Inspection Reports for Lynbrook Restorative Therapy and Nursing
243 Atlantic Avenue, Lynbrook, NY, 11563
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 11, 2024, identified deficiencies related to pharmaceutical services, including controlled substance record-keeping, medication labeling and storage, and infection prevention and control practices. Earlier inspections showed mostly clean results with occasional issues in sprinkler system installation and infection control, some of which were corrected. Inspectors cited recurring themes around medication management and infection control protocols, including failure to follow contact isolation precautions and discrepancies in medication counts. A substantiated complaint investigation in 2021 found failures in notifying family of condition changes, wound care documentation, and infection control practices, but no enforcement actions or fines were listed in the available reports. The facility’s inspection history shows some ongoing challenges in medication and infection control areas, with no clear trend of improvement or worsening in recent years.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 11, 2024
Visit Reason
The Recertification Survey was initiated on 10/7/2024 and completed on 10/11/2024 to assess compliance with regulatory requirements for Lynbrook Restorative Therapy and Nursing.
Findings
The facility was found deficient in pharmaceutical services related to controlled substance record-keeping, labeling and storage of drugs and biologicals, and infection prevention and control practices. Specific issues included discrepancies in controlled substance counts, undated opened supplement bottles, and failure to follow contact isolation precautions.
Deficiencies (5)
Discrepancy in controlled substance count for Resident #29's Lacosamide medication; the administration record indicated 56 tablets but only 55 tablets were present.
Failure to document administration of controlled medication immediately after administration by Licensed Practical Nurse #1.
Opened bottle of Lipopolysaccharide-Sugar Free supplement on Unit 2 medication cart was not dated to indicate when first opened.
Failure to discard undated opened supplement bottle as per manufacturer's guidelines.
Certified Nursing Assistant #1 entered Resident #58's room on contact isolation without wearing required Personal Protective Equipment (gown and gloves) and without performing hand hygiene.
Report Facts
Tablets discrepancy: 1
Supplement dosage: 30
Supplement discard timeframe: 60
Antibiotic dosage: 1
Antibiotic dosage: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in medication administration documentation deficiency and undated supplement bottle | |
| Registered Nurse #2 | Nurse Supervisor for Unit 2 | Stated expectations for controlled substance record updates and medication cart checks |
| Director of Nursing Services | Stated expectations for medication documentation and infection control compliance | |
| Pharmacist #1 | Stated supplement discard guidelines and expectations | |
| Registered Nurse #1 | Unit Supervisor | Stated expectations for contact isolation precautions compliance |
| Certified Nursing Assistant #1 | Observed breaching infection control by not wearing PPE and not performing hand hygiene | |
| Infection Preventionist | Stated requirements for contact isolation precautions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Oct 11, 2024
Visit Reason
Deficiencies found in infection prevention & control, medication labeling, pharmacy services, fire alarm system testing and maintenance, physical environment, and sprinkler system installation; all corrected.
Findings
Deficiencies found in infection prevention & control, medication labeling, pharmacy services, fire alarm system testing and maintenance, physical environment, and sprinkler system installation; all corrected.
Deficiencies (6)
Infection prevention & control
Label/store drugs and biologicals
Pharmacy srvcs/procedures/pharmacist/records
Fire alarm system - testing and maintenance
Physical environment
Sprinkler system - installation
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 17, 2023
Visit Reason
The document is an annual inspection report for Lynbrook Restorative Therapy and Nursing conducted by the Department of Health & Human Services and Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during this inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 17, 2023
Visit Reason
One deficiency found in sprinkler system installation; corrected.
Findings
One deficiency found in sprinkler system installation; corrected.
Deficiencies (1)
Sprinkler system - installation
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 2, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey triggered by Complaint #NY00272086 to investigate allegations related to failure to notify family of resident condition changes, inadequate pressure ulcer care, and infection control deficiencies.
Complaint Details
Complaint #NY00272086 was substantiated based on findings that the facility did not notify the Health Care Proxy for Resident #139 of a change in condition, failed to provide thorough wound assessments for Resident #36, and did not follow infection control protocols for Resident #289 with C-Diff.
Findings
The facility failed to promptly notify the family of a resident's change in condition related to intravenous fluids, did not ensure thorough weekly wound assessments for pressure ulcers, and did not maintain proper infection prevention and control practices, including failure to don appropriate PPE and perform hand hygiene during medication administration to a resident with C-Diff.
Deficiencies (3)
Failure to promptly notify the resident's family of a change in medical condition involving intravenous fluids.
Inadequate weekly wound assessments for pressure ulcers, lacking complete documentation of wound characteristics.
Failure to maintain an infection prevention and control program, including not donning appropriate PPE and not performing hand hygiene during medication pass for a resident with C-Diff.
Report Facts
Blood Urea Nitrogen (BUN) level: 42
Sodium (NA) level: 149
IV fluid rate: 75
Dates of weekly wound assessments: 28
Vancomycin dosage: 125
Date of positive C. Difficile toxin lab report: May 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #7 | Registered Nurse Supervisor | Interviewed and acknowledged failure to notify family of resident's change in condition |
| Director of Nursing Services | Director of Nursing | Interviewed and stated family should be notified of any change in condition and thorough wound assessments should be documented |
| RN #2 | Wound Care Registered Nurse | Interviewed regarding wound assessment responsibilities and documentation |
| RN #3 | Wound Care Registered Nurse | Interviewed and admitted wound assessments were not thorough |
| Wound Care Physician | Physician | Interviewed and acknowledged poor documentation and lack of access to EMR |
| LPN #1 | Licensed Practical Nurse | Observed not donning PPE and not performing hand hygiene during medication pass for resident with C-Diff; admitted oversight |
| RN Infection Preventionist | Infection Preventionist | Interviewed regarding PPE requirements and hand hygiene recommendations for C-Diff resident |
| RN Supervisors #2 and #3 | Registered Nurse Supervisors | Interviewed and stated PPE should have been worn during medication pass for C-Diff resident |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
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