Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Edge At Port Jefferson For Rehab And Nrsg during CMS and state inspections, most recent first.
A resident with heart failure, acute kidney injury, and pneumonia exhibited critical symptoms and lab results, but was not sent to the hospital immediately as ordered. The resident was found unresponsive and later pronounced deceased. Interviews revealed communication failures and a lack of adherence to facility policy, resulting in Immediate Jeopardy.
Three residents at risk for aspiration were not provided with appropriate care. A resident with a PEG tube was given oral medications despite being NPO. Another resident on a puree diet ingested a dog biscuit, leading to coughing and stridor. A third resident, also NPO, received oral medications instead of through the feeding tube. Staff failed to notify the physician to change orders, and attempts to contact the Physician Assistant were unsuccessful.
Two residents in a facility were administered oral medications despite having orders for nothing by mouth (NPO) and feeding tubes. The physician failed to review and document the residents' care appropriately, leading to inappropriate medication orders and administration. Attempts to contact the responsible Physician Assistant were unsuccessful, and a Nurse Practitioner failed to discontinue a medication as recommended by a pharmacy review.
A resident experienced significant health changes, including fever, tachycardia, hypotension, and critical lab results, but the facility failed to notify the resident's representative as required by policy. Despite the initiation of a sepsis protocol and administration of antibiotics, the representative was not informed until after the resident's passing. Interviews with staff confirmed the lack of communication, and the Director of Nursing Services acknowledged the oversight.
The facility failed to initiate the bowel protocol for several residents who experienced extended periods without documented bowel movements, despite having care plans that required monitoring for constipation. Interviews revealed a lack of adherence to the protocol and awareness of the residents' bowel records among staff.
Failure to Provide Timely Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident, leading to a critical situation. The resident, who had been readmitted with heart failure, acute kidney injury, and pneumonia, exhibited symptoms of fever and tachycardia. Despite critical lab results indicating a dangerously low hemoglobin level and other concerning signs, the resident was not sent to the hospital immediately as ordered by the Nurse Practitioner. Instead, the Registered Nurse Supervisor documented that the resident would be sent to the hospital the following morning. The resident's condition deteriorated, and they were found unresponsive, pulseless, and without respirations in the early hours of the morning. Despite efforts to resuscitate, the resident was pronounced deceased shortly after. Interviews with facility staff revealed a breakdown in communication and a failure to act on critical lab results and vital signs, which were not indicative of stable conditions. The Nurse Practitioner and Physician both indicated that the resident should have been sent to the hospital immediately given the critical lab results and unstable vital signs. The facility's policy required timely medical assessments and appropriate responses to acute changes in a resident's condition. However, the failure to adhere to these standards resulted in Immediate Jeopardy, with the likelihood of serious harm or death for the resident. The Director of Nursing confirmed that the resident's condition was not stable, contradicting the decision to delay the transfer to the hospital.
Failure to Prevent Aspiration Risks in Residents
Penalty
Summary
The facility failed to provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for three residents reviewed for accidents. Resident #2, identified as high risk for aspiration, was supposed to be fed via a PEG tube, yet physician orders documented medications to be administered by mouth. Despite the speech therapy evaluation recommending nothing by mouth (NPO), the physician orders did not reflect this, and medications were administered orally. Multiple attempts to contact the Physician Assistant regarding this issue were unsuccessful. Resident #3, who was at risk for aspiration and had a physician's order for a puree diet, was given a dog biscuit during pet therapy, which the resident ingested. This led to coughing and abnormal lung sounds (stridor). The incident was documented, and the Registered Nurse Supervisor was notified, but the resident refused vital signs at the time. The Speech Language Pathologist confirmed that the resident could not tolerate solid foods, indicating a risk for aspiration. Resident #5, also at risk for aspiration, was evaluated with recommendations for nothing by mouth (NPO) and was on a tube feed diet. However, the medication administration records indicated multiple medications were given orally. The Director of Nursing and Medical Doctor confirmed that residents assessed as NPO should have medications administered through the feeding tube, and staff should have notified the physician to change the order. Multiple attempts to reach the Physician Assistant regarding this issue were also unsuccessful.
Failure to Review and Document Resident Care Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, including treatments, at each visit, leading to inappropriate medication orders and administration for two residents. Resident #2, who was admitted with orders for nothing by mouth (NPO) and a feeding tube, did not have an NPO order included in the admission orders. Despite recommendations from a speech therapist, the resident was prescribed and administered oral medications such as Tylenol and Tamiflu, which contradicted the NPO status. Attempts to contact the responsible Physician Assistant were unsuccessful. Resident #5 was also admitted with orders for nothing by mouth and a feeding tube. However, the resident was evaluated by a Physician Assistant who ordered oral medications, including Amoxicillin, Prednisone, and Tamiflu, which were administered despite the NPO status. Additionally, a pharmacy review recommended discontinuing Proscar and starting Rapaflo, but the Nurse Practitioner failed to discontinue Proscar, resulting in the resident receiving both medications for 30 days. The facility's Physician's Visit policy requires the attending physician to review the resident's total program of care and document appropriately at each visit. However, this was not adhered to, as evidenced by the inappropriate medication orders and administration for Residents #2 and #5. The Medical Director acknowledged the oversight and emphasized the need for physician orders to reflect the residents' intake status, particularly for those deemed NPO.
Failure to Notify Resident's Representative of Significant Health Changes
Penalty
Summary
The facility failed to ensure that a resident's representative was immediately informed of significant changes in the resident's condition, as required by their policy. This deficiency was identified during an Abbreviated Survey for one resident who experienced a decline in health status. The resident presented with fever, tachycardia, hypotension, and critical lab results, including a hemoglobin level of 4.9g/dL, which is significantly below the normal range. Despite these critical changes, the resident's representative was not notified of the condition or the interventions provided. The facility's policy mandates prompt notification of the resident, their attending physician, and representative in the event of a significant change in condition. However, documentation and interviews revealed that the facility staff did not adhere to this policy. The resident's representative was not informed of the initiation of a sepsis protocol or the administration of antibiotics. Additionally, the representative was unaware of the resident's symptoms and critical lab results until after the resident's passing. Interviews with facility staff, including nurses and the Director of Nursing Services, confirmed the lack of communication with the resident's representative. Staff members acknowledged the failure to notify the representative and could not provide a reason for this oversight. The Director of Nursing Services stated that the facility staff should have informed the resident's representative about the changes in the resident's medical condition and the new interventions.
Failure to Initiate Bowel Protocol for Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. This deficiency was identified during an abbreviated survey for six residents, focusing on the lack of documented bowel movements over several consecutive days. Specifically, three residents were noted to have no documented bowel movements for periods ranging from five to eight days, despite having care plans that required monitoring and intervention for constipation. Resident #1, who had a history of Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Iron Deficiency Anemia, was admitted with a care plan that included interventions for constipation. However, there was no documented evidence of bowel movements for eight days, and the facility's bowel protocol was not initiated. Similarly, Resident #2 and Resident #3 also experienced five consecutive days without documented bowel movements, and the bowel protocol was not initiated in a timely manner for these residents either. Interviews with facility staff revealed a lack of awareness and adherence to the bowel protocol, with several staff members unaware of the full extent of the residents' bowel records. The Director of Nursing Services and the Medical Director both acknowledged that the bowel protocol should have been initiated after two to three days without a bowel movement, but this was not done. The facility's policy did not clearly outline the steps to be taken in the event of constipation, contributing to the oversight and resulting in the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Port Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| John T Mather Memorial Hosp T C U | 1.2 mi | — | 0 | 0 |
| Allegria Nursing & Rehab Center Of Port Jefferson | 2.2 mi | — | 0 | 0 |
| Jefferson's Ferry | 2.7 mi | — | 0 | 0 |
| Long Island State Veterans Home | 3 mi | — | 0 | 0 |
| St James Rehabilitation & Healthcare Center | 5.5 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.