: 99
One-time weight orders: 5
Unidentified loose medications: 27
Food temperature: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Interviewed regarding suction machine maintenance and cleaning. | |
| Licensed Practical Nurse #2 | Observed transporting dirty linens without sealed bag. | |
| Dietary Aide #1 | Observed licking fingers while preparing meal trays without hand hygiene. | |
| Registered Nurse #6 | Entered incorrect x-ray order and interviewed about treatment error. | |
| Nurse Practitioner #1 | Interviewed about telephone order error and failure to review x-ray results. | |
| Licensed Practical Nurse #3 | Observed with loose medications in medication cart. | |
| Licensed Practical Nurse #4 | Observed with loose medications in medication cart. | |
| Licensed Practical Nurse #5 | Observed with loose medications and non-medication items in medication cart. | |
| Director of Nursing Services | Interviewed about medication cart deficiencies and infection control issues. | |
| Food Service Director | Interviewed about food safety violations and dietary aide conduct. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 2024-08-26 to 2024-09-05 to assess compliance with professional standards of care, specifically related to pain management for a resident.
Findings
The facility failed to ensure that all residents received treatment and care according to professional standards. A transcription error led to an x-ray being ordered and performed on the wrong hand, and the x-ray results were not reviewed by the medical doctor or nurse practitioner.
Deficiencies (1)
F 0684: The facility did not provide appropriate treatment and care according to orders and resident preferences. A telephone order for an x-ray of the left hand was erroneously transcribed as an order for the right hand, and the x-ray results were not reviewed by the medical doctor or nurse practitioner.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding the telephone order for x-ray and failure to review x-ray results |
| Registered Nurse #6 | Registered Nurse | Entered erroneous telephone order for x-ray of right hand instead of left hand |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed about administration of acetaminophen and resident pain complaints |
| Acting Director of Nursing Services | Acting Director of Nursing Services | Interviewed regarding responsibilities for telephone orders and follow-up on radiology results |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 26, 2023
Visit Reason
Two level 4 immediate jeopardy standard health citations related to investigating and reporting alleged violations, isolated scope, corrected by February 14, 2024.
Findings
Two level 4 immediate jeopardy standard health citations related to investigating and reporting alleged violations, isolated scope, corrected by February 14, 2024.
Deficiencies (2)
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 26, 2023
Visit Reason
The inspection was conducted as an abbreviated survey triggered by Complaint #NY00329617 concerning allegations of sexual abuse involving two residents at the facility.
Complaint Details
Complaint #NY00329617 involved allegations that Certified Nursing Assistant #1 sexually abused Resident #1 and Resident #2. The allegations were substantiated by interviews and grievance reports. The facility failed to report the allegations timely to local law enforcement and the state health department and failed to conduct proper investigations or take corrective actions.
Findings
The facility failed to timely report and properly investigate two allegations of sexual abuse involving Certified Nursing Assistant #1 and Residents #1 and #2. The allegations were not reported to local law enforcement or the New York State Department of Health within the required two-hour timeframe, and no thorough investigations were conducted. The facility's staff and administration did not suspend or re-educate the accused staff member, and the Medical Director was unaware of the allegations until the facility was placed in Immediate Jeopardy.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse to proper authorities within two hours as required, resulting in Immediate Jeopardy to resident health or safety for two residents.
F 0610: The facility failed to appropriately investigate allegations of sexual abuse involving two residents, did not suspend or re-educate the accused staff member, and did not report the allegations to authorities, resulting in Immediate Jeopardy.
Report Facts
Residents affected: 2
Potentially affected residents: 104
Brief Interview for Mental Status score: 6
Brief Interview for Mental Status score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Accused staff member involved in sexual abuse allegations. | |
| Certified Occupational Therapist Assistant #1 | Reported Resident #1's allegation to nursing staff but did not document it. | |
| Social Worker #1 | Received and documented allegations but did not pursue investigation further. | |
| Social Worker #2 | Interviewed residents and documented allegations on grievance reports. | |
| Registered Nurse #1 | Aware of allegations but did not assess residents or report further. | |
| Registered Nurse #2 | Notified Director of Nursing of alleged abuse via email. | |
| Director of Nursing | Received reports but did not report allegations to authorities or investigate due to being out sick. | |
| Administrator | Aware of allegations but did not report to law enforcement or suspend accused staff, believing it was discrimination. | |
| Medical Director | Unaware of allegations until facility was in Immediate Jeopardy; stated facility should have investigated. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 5, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 17, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 9, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Capacity: 120
Deficiencies: 6
Date: Nov 23, 2022
Visit Reason
The survey was a Recertification and Abbreviated Survey conducted to assess compliance with regulatory requirements, including complaint investigations related to resident care and safety.
Complaint Details
The survey included complaint investigations (Complaint # NY 00286139 and NY 00281584) related to allegations of neglect, inadequate supervision, and failure to provide care as ordered. Resident #31's fall and Resident #61's incontinent care were key complaint issues. The complaint was substantiated with findings of neglect and inadequate care.
Findings
The facility was found deficient in timely reporting of abuse and neglect, thorough investigation of alleged violations, ensuring adequate supervision to prevent accidents, providing appropriate care for incontinent residents, and maintaining sufficient nursing staff to meet resident needs. Specific incidents involved Resident #31's fall resulting in a cervical fracture due to inadequate supervision, Resident #61's unmet toileting needs, and Resident #5 not being ambulated as ordered.
Deficiencies (6)
F 0609: The facility failed to timely report an alleged abuse incident involving Resident #31's fall resulting in a cervical fracture, not reporting to the NYSDOH within required timeframes.
F 0610: The facility did not thoroughly investigate alleged violations of abuse, neglect, or mistreatment for Residents #153 and #31, missing key factors such as wheelchair brake use and root causes of falls.
F 0676: Resident #61 was found lying in a urine and stool-soaked brief for extended periods without timely care, and Resident #5 was not ambulated as ordered, indicating failure to maintain residents' ability to perform activities of daily living.
F 0689: Resident #31 was left unsupervised in their room despite care plans requiring constant supervision, resulting in a fall with actual harm (cervical fracture).
F 0690: Resident #61, incontinent of bowel and bladder, did not receive appropriate incontinent care, lying in soiled briefs for prolonged periods due to staffing shortages and prioritization of other residents.
F 0725: The facility was short staffed with Certified Nursing Assistants (CNAs), with staffing levels below those indicated in the facility assessment, impacting resident care including toileting and ambulation.
Report Facts
Facility total capacity: 120
Staffing shortfall: 4
Staffing shortfall: 1
Fall risk score: 26
Deficiency counts: 10
Deficiency counts: 13
Deficiency counts: 7
Deficiency counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in Resident #31 fall incident and failure to supervise. |
| CNA #4 | Certified Nursing Assistant | Named in Resident #61 incontinent care failure. |
| CNA #5 | Certified Nursing Assistant | Named in Resident #5 ambulation failure. |
| LPN #1 | Licensed Practical Nurse | Responded to Resident #31 fall incident. |
| LPN #2 | Licensed Practical Nurse | Supervised CNA #4 and Resident #61 care. |
| Acting DNS | Acting Director of Nursing Services | Oversaw investigations and supervision related to Resident #31 fall. |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding Resident #31 fall and care plans. |
| Acting Administrator | Acting Administrator | Interviewed regarding staffing shortages. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 24, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 31, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
Annual inspection survey of San Simeon by the Sound Center for Nursing & Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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