Sands Point Center for Health and Rehabilitation

Inspectors wroteBased on record review and interviews the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on five (5) (Unit 1 Center, Unit 1 North, Unit 1 West, Unit 2 Center, and Unit 2 West) of five (5) units reviewed for the Sufficient Nursing Staffing Task. Specifically, the Payroll-Based Journal Staffing Data Report indicated the facility had excessively low weekend staffing for Quarter one (1) through Quarter four (4) for Fiscal Year 2025 and for Quarter one (1) for Fiscal Year 2026. A random sampling of the facility nursing staffing assignments did not reflect the staffing numbers as indicated in the facility assessment for the Certified Nursing Assistants and Registered Nurses. [...]

Inspectors wroteBased on record review, and staff interviews the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development, and transmission of communicable diseases and infections. This was identified during the Infection Control Task. Specifically, the facility did not provide documented evidence of testing all portions of the potable water system for Legionnaires' and other Waterborne pathogens. The facility did not provide documents describing the building's water distribution systems to identify legionella sampling points.

Inspectors wroteBased on record review and interviews the facility did not ensure a resident assessment was completed to accurately reflect each resident's status. This was identified for one (1) of two (2) residents reviewed for Tube Feeding. Specifically, Resident #1 was admitted to the facility with a percutaneous endoscopic gastrostomy (PEG) tube (a type of feeding tube inserted into the stomach). The admission Minimum Data Set assessment dated [DATE] did not reflect the resident had a feeding tube while a resident. The finding is:A facility policy titled MDS last reviewed 10/01/2025 documented the Minimum Data Set 3.0 process requires input form the health care team to complete the designated areas in a timely and accurate fashion in accordance with state and federal regulations. [...]

Inspectors wroteBased on record review and interviews, during the abbreviated survey (2729430), the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was identified for two (2) (Resident #115 and Resident #41) of four (4) residents reviewed for accidents. Specifically, on 1/28/2026 Resident #41 exhibited anger when Resident #115 approached Resident #41 in the dining room. Certified Nursing Aide #3 identified Resident #41's trigger and removed Resident #115 from the dining room; however, did not notify the nurse of Resident #41's behavior or the need to monitor Resident #115 to prevent them from going near Resident #41. Shortly afterwards, Resident #115 returned to the dining room and reapproached Resident #41. Resident #41 got angrier and hit Resident #115 on the head with an empty meal tray. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that each resident was free from significant medication errors. This was identified for one (1) (Resident #15) of five (5) residents observed during medication administration task. Specifically, during the medication administration observation for Resident #15, Licensed Practical Nurse #1 crushed the extended-release (designed to release the medication slowly over time) Metoprolol Succinate tablet (a medication which slows the heart rate and reduces cardiac workload). The directions on the extended-release Metoprolol Succinate blister pack indicated Swallow Whole, Do Not Chew Or Crush. The finding is:The facility policy titled Medication Pass, revised 01/2025, documented medications are administered safely and timely as per the physician's orders. Know the diagnosis and indication for every medication. [...]

Inspectors wroteBased on observations, record review, and interviews the facility did not ensure that drugs and biologicals used in the facility were labelled with currently accepted professional principles for one (1) (Resident #127) of two residents reviewed for tube feeding, and for one (1) (Resident #33) of one (1) resident reviewed for Hydration. Specifically, 1) on 03/09/2026, Resident #127 was in bed receiving the physician ordered tube feeding; however, the tube feeding bottle did not have the resident name, room number, start time of the tube feeding, flow rate, or name of nurse who started the tube feeding; and 2) Resident #33 had a physician's order to receive intravenous hydration. On two separate observations the intravenous fluid (administered directly into a vein) bag was not labeled.

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that medical records were maintained in accordance with professional standards of practice and were complete and accurately documented. This was identified for one (1) (Resident #127) of two (2) residents reviewed for respiratory care. Specifically, Resident #127 had an as-needed order for oxygen administration. On multiple occasions the resident was administered the as-needed oxygen, but there was no documentation in the medical record that the oxygen was administered as per the physician's orders. The finding is:The untitled facility policy addressing oxygen delivery, dated 12/2025, documented it is the policy of the facility that residents requiring supplemental oxygen have it administered as per the physician's order. If determined, the Physician will order oxygen therapy either continuous or as needed. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00329525) initiated on 5/22/2024 and completed on 5/30/2024, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Payroll-Based Journal Staffing Data Report indicated that the facility had a 1-star staffing rating; Ten (Resident #8, #20, #55, #59, #66, #72, #99, #113, #117, and #119) out of Ten residents in the Resident Council Task reported complaints about short staffing; and a random sampling of facility nursing staffing assignments did not reflect the staffing ratio as indicated in the facility assessment for the Certified Nurse Aides.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024 the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #86) of three residents reviewed for Pressure Ulcers. Specifically, Resident #86, who was assessed to be at risk for developing pressure ulcers, was observed in bed on multiple occasions not wearing the physician-ordered protective heel boots. The finding is: The facility's undated policy titled Pressure Ulcer documented to always maintain the highest degree of skin and tissue integrity. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident # 126 and Resident #124) of three residents reviewed for Pressure Ulcers. Specifically, 1) Resident #126 had a Physician's order for an alternating pressure relief air mattress secondary to a pressure ulcer of the sacral region. During multiple observations, the adjustable weight setting on the air mattress was not set accurately according to the resident's weight. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024, the facility did not ensure that the resident environment remained as free of accident hazards as is possible. This was identified for three (Resident #58, #91, and #140) of five residents reviewed for Accidents. Specifically, 1) Resident #140 was observed with a Symbicort inhaler medication at the bedside; however, the resident was not assessed to self-administer their medications 2) Resident #58 was observed on two occasions with air freshener spray and a bottle of multi-surface disinfectant cleaner spray at the bedside table; and 3) Resident #91 had an oxygen E-Cylinder oxygen tank freely standing next to the bed with no metal rack or movable caddy to secure the tank.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for one (Resident #140) of five residents reviewed for Accidents. Specifically, on 5/22/2024 at 11:55 AM and 3:00 PM, Resident #140 was observed with a Symbicort 160 micrograms to 4.5 micrograms per actuation Hydrofluoroalkane aerosol inhaler stored at the bedside and there was no staff in the vicinity. Additionally, Resident #140 was not assessed to self-administer their medications. The finding is: The undated facility's Medication Storage policy documented that medications must be stored and secured in locked storage areas in compliance with State and Federal requirements and professional standards of practice. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident #81) of one resident reviewed for skin conditions. Specifically, during the wound care observation of Resident #81's left heel ulcer, performed by Registered Nurse #5, the nurse did not perform hand hygiene after cleaning the wound and allowed the cleansed heel wound to come in direct contact with a dirty surface (the bed sheet). The finding is: The facility policy titled Clean Dressing, revised 12/2023, documented to ensure that procedures are followed to prevent the wound from becoming worse and to promote healing. [...]

Inspectors wroteBased on record review and interview during the Recertification Survey initiated on 5/22/2024 and completed on 5/30/2024, the facility did not ensure that the facility assessment included what resources were necessary to care for its residents competently during day-to-day operations. Specifically, the facility assessment did not include the overall number of qualified nursing staff to meet each resident's needs. The finding is: The facility assessment dated [DATE] documented the following staffing plan: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated survey (Complaint #NY 00299247) initiated on 8/24/2022 and completed on 8/31/2022 the facility did not ensure that accidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. This was identified for two (Resident #270 and Resident #106) of 6 residents reviewed for Accidents. Specifically, 1) Resident #270 had a fall on 7/8/2022 in their (Resident #270) room; however, the accident and incident (A/I) report did not include an accurate written statement from Licensed Practical Nurse (LPN) #1, the nurse who responded to the resident's fall; and 2) Resident #106 had unwitnessed falls on 6/20/2022, 6/28/2022, and 8/12/2022; however, the A/I reports did not have complete statements from the staff members who discovered the resident on the floor.

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 8/24/2022 and completed 8/31/2022 the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #101) of 3 residents reviewed for Pressure Ulcers. Specifically, during the wound care observation for Resident #101, the Registered Nurse (RN) #2 did not sanitize the overbed table prior to placing the clean wound care supplies on the table; did not wash their hands and change their gloves after cleansing the left heel wound prior to applying the ordered treatment; and placed the cleansed left heel wound directly back onto the heel bootie without a barrier. The finding is: [...]