Inspection Reports for Nassau Rehabilitation and Nursing Center
1 Greenwich St, Hempstead, NY 11550, United States, NY, 11550
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Capacity: 102
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with ensuring food was prepared in a form designed to meet individual resident needs, following concerns about diet order discrepancies for Resident #1.
Findings
The facility failed to ensure food was prepared according to the prescribed modified consistency diet for Resident #1, resulting in the resident becoming unresponsive due to upper airway obstruction from food and subsequent death. The facility diet order incorrectly documented a chopped consistency with thin liquids instead of the hospital-ordered minced moist consistency with thickened liquids. This deficiency posed immediate jeopardy to resident health and safety and had the potential to affect all 102 residents with modified consistency diets.
Deficiencies (1)
Failure to ensure food was prepared in a form designed to meet individual resident needs, specifically incorrect diet consistency for Resident #1 leading to upper airway obstruction and death.
Report Facts
Residents affected: 102
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Admissions Nurse | Stated diet was transcribed incorrectly for Resident #1 |
| Certified Nursing Assistant #1 | Reported not assisting Resident #1 with breakfast meal on 09/10/2024 | |
| Licensed Practical Nurse #1 | Observed Resident #1's food tray prior to becoming unresponsive | |
| Director of Nursing | Confirmed diet transcription error by Registered Nurse #1 | |
| Medical Doctor #2 | Provided medical opinion on timing and cause of food obstruction |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 8, 2025
Visit Reason
One immediate jeopardy deficiency related to food form to meet individual needs; corrected by June 25, 2025.
Findings
One immediate jeopardy deficiency related to food form to meet individual needs; corrected by June 25, 2025.
Deficiencies (1)
Food in form to meet individual needs
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Apr 28, 2025
Visit Reason
Multiple level 2 deficiencies in standard health and life safety code citations, all corrected by June 25, 2025 or earlier.
Findings
Multiple level 2 deficiencies in standard health and life safety code citations, all corrected by June 25, 2025 or earlier.
Deficiencies (8)
ADL care provided for dependent residents
Facility assessment
Label/store drugs and biologicals
Resident rights/exercise of rights
Treatment/services to prevent/heal pressure ulcer
Cooking facilities
Elevators
Fire drills
Inspection Report
Annual Inspection
Capacity: 280
Deficiencies: 5
Date: Apr 21, 2025
Visit Reason
The Recertification Survey was initiated on 4/21/2025 and completed on 4/28/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including dignity and respect during meal assistance, inadequate assistance with activities of daily living, improper air mattress weight settings for pressure ulcer prevention, unsecured medication storage, and incomplete facility-wide staffing assessment documentation.
Deficiencies (5)
Staff were observed standing over residents while assisting with meals, contrary to facility policy requiring staff to sit to maintain dignity.
Resident #232 did not receive necessary assistance with incontinence care and personal hygiene as per care plan, resulting in strong urine odor and lack of care documentation.
Air mattress weight settings for Residents #176 and #196 were not adjusted according to residents' actual weights, potentially compromising pressure ulcer prevention.
Resident #28 was found with an unlabeled, unsecured bottle of cough medication without a physician's order or assessment for self-administration.
Facility assessment did not specify required numbers of Certified Nursing Assistants and Licensed Practical Nurses per unit per shift, lacking detailed staffing plan documentation.
Report Facts
Facility licensed beds: 280
Weekly nursing staff hours - Registered Nurses: 375
Weekly nursing staff hours - Licensed Practical Nurses: 1365
Weekly nursing staff hours - Certified Nursing Assistants: 4080
Air mattress weight setting for Resident #176: 450
Air mattress weight setting for Resident #196: 850
Certified Nursing Assistants required on 7AM-3PM shift (long-term care units): 4
Certified Nursing Assistants required on 7AM-3PM shift (2 South and 5 North units): 5
Certified Nursing Assistants required on 3PM-11PM shift (2 South and long-term units): 4
Certified Nursing Assistants required on 3PM-11PM shift (5 North unit): 5
Certified Nursing Assistants required on 11PM-7AM shift (2 South and 5 North units): 3
Certified Nursing Assistants required on 11PM-7AM shift (long-term units): 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Occupational Therapist Assistant #1 | Observed standing over Resident #78 while assisting with lunch meal; admitted should have been seated. | |
| Transporter #1 | Observed standing over Resident #155 while assisting with lunch meal; unaware they should sit. | |
| Licensed Practical Nurse #5 | Stated staff should not stand over residents when assisting with meals. | |
| Infection Preventionist/Registered Nurse Educator | Stated staff assisting residents during meals should sit, not stand. | |
| Director of Nursing Services | Stated staff should not stand while assisting residents with meals; also commented on air mattress education and staffing levels. | |
| Certified Nursing Assistant #2 | Reported providing morning care to Resident #232 and noted urine odor due to lack of overnight care. | |
| Certified Nursing Assistant #3 | Documented Resident #232 was continent and did not provide personal hygiene care during overnight shift. | |
| Certified Nursing Assistant #4 | Reported Resident #232's room smelled of urine and care was refused due to resident's anger. | |
| Certified Nursing Assistant #5 | Provided morning care to Resident #232 and noted strong urine odor upon entering room. | |
| Licensed Practical Nurse #3 | Acknowledged care should have been provided to Resident #232 and that CNA should have reported refusal. | |
| Wound Care Registered Nurse | Responsible for evaluating need for air mattress and stated mattress settings should match resident weight and comfort. | |
| Director of Maintenance | Responsible for installing air mattresses but not adjusting weight settings. | |
| Licensed Practical Nurse #2 | Medication and Treatment Nurse | Did not adjust air mattress weight settings due to lack of knowledge. |
| Staff Educator | Stated no in-service training provided on air mattress care; responsibility lies with Maintenance and Wound Care Nurse. | |
| Registered Nurse #2 | Unit Manager | Stated mattress weight setting should be based on resident comfort; noted no documentation of mattress checks. |
| Registered Nurse #1 | Unit Manager | Noted Resident #28 was not assessed for self-medication and should not have had unattended medication. |
| Licensed Practical Nurse #1 | Medication and Treatment Nurse | Did not see unattended cough medicine on Resident #28's nightstand; stated resident should not have unattended meds. |
| Licensed Pharmacist | Described potential side effects of Safetussin Cough and Chest Congestion medication. | |
| Staffing Coordinator #1 | Stated nursing staffing levels were memorized and not documented. | |
| Administrator | Unaware of how staffing levels were determined and that staffing levels per unit per shift should be documented. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 23, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 1/16/2024 to 1/23/2024 to assess compliance with regulatory requirements for Nassau Rehabilitation & Nursing Center.
Findings
The facility was found deficient in several areas including inadequate supervision to prevent accidents for a high fall-risk resident, improper care and administration of enteral feeding, failure to ensure physician oversight for significant weight loss, and inappropriate use of psychotropic medication for a resident without proper indication.
Deficiencies (4)
Failure to ensure adequate supervision to prevent accidents for Resident #26, a high fall-risk resident who was observed toileting unassisted contrary to care plan.
Failure to provide appropriate care for Resident #184 with enteral feeding, including lying flat during feeding and early administration of tube feeding against physician orders.
Failure to ensure medical care supervision by physician for Resident #75 with significant weight loss not addressed in medical record.
Inappropriate use of psychotropic medication (Risperdal) for Resident #75 to address medication refusal, without proper indication or assessment of capacity.
Report Facts
Fall Risk Assessment Score: 13
Weight Loss Percentage: 8.5
Tube Feeding Volume: 237
Tube Feeding Frequency: 4
Risperidone Dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Unit Manager | Interviewed regarding Resident #26's supervision and care |
| Physical Therapist #3 | Physical Therapist | Interviewed regarding Resident #26's rehabilitation and transfer abilities |
| Registered Nurse #4 | Inservice Coordinator | Interviewed regarding staff responsibilities for Resident #26 |
| Director of Nursing Services | Director of Nursing | Interviewed regarding supervision and medical care oversight |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding administration of tube feeding to Resident #184 |
| Registered Dietitian #1 | Registered Dietitian | Interviewed regarding significant weight loss monitoring for Resident #75 |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding medical care and psychotropic medication for Resident #75 |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Interviewed regarding psychiatric assessment and medication for Resident #75 |
| Social Worker #1 | Social Worker | Interviewed regarding communication and medication compliance for Resident #75 |
| Registered Nurse #2 | Nurse Manager | Documented and interviewed regarding Resident #75's medication refusal and psychiatric consult |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed regarding supervision of Resident #26 |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding care of Resident #75 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Jan 23, 2024
Visit Reason
Several level 2 standard health and life safety code deficiencies, all corrected by March 2024.
Findings
Several level 2 standard health and life safety code deficiencies, all corrected by March 2024.
Deficiencies (6)
Free from unnecessary psychotropic meds/prn use
Free of accident hazards/supervision/devices
Resident's care supervised by a physician
Tube feeding management/restore eating skills
Electrical systems - essential electric system
Sprinkler system - maintenance and testing
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 7, 2022
Visit Reason
One level 2 deficiency related to reporting to national health safety network; not corrected as of report date.
Findings
One level 2 deficiency related to reporting to national health safety network; not corrected as of report date.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 21, 2021
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory standards for Nassau Rehabilitation & Nursing Center.
Findings
The facility was found deficient in multiple areas including environmental safety hazards, respiratory care without physician orders, failure to post daily nurse staffing information, and inadequate meal/snack scheduling. Specific issues included a sharp metal hazard in a resident's room, oxygen administration without physician order, lack of posted nurse staffing information, and excessive time lapse between evening meal and breakfast without adequate snacks.
Deficiencies (4)
Sharp metal protruding from heating/ventilation unit in Resident #124's room creating accident hazard.
Resident #494 received oxygen therapy at 4 L/min via nasal cannula without a Physician's order.
Daily nursing staffing information was not posted in a prominent area accessible to residents and visitors.
Facility did not ensure no more than 14 hours between evening meal and breakfast; Resident #88 experienced a 15-hour lapse and inconsistent provision of midnight snacks.
Report Facts
Length of protruding metal: 2
Oxygen flow rate: 4
Time lapse between meals: 15
Residents affected by deficiencies: 7
Residents affected by respiratory care deficiency: 1
Residents affected by staffing posting deficiency: Many
Residents affected by meal/snack deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Worker #8 | Maintenance Worker | Observed and measured protruding metal in Resident #124's room; unaware of heating unit issue prior to observation. |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding heating unit hazard and stated unit would be replaced immediately. |
| LPN #5 | Licensed Practical Nurse | Assigned nurse for Resident #494; unaware of lack of physician order for oxygen therapy. |
| RN #4 | Registered Nurse | Interviewed about Resident #494's oxygen therapy without physician order. |
| Director of Nursing Services | Director of Nursing Services | Unaware of oxygen therapy without physician order and lack of posted nurse staffing information. |
| Primary Care Physician | Primary Care Physician | Unaware Resident #494 needed oxygen and was not contacted for orders. |
| Staffing Coordinator | Staffing Coordinator | Unaware of requirement to post daily nursing staffing information. |
| Dietitian | Dietitian | Interviewed about lack of substantial bedtime snacks and Resident #88's non-compliance with diet. |
| Food Service Director | Food Service Director | Aware of meal delivery times and 15-hour lapse but unaware of requirement for no more than 14 hours between meals. |
| Director of Recreation | Director of Recreation | Reviewed resident council minutes; no discussion of meal time lapse documented. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Dec 21, 2021
Visit Reason
Multiple level 1 and 2 deficiencies in standard health and life safety code citations, all corrected by January 31, 2022.
Findings
Multiple level 1 and 2 deficiencies in standard health and life safety code citations, all corrected by January 31, 2022.
Deficiencies (11)
Free of accident hazards/supervision/devices
Frequency of meals/snacks at bedtime
Posted nurse staffing information
Respiratory/tracheostomy care and suctioning
Corridor - doors
Electrical equipment - power cords and extensions
Elevators
Emergency lighting
Hazardous areas - enclosure
Physical environment
Standards of construction for new nursing home
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