Inspection Reports for
Sands Point Center for Health and Rehabilitation
1440 Port Washington Blvd, Port Washington, NY, 11050
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Census: 161
Capacity: 180
Deficiencies: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with staffing requirements and overall facility operations.
Findings
The facility was found to be chronically understaffed, particularly with Certified Nurse Aides, failing to maintain the staffing ratios specified in the facility assessment. Residents and staff reported short staffing leading to reduced care such as missed showers and delayed meal assistance.
Deficiencies (1)
F 0725: The facility failed to provide enough nursing staff every day to meet the needs of every resident and did not have a licensed nurse in charge on each shift as required. Staffing ratios for Certified Nurse Aides were not maintained as per the facility assessment.
Report Facts
Licensed Capacity: 180
Average Daily Census: 161
Staffing Ratio: 1
Staffing Ratio: 1
Staffing Ratio: 1
Residents Reporting Short Staffing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #11 | Certified Nurse Aide | Interviewed regarding chronic understaffing and care issues |
| Certified Nurse Aide #12 | Certified Nurse Aide | Interviewed about staffing shortages and resident care delays |
| Certified Nurse Aide #10 | Certified Nurse Aide | Interviewed about day shift staffing and care impact |
| Staffing Coordinator | Staffing Coordinator | Interviewed about staffing schedules, par levels, and recruitment challenges |
| Director of Nursing Services | Director of Nursing Services | Interviewed about staffing levels, shortages, and direct care assistance |
| Administrator | Administrator | Interviewed acknowledging staffing shortages and callouts |
Inspection Report
Annual Inspection
Capacity: 180
Deficiencies: 7
Date: May 30, 2024
Visit Reason
The recertification survey was conducted to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including failure to implement comprehensive care plans for pressure ulcer prevention, improper use and monitoring of pressure relief air mattresses, unsafe resident environment hazards, inadequate nursing staffing levels, improper medication storage, and lapses in infection prevention practices.
Deficiencies (7)
F 0656: The facility failed to implement a comprehensive person-centered care plan with measurable objectives for Resident #86 at risk for pressure ulcers, who was observed not wearing physician-ordered heel boots.
F 0686: The facility did not ensure appropriate pressure ulcer care and prevention for Residents #124 and #126, including inaccurate air mattress weight settings not matching resident weights.
F 0689: The facility failed to maintain a safe environment by allowing Resident #140 to have an unsecured inhaler, Resident #58 to keep unauthorized cleaning chemicals, and Resident #91 to have an unsecured oxygen tank.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, with staffing ratios frequently exceeding the facility's own assessment standards.
F 0761: The facility failed to store all drugs and biologicals in locked compartments, as Resident #140's inhaler was left unsecured at bedside contrary to physician orders.
F 0838: The facility assessment did not include the overall number of qualified nursing staff necessary to meet resident needs competently during day-to-day operations.
F 0880: The facility failed to maintain an infection prevention program; Registered Nurse #5 did not perform hand hygiene after wound cleansing and allowed the wound to contact a dirty surface.
Report Facts
Facility licensed beds: 180
Resident Council complaints: 10
Air mattress weight setting: 325
Air mattress weight setting: 305
Resident weights: 166
Resident weights: 157
Wound measurements: 3
Wound measurements: 2
Wound measurements: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Registered Nurse | Performed wound care on Resident #81 and failed to perform hand hygiene |
| Licensed Practical Nurse #6 | Charge Nurse | Interviewed regarding medication storage and administration for Resident #140 |
| Registered Nurse #2 | Registered Nurse Unit Manager | Interviewed about air mattress monitoring and weight setting compliance |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about air mattress functioning checks |
| Director of Nursing Services | Director of Nursing | Interviewed about wound care, staffing shortages, and medication storage |
| Administrator | Facility Administrator | Interviewed about staffing shortages and facility assessment |
| Certified Nurse Aide #11 | Certified Nurse Aide | Interviewed about staffing shortages and resident care |
| Certified Nurse Aide #12 | Certified Nurse Aide | Interviewed about staffing shortages and resident care |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: May 30, 2024
Visit Reason
Complaint survey with 7 health and 2 life safety citations, all corrected by July/August 2024.
Findings
Complaint survey with 7 health and 2 life safety citations, all corrected by July/August 2024.
Deficiencies (9)
Develop/implement comprehensive care plan
Facility assessment
Free of accident hazards/supervision/devices
Infection prevention & control
Label/store drugs and biologicals
Sufficient nursing staff
Treatment/svcs to prevent/heal pressure ulcer
Electrical systems - essential electric syste
Gas and vacuum piped systems - warning system
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was initiated as an Abbreviated Survey based on Complaint #NY00310849 to investigate allegations related to improper use of physical restraints and failure to provide appropriate treatment and services to maintain residents' activities of daily living.
Complaint Details
Complaint #NY00310849 initiated the abbreviated survey due to concerns about improper use of physical restraints and failure to maintain residents' activities of daily living. The complaint was substantiated with findings related to restraint misuse and failure to follow ambulation orders.
Findings
The facility failed to ensure residents were free from physical restraints used for convenience or discipline, as evidenced by Resident #3 being restrained improperly. Additionally, the facility did not ensure that residents on the Floor Ambulation Program (Residents #1 and #2) were ambulated as ordered by the physician, with multiple documented occasions of non-compliance due to staffing issues and failure to report refusals.
Deficiencies (2)
F 0604: The facility did not ensure residents were free from physical restraints unless medically necessary. Resident #3 was found restrained by bed placement against a wall and objects confining movement, contrary to facility policy and care plans.
F 0676: The facility failed to provide appropriate treatment to maintain residents' ability to perform activities of daily living. Residents #1 and #2 were not ambulated according to their Floor Ambulation Program orders due to staffing shortages and failure to report refusals.
Report Facts
Documentation Survey Report NA (Not Applicable) entries: 7
Documentation Survey Report NA (Not Applicable) entries: 5
Documentation Survey Report NA (Not Applicable) entries: 4
Documentation Survey Report NA (Not Applicable) entries: 6
Documentation Survey Report NA (Not Applicable) entries: 4
Documentation Survey Report NA (Not Applicable) entries: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding restraint use and resident bed placement. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about resident bed placement and restraint observations. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed about resident bed placement and restraint observations. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about failure to complete Floor Ambulation Program due to staffing. |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed about multiple occasions of not completing Floor Ambulation Program due to staffing shortages. |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed about failure to ambulate Resident #2 and failure to document refusals. |
| Acting Director of Nursing Services #1 | Acting Director of Nursing Services | Interviewed regarding restraint policy and incident with Resident #3. |
| Acting Director of Nursing Services #2 | Acting Director of Nursing Services | Interviewed regarding Floor Ambulation Program compliance and reporting procedures. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: May 22, 2023
Visit Reason
Complaint survey with 2 health citations related to activities of daily living and physical restraints, corrected by July 2023.
Findings
Complaint survey with 2 health citations related to activities of daily living and physical restraints, corrected by July 2023.
Deficiencies (2)
Activities daily living (adls)/mntn abilities
Right to be free from physical restraints
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 31, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated survey initiated on 8/24/2022 and completed on 8/31/2022, including investigation of Complaint #NY 00299247 regarding inadequate investigation of resident accidents.
Complaint Details
Complaint #NY 00299247 was investigated, focusing on inadequate investigation of resident falls and incomplete staff statements in accident/incident reports. The complaint was substantiated with findings of incomplete documentation and failure to properly investigate accidents.
Findings
The facility failed to ensure thorough investigation of resident falls to rule out abuse or neglect, with incomplete or inaccurate staff statements in accident/incident reports for two residents. Additionally, the facility failed to maintain proper infection prevention and control during wound care for one resident.
Deficiencies (2)
F 0610: The facility did not ensure accident investigations included accurate and complete written statements from staff for Resident #270's fall on 7/8/2022 and Resident #106's unwitnessed falls on 6/20/2022, 6/28/2022, and 8/12/2022.
F 0880: The facility failed to implement infection prevention during wound care for Resident #101, including failure to sanitize the overbed table, failure to wash hands and change gloves after cleansing the wound, and placing the cleansed wound directly back onto the heel bootie.
Report Facts
Residents reviewed for Accidents: 6
Residents reviewed for Pressure Ulcers: 3
Dates of falls for Resident #106: 3
Date of fall for Resident #270: 1
Stage 4 pressure ulcer size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Nurse who responded to Resident #270's fall and whose written statement was incomplete in the A/I report. | |
| Certified Nursing Assistant (CNA) #1 | Assisted charge nurse with Resident #270 and was not present at time of fall. | |
| Director of Nursing Services (DNS) | Reviewed A/I reports and interviewed staff regarding fall investigations. | |
| Certified Nursing Assistant (CNA) #2 | Assigned aide for Resident #106 on 6/20/2022 shift and provided incomplete statements in A/I reports. | |
| Registered Nurse (RN) Supervisor (RN #4) | Discovered Resident #106 on floor on 6/28/2022. | |
| Certified Nursing Assistant (CNA) #3 | Discovered Resident #106 on floor on 6/28/2022. | |
| LPN #2 | Responded to Resident #106 fall on 8/12/2022 after maintenance worker alerted nursing supervisor. | |
| RN #1 | Nurse Infection Preventionist who identified infection control breach during wound care. | |
| RN #2 | Performed wound care on Resident #101 with infection control breaches. | |
| RN Infection Preventionist (RN #5) | Interviewed regarding infection control breach and need for re-education. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Aug 31, 2022
Visit Reason
Complaint survey with 2 health and 8 life safety citations, all corrected by October 2022.
Findings
Complaint survey with 2 health and 8 life safety citations, all corrected by October 2022.
Deficiencies (9)
Infection prevention & control
Investigate/prevent/correct alleged violation
Building construction type and height
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Emergency lighting
Hazardous areas - enclosure
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 22, 2019
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, inaccurate resident assessments, incomplete baseline care plans, incomplete implementation of care plans, medication errors, lack of physician review of significant weight loss, incomplete pharmacy medication regimen review policy, and inaccurate medical records documentation.
Deficiencies (8)
F 0558: The facility failed to ensure call bells were within reach for residents #99 and #59 as required by their care plans.
F 0641: Resident assessments were inaccurate; Resident #46's prosthesis was not documented and Resident #162's discharge status was incorrectly recorded.
F 0655: The facility did not develop a baseline Contact Isolation Care Plan within 48 hours of admission for Resident #261.
F 0656: The facility failed to implement comprehensive care plans; Resident #263 was observed without hearing aids and Resident #121's 30-minute monitoring was inconsistently documented.
F 0658: Resident #262 received conflicting medications for diarrhea and constipation on the same days, contrary to physician orders.
F 0711: Resident #71's significant weight loss was not addressed by the primary physician during multiple visits.
F 0756: The facility's Pharmacy Medication Regimen Review policy did not specify time frames for completion of review steps.
F 0842: Resident #95's medical records contained inconsistent catheter size documentation between physician orders, care plans, and treatment records.
Report Facts
Weight loss percentage: 5.28
Weight loss percentage: 6.1
Medication administration count: 3
Catheter size: 26
Catheter size: 20
Catheter size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Registered Nurse (RN) Unit Manager | Interviewed regarding call bell accessibility and baseline care plan development. |
| Not provided | Assistant Director of Nursing Services (ADNS) | Interviewed regarding call bell accessibility and baseline care plan development. |
| Not provided | Registered Nurse (RN) MDS Director | Interviewed regarding resident assessments and MDS coding errors. |
| Not provided | Licensed Practical Nurse (LPN) Medication Nurse | Interviewed regarding medication administration for Resident #262. |
| Not provided | Medical Director | Interviewed regarding physician review of weight loss and medical record accuracy. |
| Not provided | Registered Dietitian (RD) | Interviewed regarding weight loss monitoring and physician notification. |
| Not provided | Unit Charge Nurse (LPN) | Interviewed regarding catheter size documentation discrepancies. |
| Not provided | Visiting Physician | Interviewed regarding catheter change and size confirmation. |
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