Inspection Reports for
Swan Lake Nursing & Rehabilitation
25 Schoenfeld Blvd, Patchogue, NY, 11772
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 1, 2025
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, cleanliness and maintenance of the environment, comprehensive care planning, accident hazard prevention, and respiratory care. Specific issues included unsanitary conditions in resident bathrooms, failure to update care plans to reflect resident needs, unsafe hot water temperatures posing immediate jeopardy, and improper oxygen administration.
Deficiencies (5)
F 0550: The facility failed to ensure Resident #39 was treated with dignity and respect, as evidenced by unsanitary bathroom conditions and staff entering without knocking.
F 0584: The facility did not maintain a safe, clean, and homelike environment, including unsanitary second-floor shower rooms and Resident #39's bathroom with strong foul odors and non-functional toilet flushing.
F 0657: The facility failed to develop and revise Resident #24's comprehensive care plan to include the use of floor mats as an intervention for fall prevention.
F 0689: The facility failed to ensure Resident #39's environment was free from accident hazards by allowing bathroom sink water temperatures up to 136.2°F, posing immediate jeopardy to resident health and safety.
F 0695: The facility did not provide safe and appropriate respiratory care for Resident #10, who was ordered to receive two liters of oxygen but was observed receiving up to four liters per minute.
Report Facts
Water temperature: 136.2
Water temperature: 123
Water temperature: 127
Oxygen flow rate: 4
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Reported Resident #39 flushed clothes in the toilet causing flooding and noted the unsanitary condition of the portable commode and toilet. | |
| Director of Environmental Services | Disabled Resident #39's toilet flushing mechanism and monitored water temperatures; acknowledged water temperature exceeded regulatory limits. | |
| Licensed Practical Nurse Unit Manager #1 | Acknowledged knowledge of Resident #39's behavior and disabled toilet flushing; unaware of water temperature issues. | |
| Administrator | Was not notified that Resident #39 continued to use disabled toilet and was unaware of water temperature preference. | |
| Certified Nursing Assistant #4 | Reported Resident #39's behavior of washing clothes in the bathroom and the need to adjust hot water temperature. | |
| Medical Doctor #1 | Aware of Resident #39's behavior and stated water temperature of 136.2°F is too hot and could cause burns. | |
| Licensed Practical Nurse #1 | Monitored Resident #39's behavior of washing clothes and refusal of showers. | |
| Assistant Director of Nursing Services | Stated Resident #10 should receive oxygen as ordered and nurses should notify physician if oxygen needs increase. | |
| Director of Nursing Services | Unaware of Resident #39's water temperature preference and stated 136.2°F is too hot. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 31, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 7/24/2024 to 7/31/2024 to assess compliance with regulatory standards for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident property, verbal abuse by staff towards a resident, inadequate provision of activities based on resident preferences, insufficient supervision to prevent resident-to-resident altercations, and lack of physician orders for oxygen therapy for a resident.
Deficiencies (5)
F 0584: The facility failed to safeguard Resident #52's personal belongings as no inventory list was maintained, resulting in lost clothing after laundry.
F 0600: Certified Nurse Assistant #4 verbally abused and threatened Resident #68, causing emotional distress; the staff member was terminated after investigation.
F 0679: The facility failed to provide an ongoing activities program based on Resident #59's preferences, with no evening activities offered and limited participation documented.
F 0689: Resident #241 was not adequately supervised, leading to a physical altercation with Resident #38, despite care plans requiring line-of-sight supervision.
F 0842: Resident #74 received oxygen therapy without a current physician's order, violating medical record standards.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Oxygen therapy liters per minute: 3
Oxygen therapy liters per minute: 2
One-to-one visits: 7
Live entertainment programs: 3
Resident council/food committee meetings: 1
Games/puzzles attendance: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #4 | Named in verbal abuse and threat to Resident #68 | |
| Social Worker #1 | Interviewed regarding missing inventory for Resident #52 | |
| Director of Guest Services | Interviewed about missing inventory for Resident #52 | |
| Administrator | Interviewed about inventory and activity staffing | |
| Registered Nurse Supervisor #2 | Witnessed verbal abuse by Certified Nurse Assistant #4 | |
| Registered Nurse Supervisor #3 | Interviewed about verbal argument involving Certified Nurse Assistant #4 and Resident #68 | |
| Director of Nursing Services | Interviewed about abuse incident and supervision failure | |
| Recreation Aide #1 | Interviewed about activity provision and attendance for Resident #59 | |
| Assistant Director of Recreation | Interviewed about activity program limitations for Resident #59 | |
| Certified Nursing Assistant #6 | Witnessed altercation between Residents #241 and #38 | |
| Licensed Practical Nurse #3 | Interviewed about supervision of Resident #241 | |
| Resident Assistant #2 | Interviewed about supervision responsibilities on 4/7/2024 | |
| Certified Nurse Assistant #7 | Interviewed about supervision on 4/7/2024 | |
| Registered Nurse Supervisor #4 | Interviewed about supervision and incident on 4/7/2024 | |
| Licensed Practical Nurse Manager #1 | Interviewed about oxygen therapy orders for Resident #74 | |
| Nurse Practitioner #1 | Interviewed about oxygen therapy orders for Resident #74 | |
| Physician #2 | Interviewed about oxygen therapy orders for Resident #74 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Jul 31, 2024
Visit Reason
Inspection identified 5 standard health citations and 3 life safety code citations, all level 2 severity, mostly isolated issues corrected by September 2024.
Findings
Inspection identified 5 standard health citations and 3 life safety code citations, all level 2 severity, mostly isolated issues corrected by September 2024.
Deficiencies (8)
Activities meet interest/needs each resident
Free from abuse and neglect
Free of accident hazards/supervision/devices
Resident records - identifiable information
Safe/clean/comfortable/homelike environment
Doors with self-closing devices
Electrical systems - essential electric syste
Sprinkler system - maintenance and testing
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
The survey was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulations related to resident abuse prevention.
Findings
The facility failed to ensure that each resident was free from abuse. Certified Nurse Assistant #4 verbally abused and threatened Resident #68, causing the resident to feel scared and upset. The incident was substantiated and reported to the New York State Department of Health and local police.
Deficiencies (1)
F 0600: The facility did not protect Resident #68 from verbal abuse and threats by Certified Nurse Assistant #4. The resident was scared and upset after the interaction.
Report Facts
Residents reviewed for abuse: 3
Date of incident: Jul 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #4 | Named in verbal abuse and threat incident towards Resident #68 | |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Witnessed verbal abuse and directed CNA #4 to supervisor's office |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Interviewed regarding verbal argument between CNA #4 and Resident #68 |
| Director of Nursing Services | Director of Nursing Services | Interviewed and stated CNA #4 was terminated for verbal abuse |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, level 2 severity, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, level 2 severity, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 3, 2023
Visit Reason
One standard health citation for infection prevention & control, isolated scope, level 2 severity, corrected by February 2023.
Findings
One standard health citation for infection prevention & control, isolated scope, level 2 severity, corrected by February 2023.
Deficiencies (1)
Infection prevention & control
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Sep 23, 2022
Visit Reason
Multiple standard health citations including psychotropic medication use, accident hazards, physician supervision, nursing staff sufficiency, and environment; life safety citations for egress doors and electrical systems; all level 2 severity, mostly isolated or pattern scope, corrected by November 2022.
Findings
Multiple standard health citations including psychotropic medication use, accident hazards, physician supervision, nursing staff sufficiency, and environment; life safety citations for egress doors and electrical systems; all level 2 severity, mostly isolated or pattern scope, corrected by November 2022.
Deficiencies (7)
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Resident's care supervised by a physician
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Egress doors
Electrical systems - essential electric syste
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 23, 2022
Visit Reason
The inspection was a Recertification Survey conducted from 9/18/2022 to 9/23/2022 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in maintaining a clean and safe environment, ensuring accident hazard prevention, providing adequate physician supervision of medical care, maintaining sufficient nursing staff, and properly managing medications including psychotropic drugs. Several residents were affected by issues such as unclean rooms, unattended medications, unsafe use of razors, inadequate footwear for fall risk residents, and abrupt discontinuation of antipsychotic medication without proper monitoring.
Deficiencies (5)
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment on one nursing unit, evidenced by a vacant room with a commode containing feces and urine with flies present.
F 0689: The facility did not ensure the resident environment was free from accident hazards, including unattended medication, unsafe use of razors by a resident needing assistance, and a resident walking without appropriate footwear despite fall risk.
F 0710: The facility failed to ensure medical care was effectively supervised by a physician, as Resident #107's antipsychotic medication was abruptly discontinued without tapering or monitoring, and an inappropriate schizophrenia diagnosis was made.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in delayed diaper changes, incomplete wound care treatments, and inadequate assistance with activities of daily living.
F 0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications, abruptly discontinuing Seroquel for Resident #107 without monitoring for withdrawal symptoms.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Certified Nursing Assistants (CNA) staffing: 8
Certified Nursing Assistants (CNA) staffing: 4.5
Medication dosage: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration finding for leaving dissolved Potassium Chloride unattended |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding multiple findings including medication supervision, staffing, and environmental issues |
| Medical Director | Medical Director | Gave order to discontinue Seroquel abruptly and acknowledged lack of awareness of full dosage |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner (NP) | Interviewed regarding inappropriate Seroquel use and abrupt discontinuation risks |
| Attending Physician | Attending Physician | Interviewed regarding inappropriate schizophrenia diagnosis and Seroquel use |
| LPN #5 | Licensed Practical Nurse | Named in incomplete wound care treatment on 9/17/2022 |
| LPN #6 | Licensed Practical Nurse | Named in wound care treatment on 9/15/2022 |
| CNA #4 | Certified Nursing Assistant | Named in environmental and staffing findings related to commode cleaning and resident care |
| CNA #1 | Certified Nursing Assistant | Named in accident hazard findings related to Resident #65 footwear and Resident #56 shaving |
| LPN #3 | Licensed Practical Nurse | Named in accident hazard findings related to Resident #56 shaving and Resident #65 footwear |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, level 2 severity, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, level 2 severity, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
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