Inspection Reports for
Rockville Skilled Nursing & Rehabilitation Center, LLC
50 Maine Avenue, Rockville Centre, NY, 11570
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 5
Date: Jun 27, 2025
Visit Reason
Certification Survey identified deficiencies in essential equipment, pharmacy services, professional standards, building construction, hazardous areas, and life safety systems with most corrected by August 2025.
Findings
Certification Survey identified deficiencies in essential equipment, pharmacy services, professional standards, building construction, hazardous areas, and life safety systems with most corrected by August 2025.
Deficiencies (5)
Essential equipment, safe operating condition
Pharmacy srvcs/procedures/pharmacist/records
Services provided meet professional standards
Building construction type and height
Hazardous areas - enclosure
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 27, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 6/23/2025 to 6/27/2025 to assess compliance with professional standards of quality, pharmaceutical services, and equipment safety at the nursing facility.
Findings
The facility failed to ensure accurate medication administration for Resident #58 due to pharmacy dispensing errors and nursing documentation inaccuracies. Additionally, the facility did not maintain patient care equipment safely, as evidenced by malfunctioning air mattress equipment for Resident #161.
Deficiencies (3)
F 0658: The facility did not ensure services met professional standards of quality. Resident #58 was prescribed 150 mg Topiramate but received 100 mg due to pharmacy dispensing errors and inaccurate nursing documentation.
F 0755: The facility failed to provide pharmaceutical services to meet resident needs. Resident #58's 150 mg Topiramate order was not filled by the pharmacy, resulting in continued administration of the discontinued 100 mg dose for about 20 days.
F 0908: The facility did not maintain all patient care equipment safely. Resident #161's air mattress pump showed a low-pressure warning light multiple times before replacement, indicating unsafe equipment conditions.
Report Facts
Medication administration record days: 20
Weight setting range: 600
Weight setting: 220
Resident weight: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Prepared medications for Resident #58 and noted blister pack issues during medication pass observation. | |
| Licensed Practical Nurse #2 | Administered 100 mg Topiramate but signed medication record indicating 150 mg for Resident #58. | |
| Licensed Practical Nurse #3 | Administered 100 mg Topiramate but signed medication record indicating 150 mg for Resident #58. | |
| Pharmacist #1 | Reported pharmacy dispensing error and oversight regarding Topiramate orders for Resident #58. | |
| Director of Nursing Services | Acknowledged medication errors and initiated investigation and pharmacy review for Resident #58. | |
| Licensed Practical Nurse #4 | Unit medication/treatment nurse | Observed flashing low-pressure light on Resident #161's air mattress pump and was unsure of next steps. |
| Maintenance Director #1 | Replaced Resident #161's malfunctioning air mattress after being alerted to low-pressure light. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Dec 22, 2023
Visit Reason
Complaint Survey found deficiencies in resident care supervision, respiratory care, pressure ulcer treatment, building construction, electrical systems, elevators, exit signage, fire drills, portable fire extinguishers, and sprinkler system maintenance, mostly corrected by early 2024.
Findings
Complaint Survey found deficiencies in resident care supervision, respiratory care, pressure ulcer treatment, building construction, electrical systems, elevators, exit signage, fire drills, portable fire extinguishers, and sprinkler system maintenance, mostly corrected by early 2024.
Deficiencies (11)
Resident's care supervised by a physician
Respiratory/tracheostomy care and suctioning
Treatment/svcs to prevent/heal pressure ulcer
Building construction type and height
Electrical systems - essential electric syste
Elevators
Exit signage
Fire drills
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 22, 2023
Visit Reason
The inspection was a Recertification and Abbreviated Survey initiated on 2023-12-19 and completed on 2023-12-22 to assess compliance with regulatory standards, including a complaint investigation (Complaint #NY00326729).
Complaint Details
The survey included a complaint investigation (Complaint #NY00326729) related to pressure ulcer care and prevention for Resident #68. The complaint was substantiated based on findings.
Findings
The facility failed to ensure that Resident #68 received a physician-ordered wheelchair gel cushion in a timely manner, resulting in the development of a Stage 2 sacral pressure ulcer. Documentation and care plans did not reflect the implementation of the pressure-relieving device until nearly two months after the order.
Deficiencies (1)
10 NYCRR 415.12(c)(2) The facility did not provide the pressure relieving gel cushion ordered on 8/26/2023 to Resident #68 until 10/19/2023, contributing to a Stage 2 sacral pressure ulcer.
Report Facts
Residents affected: 3
Residents affected: 1
Wound measurement length: 0.6
Wound measurement width: 0.6
Wound measurement depth: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding documentation and care plan updates for pressure ulcer interventions |
| Primary Physician #3 | Primary Physician and Medical Director | Interviewed regarding expectations for staff to follow physician orders for pressure relieving devices |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding provision and documentation of pressure relieving devices |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding care plan documentation and implementation of pressure relieving cushion |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with regulatory standards for nursing care and facility operations.
Findings
The facility was found deficient in providing timely pressure ulcer care, ensuring physician orders for oxygen therapy, and including necessary parameters in medication orders. Deficiencies involved delayed provision of pressure-relieving devices, oxygen therapy without physician orders, and incomplete medication order parameters.
Deficiencies (3)
F 0686: The facility failed to provide a pressure-relieving gel cushion to Resident #68 from the physician's order date 8/26/2023 until 10/19/2023, resulting in a Stage 2 sacral pressure ulcer.
F 0695: Resident #317 received oxygen therapy from admission on 9/28/2023 until 12/19/2023 without a physician's order, which was only obtained after surveyor observation.
F 0710: Resident #318 had a physician's order to administer Midodrine without blood pressure parameters for holding medication or when to notify the physician, which was corrected only after observation and intervention.
Report Facts
Residents reviewed for Pressure Ulcers: 3
Residents reviewed for Respiratory Care: 4
Residents reviewed during Medication Administration task: 7
Pressure ulcer wound size: 0.6
Midodrine dosage: 2.5
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed medication administration and interviewed regarding Midodrine order. |
| Primary Physician #3 | Medical Director | Interviewed regarding expectation of staff to follow physician orders for Resident #68. |
| Director of Rehabilitation | Interviewed about provision of pressure-relieving devices for Resident #68. | |
| Director of Nursing Services | Interviewed regarding nursing care and documentation for Residents #68, #317, and #318. | |
| Physician #2 | Primary Care Physician | Interviewed regarding Midodrine order parameters for Resident #318. |
| Medical Doctor #1 | Physician | Interviewed about oversight of oxygen therapy orders for Resident #317. |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Dec 9, 2021
Visit Reason
The survey was conducted as a Recertification Survey and Abbreviated Survey triggered by complaints to assess compliance with regulatory requirements.
Complaint Details
Complaint # NY 00261362 and Complaint # NY 00255243 triggered the abbreviated survey and recertification survey.
Findings
The facility failed to notify the physician of a resident's abnormal blood pressure, delayed administration of prescribed pain medication due to prescription issues, and did not fully implement pressure ulcer care interventions including proper offloading of heels and wound care procedures.
Deficiencies (4)
F 0580: The facility did not notify the physician when Resident #205 had a significantly low blood pressure of 83/46 mmHg as ordered.
F 0656: Resident #105 did not receive Methadone pain medication timely due to pharmacy prescription delays, and LPN #1 failed to cleanse Resident #158's heel ulcer with Normal Saline as ordered.
F 0686: Resident #158's pressure ulcer care was inadequate as heels were not consistently offloaded and heel boots were not applied timely per wound care recommendations.
F 0710: The facility did not ensure timely physician orders and prescriptions for Resident #105's pain medication, resulting in a week-long delay in medication administration.
Report Facts
Date of survey completion: Dec 9, 2021
Blood pressure reading: 83
Blood pressure reading: 46
Braden Scale score: 9
Pressure ulcer size: 4
Pressure ulcer size: 6
Methadone supply delay: 6
Methadone emergency supply: 10
Methadone prescription: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | DNS | Interviewed regarding failure to notify physician of low BP and wound care procedures |
| Medical Director | Physician | Interviewed regarding expectations for nurse notification and medication orders |
| LPN #1 | Licensed Practical Nurse | Observed failing to cleanse wound as ordered and improper pressure ulcer care |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding application of heel boots and pressure ulcer care |
| Director of Quality | Pharmacy Director | Interviewed regarding delays in Methadone prescription and delivery |
| Administrator | Facility Administrator | Interviewed regarding medication delay and facility responsibilities |
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