Inspection Reports for
South Shore Rehabilitation and Nursing Center
275 W Merrick Road, Freeport, NY, 11520
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
190% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Aug 15, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 08/11/2025 to 08/15/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents, medication administration errors, inadequate assistance with activities of daily living, improper pressure ulcer care, incomplete pharmacist medication regimen reviews, insufficient infection control practices, lack of unit-specific staffing assessment, and ineffective pest control measures.
Deficiencies (10)
10 NYCRR 415.11(c)(1) - The facility failed to develop and implement comprehensive care plans with measurable objectives for residents with skin infections and cardiovascular conditions.
10 NYCRR 415.11(c)(3)(i) - Registered Nurse did not follow the five rights of medication administration and failed to check gastrostomy tube placement before medication administration.
10 NYCRR 415.12(a)(3) - Resident did not receive scheduled showers twice weekly as per care plan due to combative behavior without proper documentation or intervention.
10 NYCRR 415.12 - Resident with hypotension did not receive prescribed medication as ordered and blood pressure monitoring was inadequate.
10 NYCRR 415.12(c)(1) - Air mattress weight settings were not adjusted to reflect residents' actual weights, risking pressure ulcer development.
10 NYCRR 415.18(a) - Nurses failed to check gastrostomy tube placement prior to medication administration via feeding tube.
10 NYCRR 415.18(c)(2) - Physician responses to pharmacist medication regimen reviews were not documented or acted upon for multiple residents.
10 NYCRR 415.26 - Facility assessment did not consider nursing staffing needs specific to each resident unit.
10 NYCRR 415.19(a)(1-3)(b)(4) - Staff failed to adhere to contact precautions and infection control protocols, including improper use of personal protective equipment and hand hygiene.
10 NYCRR 415.29 (J)(5) - Facility did not maintain an effective pest control program; kitchen exit door had a gap allowing pest entry.
Report Facts
Medication non-administration: 16
Medication non-administration: 26
Resident weight: 84.7
Resident weight: 115
Medication regimen review dates: 3
Shower frequency: 1
Medication administration observation date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in care plan deficiency for Resident #14's Methicillin-Resistant Staphylococcus Aureus Infection. |
| Registered Nurse #4 | Unit Nursing Supervisor | Named in care plan deficiency for Resident #32's cardiovascular care plan. |
| Director of Nursing Services | Director of Nursing Services and Infection Preventionist | Named in multiple findings including care plan deficiencies, medication administration, infection control, and facility assessment. |
| Registered Nurse #6 | Registered Nurse | Named in medication administration observation for Resident #75 with errors. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in bathing care deficiency for Resident #24. |
| Assistant Director of Nursing/Educator | Assistant Director of Nursing/Educator | Named in medication administration and infection control findings. |
| Pharmacist #1 | Pharmacist | Named in medication regimen review deficiency. |
| Primary Physician #1 | Primary Physician | Named in medication administration and medication regimen review deficiencies. |
| Medical Director | Medical Director | Named in medication regimen review deficiency. |
| Director of Environmental Services | Director of Environmental Services | Named in pest control deficiency. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in infection control deficiency for failure to use PPE and hand hygiene. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in infection control deficiency for failure to use PPE and hand hygiene. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with care standards for residents, specifically focusing on activities of daily living.
Findings
The facility failed to ensure that Resident #24 received the necessary care for activities of daily living, including scheduled showers and grooming, resulting in minimal harm or potential for actual harm. The resident did not receive showers as per the care plan due to behavioral issues, and documentation was incomplete regarding these deviations.
Deficiencies (1)
F 0677: The facility did not provide scheduled showers twice weekly to Resident #24 as required by the care plan, resulting in inadequate personal hygiene. The resident was observed unshaven and with mussed hair, and staff failed to document behavioral reasons for missed showers.
Report Facts
Shower frequency: 1
Date of survey completion: Aug 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #5 | Registered Nurse Supervisor | Interviewed regarding missed showers and resident care. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided care to Resident #24 and reported reasons for missed showers. |
| Assistant Director of Nursing/Nurse Educator | Assistant Director of Nursing/Nurse Educator | Reviewed Resident #24's medical record and care plan. |
| Director of Nursing Services | Director of Nursing Services | Initiated care plan additions and provided statements on care requirements. |
| Physical Therapist Rehabilitation Department Director #1 | Physical Therapist Rehabilitation Department Director | Provided information on resident's dependency for showers and transfers. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Aug 15, 2025
Visit Reason
Complaint Survey with 10 health citations and 1 life safety code citation, mostly Level 2 severity, no actual harm but minor discomfort potential. One life safety code deficiency corrected as of September 4, 2025.
Findings
Complaint Survey with 10 health citations and 1 life safety code citation, mostly Level 2 severity, no actual harm but minor discomfort potential. One life safety code deficiency corrected as of September 4, 2025.
Deficiencies (11)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Drug regimen review, report irregular, act on
Facility assessment
Infection prevention & control
Maintains effective pest control program
Pharmacy srvcs/procedures/pharmacist/records
Quality of care
Services provided meet professional standards
Treatment/svcs to prevent/heal pressure ulcer
Physical environment
Inspection Report
Recertification
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Extended Survey to assess compliance with regulatory requirements and investigate a complaint.
Complaint Details
Complaint #NY 00326378 was investigated, revealing the facility was not administered to use resources effectively and allowed unlicensed nursing practice beyond waiver expiration.
Findings
The facility failed to timely report an injury of unknown origin to the New York State Department of Health within 24 hours as required. Additionally, the facility allowed an unlicensed graduate nurse to work as a registered nurse beyond the expiration of the Public Health Emergency waiver.
Deficiencies (2)
F 0609: The facility did not report an injury of unknown origin for Resident #35 to the New York State Department of Health within 24 hours as required. The injury was identified on 8/5/2023 but reported on 8/7/2023.
F 0835: The facility allowed an unlicensed graduate nurse to work as a registered nurse until almost four months beyond the expiration of the Public Health Emergency waiver, violating nursing licensure requirements.
Report Facts
Residents affected: 1
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Responsible for reporting injury of unknown origin and managing nursing staff licensure | |
| Assistant Director of Nursing/Risk Manager | Completed investigation related to injury of unknown origin for Resident #35 | |
| Unlicensed Graduate Nurse #1 | Unlicensed Nurse | Worked as Registered Nurse without license beyond waiver expiration |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Apr 11, 2024
Visit Reason
Complaint Survey with 11 health citations and 6 life safety code citations, mostly Level 2 severity, no actual harm but minor discomfort potential. Multiple deficiencies corrected as of May and June 2024.
Findings
Complaint Survey with 11 health citations and 6 life safety code citations, mostly Level 2 severity, no actual harm but minor discomfort potential. Multiple deficiencies corrected as of May and June 2024.
Deficiencies (17)
Administration
Develop/implement comprehensive care plan
Dialysis
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Maintains effective pest control program
Reporting of alleged violations
Resident records - identifiable information
Safe/clean/comfortable/homelike environment
Treatment/svcs to prevent/heal pressure ulcer
Tube feeding mgmt/restore eating skills
Corridor - doors
Development of ep policies and procedures
Gas and vacuum piped systems - inspection and
Gas equipment - cylinder and container storag
Means of egress - general
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Apr 11, 2024
Visit Reason
The survey was a Recertification Survey initiated on 4/7/2024 and completed on 4/11/2024 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including maintenance of a homelike environment, timely reporting of injuries, development and implementation of care plans, pressure ulcer care, feeding tube care, dialysis care, food safety, staff licensing compliance, medication record accuracy, infection control, and pest control.
Deficiencies (11)
F 0584: The facility failed to maintain a homelike environment with unrepaired water damage and holes in walls in multiple resident rooms, including Resident #60's room.
F 0609: The facility did not timely report an injury of unknown origin for Resident #35 to the New York State Department of Health within 24 hours as required.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #47, who was observed multiple times without a physician-ordered hand roll.
F 0686: The facility did not ensure appropriate pressure ulcer care for Resident #55, including failure to adjust the air mattress weight setting to the resident's actual weight, impairing pressure relief.
F 0693: The facility failed to label enteral feeding bags with resident information and feeding start time for Resident #302 during tube feeding administration.
F 0698: The facility did not ensure Resident #31 received dialysis care consistent with professional standards, failing to apply warm compresses as recommended by the dialysis center.
F 0812: The facility stored frozen egg product thawing at room temperature in the kitchen, contrary to food safety standards.
F 0835: The facility allowed an unlicensed graduate nurse to work as a registered nurse for almost four months beyond the Public Health Emergency waiver expiration date.
F 0842: The facility did not accurately document Resident #39's self-administered insulin and blood glucose readings, and nurses failed to verify and monitor the resident's medication administration.
F 0880: The facility failed to maintain infection prevention and control for Resident #55 on contact precautions for Candida Auris; the Maintenance Director entered the resident's room without personal protective equipment.
F 0925: The facility did not adequately address pest control in the kitchen, with a half-inch gap under the exit door allowing potential vermin entry and recent sightings of mice.
Report Facts
Work order number: 1625
Blood sugar reading: 255
Insulin units administered: 8
Air mattress weight setting: 240
Pest control visits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Medication Nurse | Documented inaccurate blood sugar reading and insulin dosage for Resident #39 |
| Licensed Practical Nurse #3 | Medication Nurse | Regularly assigned nurse for Resident #39, failed to verify blood sugar and insulin administration |
| Registered Nurse #4 | Unit Supervisor | Supervised nursing staff responsible for Resident #39's medication administration |
| Maintenance Director #1 | Director of Maintenance | Entered Resident #55's room without PPE and handled mattress despite contact precautions |
| Wound Care Nurse #1 | Licensed Practical Nurse | Reported air mattress malfunction for Resident #55 |
| Director of Nursing Services | Director of Nursing | Interviewed regarding multiple deficiencies including injury reporting, dialysis care, infection control, and medication documentation |
| Administrator | Facility Administrator | Interviewed regarding unlicensed nurse working beyond waiver expiration |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of abuse involving Resident #1 by a Certified Nursing Aide (CNA #1) during care on 4/7/2023.
Findings
The facility failed to ensure that Resident #1 was free from abuse when CNA #1 squeezed the resident's scrotum to control combative behavior. The investigation initially concluded no abuse, but further statements confirmed CNA #1 admitted to the act, constituting abuse. CNA #1 was removed and resigned.
Deficiencies (1)
F 0600: Protect each resident from all types of abuse including physical abuse and neglect. CNA #1 squeezed Resident #1's scrotum during care to control combative behavior, constituting abuse.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in abuse finding for squeezing Resident #1's scrotum. |
| LPN #1 | Licensed Practical Nurse | Witnessed and documented events related to Resident #1 and CNA #1. |
| LPN #2 | Licensed Practical Nurse | Provided statements confirming CNA #1 admitted to squeezing Resident #1's scrotum. |
| RN #1 | Registered Nurse | Provided statements confirming CNA #1 admitted to squeezing Resident #1's scrotum. |
| DNS | Director of Nursing Services | Notified of incident, conducted investigation, and terminated CNA #1's employment. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
Complaint Survey with 1 health citation related to abuse and neglect, Level 2 severity, no actual harm but minor discomfort potential. Deficiency corrected as of July 17, 2023.
Findings
Complaint Survey with 1 health citation related to abuse and neglect, Level 2 severity, no actual harm but minor discomfort potential. Deficiency corrected as of July 17, 2023.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 19, 2022
Visit Reason
The inspection was a Recertification Survey conducted from 7/12/2022 to 7/19/2022 to assess compliance with regulatory requirements for South Shore Rehabilitation and Nursing Center.
Findings
The facility failed to develop and implement a comprehensive care plan with measurable goals for a resident's Stage II pressure ulcer and did not ensure medication error rates were below five percent. Specifically, medication administration errors were observed related to eye drop medications for one resident.
Deficiencies (3)
F 0656: The facility did not ensure a comprehensive care plan with measurable goals and interventions was completed for Resident #43's Stage II pressure ulcer identified on 7/5/2022.
F 0759: The facility did not ensure its medication error rate was below five percent based on observation of 25 medication administrations, including incorrect timing and administration of eye drop medications for Resident #26.
F 0760: The facility did not ensure Resident #26 was free from significant medication errors, as four different eye drop medications were administered without appropriate spacing, contrary to physician orders and facility policy.
Report Facts
Medication administrations observed: 25
Medication error rate: 5
Number of residents reviewed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in deficiency related to incomplete care plan for pressure ulcer |
| RN #2 | Registered Nurse | Named in medication error findings related to eye drop administration |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding care plan and medication administration policies |
| Resident #26's Physician | Physician and Medical Director | Interviewed regarding medication administration timing and orders |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jul 19, 2022
Visit Reason
Complaint Survey with 3 health citations and 10 life safety code citations, mostly Level 2 severity, no actual harm but minor discomfort potential. Deficiencies corrected mostly by October 2022.
Findings
Complaint Survey with 3 health citations and 10 life safety code citations, mostly Level 2 severity, no actual harm but minor discomfort potential. Deficiencies corrected mostly by October 2022.
Deficiencies (13)
Develop/implement comprehensive care plan
Free of medication error rts 5 prcnt or more
Residents are free of significant med errors
Egress doors
Electrical equipment - power cords and extens
Gas and vacuum piped systems - warning system
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Hvac
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network, Level 2 severity, no actual harm but minor discomfort potential.
Deficiencies (1)
Reporting - national health safety network
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