Inspection Reports for
Ross Center for Nursing and Rehabilitation
839 Suffolk Avenue, Brentwood, NY, 11717
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 20, 2026
Visit Reason
The inspection was conducted in response to a complaint alleging verbal abuse of Resident #116 by a staff member at Ross Center for Nursing and Rehabilitation.
Complaint Details
The complaint involved Resident #116 alleging verbal abuse by a Certified Nursing Assistant on 11/22/2025. The allegation was reported to Licensed Practical Nurse #5 and then to Registered Nurse #2, who delayed notifying administration and the New York State Department of Health beyond the required two-hour timeframe. The facility investigated and removed the alleged perpetrator from the schedule. The abuse allegation was ultimately not substantiated.
Findings
The facility failed to report the abuse allegation to the administration and the New York State Department of Health within the required two-hour timeframe. The investigation concluded there was no cause to believe abuse occurred, but the reporting delays violated policy requirements.
Deficiencies (1)
F 0609: The facility did not ensure timely reporting of suspected abuse, neglect, or theft to proper authorities. Registered Nurse #2 delayed reporting Resident #116's verbal abuse allegation by more than 24 hours.
Report Facts
Residents Affected: 1
Reporting delay: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Nursing Supervisor | Delayed reporting abuse allegation to administration and state authorities |
| Licensed Practical Nurse #5 | Received abuse allegation from Resident #116 and reported to Registered Nurse #2 | |
| Certified Nursing Assistant #6 | Alleged perpetrator removed from schedule; denied abuse | |
| Assistant Director of Nursing Services | Signed incident report and notified state authorities | |
| Director of Nursing Services | Not involved in incident reporting due to vacation; commented on policy deficiencies |
Inspection Report
Capacity: 60
Deficiencies: 3
Date: Jan 17, 2025
Visit Reason
Covid-19 Survey with 2 standard health citations and 1 life safety code citation, all corrected by February 2025.
Findings
Covid-19 Survey with 2 standard health citations and 1 life safety code citation, all corrected by February 2025.
Deficiencies (3)
Essential equipment, safe operating condition
Safe/clean/comfortable/homelike environment
Portable space heaters
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as an abbreviated survey triggered by a complaint regarding cold temperatures in the East unit of the facility affecting residents.
Complaint Details
Complaint investigation NY00368340 was substantiated, triggered by reports of cold temperatures in the East unit affecting residents' comfort and health.
Findings
The facility failed to maintain safe and comfortable temperatures in resident rooms, shower rooms, and common areas across multiple units. Heating systems were malfunctioning or absent, windows were drafty, and there was no consistent maintenance or temperature monitoring system in place.
Deficiencies (2)
F 0584: The facility did not ensure residents' right to a safe, clean, and comfortable environment, with multiple residents exposed to cold temperatures below 70 degrees Fahrenheit and inadequate heating measures.
F 0908: The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, including heating systems and windows, resulting in temperatures below required ranges in resident rooms, shower rooms, and common areas.
Report Facts
Residents reviewed for Quality of Care: 18
Temperature readings: 63
Temperature readings: 70
Temperature readings: 60
Temperature readings: 42
Temperature readings: 44
Temperature readings: 67.1
Temperature readings: 66
Temperature logs reviewed: 2
Temperature log date ranges: 4
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 13
Date: Nov 1, 2024
Visit Reason
Certification Survey with 11 standard health citations and 2 life safety code citations, all corrected by December 2024 or earlier.
Findings
Certification Survey with 11 standard health citations and 2 life safety code citations, all corrected by December 2024 or earlier.
Deficiencies (13)
Accuracy of assessments
Administration
Care plan timing and revision
Food procurement,store/prepare/serve-sanitary
Label/store drugs and biologicals
Nutritive value/appear, palatable/prefer temp
Physical environment
Qapi prgm/plan, disclosure/good faith attmpt
Request/refuse/dscntnue trmnt;formlte adv dir
Resident call system
Safe/clean/comfortable/homelike environment
Dietary services
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 1, 2024
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to honor residents' advance directives accurately, inadequate hot water temperatures in resident areas, inaccurate Minimum Data Set assessments and care plans, improper medication storage, serving food at unsafe temperatures, malfunctioning call bell systems, and ineffective Quality Assurance Performance Improvement processes.
Deficiencies (10)
F 0578: The facility did not ensure Resident #18's advance directives were accurately identified and honored, with conflicting identification bands and documentation.
F 0584: Hot water temperatures on the East unit were below the required 90-110°F range, with temperatures as low as 79°F in resident rooms and 81°F in shower rooms.
F 0641: The Minimum Data Set assessment for Resident #27 did not accurately reflect the resident's advanced directive of Do Not Hospitalize.
F 0657: The comprehensive care plans for Residents #18 and #27 were not updated timely to reflect changes in advance directives.
F 0761: Medications were improperly stored in Unit North Medication Cart #1, which contained non-medication items such as hearing aids, tape, and rubber bands.
F 0804: Residents reported receiving cold food during meals; hot food temperatures on three units were below the required 135°F, with some as low as 95°F.
F 0812: The dishwashing machine did not maintain proper wash and rinse temperatures (110°F observed vs. required 120°F wash and 140°F rinse), risking inadequate sanitation.
F 0835: The facility was not effectively administered to ensure food served was at acceptable temperatures, with ongoing resident complaints and no effective corrective actions.
F 0865: The Quality Assurance Performance Improvement committee failed to address and act on repeated complaints about cold food service, lacking documented plans for improvement.
F 0919: The call bell system in Resident #102's bathroom was not functioning, resulting in a fall with injury when the resident attempted to transfer without assistance.
Report Facts
Dishmachine temperature: 110
Hot water temperature: 79
Hot water temperature: 81
Food temperature: 95
Food temperature: 113
Food temperature: 115
Food temperature: 122
Food temperature: 128
Food temperature: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Confirmed Resident #18 was not wearing an identification band and had two different bands on wheelchair. | |
| Social Worker #2 | Responsible for ensuring correct identification of advance directive status on identification bands. | |
| Director of Nursing Services | Stated facility policies do not use red dots on ID bands for advance directives and confirmed deficiencies in care plans and call bell system. | |
| Minimum Data Set Coordinator | Acknowledged inaccuracies in Minimum Data Set assessments for Resident #27. | |
| Social Worker #1 | Responsible for completing and ensuring accuracy of advanced directives on Minimum Data Set and care plans. | |
| Registered Nurse Manager #1 | Observed medication cart with non-medication items and stated items were related to medical needs. | |
| Licensed Practical Nurse #2 | Stated observed non-medication items in medication cart had to stay because they were health-related. | |
| Food Service Director | Acknowledged resident complaints about cold food, lack of monitoring on units, and ineffective QAPI actions. | |
| Dietician | Recommended methods to maintain hot food temperatures which were not implemented. | |
| Director of Recreation | Recorded Resident Council meetings and acknowledged cold food concerns were not documented properly. | |
| Dietary Aide #1 | Operated dishmachine and reported initial temperature readings. | |
| Maintenance Personnel #1 | Reported call bell in Resident #102's bathroom was not lighting up and had to be replaced. | |
| Licensed Practical Nurse #1 | Reported Resident #102's fall after call bell malfunction. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 6, 2023
Visit Reason
The survey was initiated as a Recertification Survey and Abbreviated Survey related to Complaint #NY00324033 concerning notification procedures for a resident's change in treatment.
Complaint Details
Complaint #NY00324033 was investigated and substantiated. The facility failed to notify the resident's Designated Representative about the initiation of IV antibiotic therapy.
Findings
The facility failed to ensure that the Designated Representative of Resident #56 was notified when intravenous antibiotic therapy was initiated. Interviews with nursing staff and the physician confirmed the notification was not made as required by policy.
Deficiencies (1)
F 0580: The facility did not notify Resident #56's Designated Representative when intravenous Ceftriaxone antibiotic therapy was started, violating the resident's right to be informed in advance of treatment changes.
Report Facts
Duration of antibiotic therapy: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | RN Supervisor | Responsible for notifying the resident's Designated Representative; inserted IV line for Resident #56 |
| Licensed Practical Nurse #3 | Charge Nurse | On duty when IV antibiotic was started; did not notify Designated Representative |
| Licensed Practical Nurse #1 | Medication Nurse | Administered IV antibiotic; stated RN Supervisor was responsible for notification |
| Physician #2 | Resident's currently assigned Physician | Interviewed regarding notification responsibility; did not prescribe the IV antibiotic |
| Director of Nursing Services | Director of Nursing Services | Interviewed about notification responsibilities and facility policy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Oct 6, 2023
Visit Reason
Complaint Survey with 5 standard health citations and 2 life safety code citations, all corrected by December 2023 or earlier.
Findings
Complaint Survey with 5 standard health citations and 2 life safety code citations, all corrected by December 2023 or earlier.
Deficiencies (7)
Free from abuse and neglect
Notify of changes (injury/decline/room, etc. )
Reporting of alleged violations
Resident's care supervised by a physician
Services provided meet professional standards
Fire alarm system - testing and maintenance
Ramps and other exits
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 6, 2023
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey including complaint investigation, conducted to assess compliance with regulatory standards for nursing home care.
Complaint Details
Complaint investigation included failure to notify a resident's designated representative about new treatment and failure to protect residents from abuse.
Findings
The facility was found deficient in notifying a resident's designated representative about new treatment, ensuring residents' right to be free from abuse, timely reporting of resident-to-resident altercations, and providing professional standards of care including appropriate psychiatric diagnosis and medication management.
Deficiencies (5)
F 0580: The facility failed to notify Resident #56's designated representative when intravenous antibiotic therapy was initiated, violating the resident's right to be informed in advance of treatment changes.
F 0600: The facility did not ensure Resident #53 was free from abuse after Resident #69 slapped them during a resident-to-resident altercation, and failed to implement effective interventions to prevent recurrence.
F 0609: The facility failed to timely report a resident-to-resident altercation involving Residents #53 and #69 to the New York State Department of Health as required.
F 0658: The facility did not ensure professional standards of quality in psychiatric care for Resident #75, who was prescribed antipsychotic medication for a newly added schizophrenia diagnosis without proper assessment or documented diagnosis.
F 0710: The facility failed to ensure Resident #75's medical care was adequately supervised by a physician, as the primary care physician was unaware of the schizophrenia diagnosis and antipsychotic medication use.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for unnecessary medications: 5
Days antibiotic administered: 5
Olanzapine dosage: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #1 | Initial Admitting Physician | Interviewed regarding Resident #75's medical and psychiatric history and medication management. |
| MD #2 | Physician | Interviewed regarding care of Resident #75 and awareness of schizophrenia diagnosis. |
| NP #1 | Nurse Practitioner | Interviewed regarding medication reconciliation and psychiatric diagnosis for Resident #75. |
| Psychiatrist | Psychiatrist | Interviewed regarding psychiatric care and diagnosis of Resident #75. |
| Director of Nursing Services | DNS | Interviewed regarding notification responsibilities, abuse reporting, and oversight of medical care. |
| RN #5 | RN Supervisor | Interviewed regarding responsibility for notifying designated representatives about treatment changes. |
| LPN #1 | Medication Nurse | Interviewed regarding administration of IV antibiotic to Resident #56. |
| LPN #3 | Charge Nurse | Interviewed regarding notification procedures for Resident #56's antibiotic therapy. |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding Resident #53's wandering behavior and interventions. |
| Housekeeper #1 | Housekeeper | Witnessed and reported resident-to-resident altercation between Residents #53 and #69. |
Inspection Report
Capacity: 60
Deficiencies: 4
Date: Oct 12, 2022
Visit Reason
Covid-19 Survey with 4 life safety code citations, all corrected by December 2022 or earlier.
Findings
Covid-19 Survey with 4 life safety code citations, all corrected by December 2022 or earlier.
Deficiencies (4)
Corridors - construction of walls
Illumination of means of egress
Primary/alternate means for communication
Stairways and smokeproof enclosures
Inspection Report
Renewal
Deficiencies: 5
Date: Jul 30, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for continued licensing and certification of the nursing facility.
Findings
The survey identified multiple deficiencies including failure to ensure call bell accessibility for a resident, inadequate surety bond coverage for resident funds, unclean and unsafe environment conditions, improper oxygen administration exceeding physician orders, and failure to timely schedule an orthopedic consult for a resident.
Deficiencies (5)
F 0558: The facility did not ensure that Resident #28 had a call bell accessible within reach on multiple occasions.
F 0570: The facility did not maintain a surety bond sufficient to cover accumulated resident personal funds during several months in 2021.
F 0584: The facility failed to provide a clean, comfortable, and homelike environment; resident rooms and equipment were visibly soiled and dusty.
F 0695: Resident #12 received oxygen at flow rates exceeding the physician's order on multiple occasions.
F 0840: The facility did not ensure timely scheduling of an orthopedic consult for Resident #98 as ordered by the physician.
Report Facts
Surety bond coverage amount: 60000
Surety bond coverage amount: 140000
Oxygen flow rate observed: 5.5
Oxygen flow rate observed: 7.5
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in oxygen administration finding |
| RN #2 | Registered Nurse Supervisor | Named in oxygen administration and orthopedic consult findings |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding call bell accessibility, oxygen administration, and orthopedic consult scheduling |
| Chief Finance Officer | Chief Finance Officer | Interviewed regarding surety bond coverage |
| Administrator | Facility Administrator | Interviewed regarding surety bond and environmental cleanliness |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding cleaning of resident's fan |
| Maintenance Director | Director of Maintenance | Interviewed regarding cleaning responsibilities for resident rooms |
| Physician Assistant | Physician Assistant | Named in orthopedic consult scheduling finding |
| Physician | Attending Physician | Interviewed regarding oxygen administration order |
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