Inspection Reports for
The Hamlet Rehabilitation and Healthcare Center at Nesconset
100 Southern Blvd, Nesconset, NY 11767, United States, NY, 11767
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 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/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 20, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 2/12/2025 to 2/20/2025 to assess compliance with professional standards of care in wound management, hydration, and respiratory care among residents.
Findings
The facility was found deficient in providing appropriate pressure ulcer care for Resident #11, safe administration and monitoring of a Peripherally Inserted Central Catheter for Resident #323, and ensuring oxygen therapy was available and administered as ordered for Resident #7. Deficiencies included failure to update physician orders timely, lack of routine catheter site monitoring and measurement, and an empty oxygen tank during resident use.
Deficiencies (3)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #11, including delayed implementation of wound care team recommendations.
Failure to provide safe and appropriate administration of IV fluids and monitoring of Peripherally Inserted Central Catheter for Resident #323, including lack of routine measurement of catheter external length and monitoring for infection.
Failure to provide safe and appropriate respiratory care for Resident #7, including use of an empty oxygen tank despite physician orders for oxygen therapy as needed.
Report Facts
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 10.2
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 1
Oxygen therapy flow rate: 2
PICC dressing change frequency: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in wound care observation and interview regarding adherence to Physician's orders for Resident #11 | |
| Licensed Practical Nurse #2 | Named in wound care interview regarding adherence to Physician's orders for Resident #11 | |
| Licensed Practical Nurse #3 | Assisted Wound Care Nurse during wound care observation for Resident #11 | |
| Licensed Practical Nurse #4 | Named in interview regarding oxygen tank monitoring for Resident #7 | |
| Wound Care Nurse Practitioner | Provided wound care consultation and recommendations for Resident #11 | |
| Wound Care Nurse | Performed wound care and was involved in delayed documentation of order changes for Resident #11 | |
| Director of Nursing Services | Interviewed regarding wound care order documentation and oxygen tank availability | |
| Assistant Director of Nursing Services | Interviewed regarding PICC care responsibilities | |
| Registered Nurse #1 | Interviewed regarding PICC care and documentation responsibilities | |
| Physician #1 | Interviewed regarding responsibility for orders related to PICC care | |
| Nurse Practitioner #1 | Interviewed regarding expectations for nursing staff adherence to oxygen therapy orders |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Feb 20, 2025
Visit Reason
Inspection found 3 health and 1 life safety deficiencies including issues with parenteral/iv fluids, respiratory care, pressure ulcer treatment, and egress doors; all corrected by April 2025.
Findings
Inspection found 3 health and 1 life safety deficiencies including issues with parenteral/iv fluids, respiratory care, pressure ulcer treatment, and egress doors; all corrected by April 2025.
Deficiencies (4)
Parenteral/iv fluids
Respiratory/tracheostomy care and suctioning
Treatment/svcs to prevent/heal pressure ulcer
Egress doors
Inspection Report
Complaint Investigation
Census: 221
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
The inspection was conducted as an abbreviated survey following a complaint regarding verbal abuse by a Certified Nursing Assistant towards Resident #1.
Complaint Details
The complaint was substantiated based on video evidence showing Certified Nursing Assistant #1 verbally abusive and physically aggressive towards Resident #1. The facility's investigation confirmed the abuse, resulting in termination of Certified Nursing Assistant #1 and Registered Nurse #1 for failure to intervene.
Findings
The facility failed to prevent and protect Resident #1 from verbal abuse and physical aggression by Certified Nursing Assistant #1, who was captured on video displaying abusive behavior. The facility's administration reviewed the video, confirmed the abuse, and terminated the involved staff. Registered Nurse #1 failed to intervene appropriately and was also terminated.
Deficiencies (1)
Failed to protect Resident #1 from verbal abuse and physical aggression by Certified Nursing Assistant #1.
Report Facts
Census: 221
Video length: 3.58
Dates: Aug 7, 2023
Dates: Aug 22, 2023
Dates: Jul 7, 2023
Dates: Jul 19, 2023
Dates: Sep 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Perpetrator of verbal abuse and physical aggression towards Resident #1; terminated for cause. |
| Registered Nurse #1 | Registered Nurse | Failed to intervene during abuse incident; terminated based on video review. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Floor nurse assigned to Resident #1 on the morning shift; reported abuse complaint. |
| Director of Nursing Services | Director of Nursing Services | Reviewed video footage, terminated involved staff, and conducted facility-wide abuse training. |
| Resident #1's Psychologist | Psychologist | Provided assessment notes regarding Resident #1's mental status post-incident. |
| Nursing Home Administrator | Nursing Home Administrator | Reviewed video recording during survey and supported termination of involved staff. |
| Medical Director | Medical Director | Assessed Resident #1 after abuse complaint; found no psychological or psychiatric symptoms. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
One health deficiency related to free from abuse and neglect was found and corrected by May 2024; enforcement action included a stipulation and fine for resident rights.
Findings
One health deficiency related to free from abuse and neglect was found and corrected by May 2024; enforcement action included a stipulation and fine for resident rights.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 22, 2023
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted from 11/16/2023 to 11/22/2023 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for residents' current needs. Specific deficiencies included lack of care plans for the use and monitoring of a self-release seatbelt for Resident #81, hearing aids for Resident #130, and the use and care of a PICC line and Foley catheter for Resident #391. Additionally, there were missing physician orders for the use and care of the PICC line and Foley catheter.
Deficiencies (4)
Failure to develop and implement a complete care plan that meets all the resident's needs, including the use of a self-release seat belt for Resident #81.
Failure to develop a care plan for the use of bilateral hearing aids for Resident #130.
Failure to develop a care plan and obtain physician orders for the use and care of the PICC line and Foley catheter for Resident #391.
Failure to obtain physician's orders for the use of the PICC line and Foley catheter for Resident #391.
Report Facts
Deficiencies cited: 4
PICC line antibiotic therapy duration: 42
Urine volume drained: 2300
Dates of survey: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Reviewed hospital records for PICC line documentation and acknowledged missing physician orders |
| LPN #7 | Licensed Practical Nurse | Inserted Foley catheter on 6/1/2023 per physician's verbal orders |
| NP #1 | Nurse Practitioner | Examined Resident #391 on 6/1/2023 and ordered catheterization and Foley catheter insertion but did not initiate physician orders |
| Director of Nursing Services | Director of Nursing Services | Provided statements regarding care plan and physician order deficiencies |
| Medical Director | Medical Director | Discussed the necessity of physician orders for PICC line and Foley catheter care |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #81's use of self-release seat belt |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed regarding Resident #130's use of hearing aids |
| RN #2 | Unit Charge Nurse | Interviewed about awareness of Resident #130's hearing aids |
| MDS Coordinator #1 | MDS Coordinator | Responsible for updating care plans; interviewed about Resident #81 and #130 care plans |
| Director of Rehabilitation Services | Director of Rehabilitation Services | Interviewed about care plan requirements for self-release seat belts |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 22, 2023
Visit Reason
The survey was a Recertification Survey and Abbreviated Survey conducted to assess compliance with regulatory requirements including care planning, medication administration, and physician orders.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for residents' current needs. Deficiencies were found in care planning for residents with PICC lines, Foley catheters, hearing aids, physical restraints, and assistive devices. The facility also failed to ensure adequate supervision to prevent accidents, including leaving medications unattended at a resident's bedside. Physician orders were missing for the use and care of PICC lines and Foley catheters. Care plans were not updated to reflect residents' behaviors such as removing assistive devices.
Deficiencies (4)
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions, including for residents with PICC lines, Foley catheters, hearing aids, and physical restraints.
Failure to revise comprehensive care plans to reflect residents' current status and behaviors, including removal of Wanderguard bracelets and Miami J collars.
Failure to ensure residents' environment remained free from accident hazards and provide adequate supervision to prevent accidents, including leaving multiple medications unattended at a resident's bedside without assessment for self-administration.
Failure to obtain physician's orders for the use and care of PICC lines and Foley catheters upon admission and during care.
Report Facts
Medication count: 6
Urine volume drained: 2300
PICC line antibiotic therapy duration: 42
BIMS score: 15
BIMS score: 9
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding Resident #81's use of self-release seat belt. |
| Director of Rehabilitation Services | Interviewed regarding care plan requirements for self-release seat belts. | |
| MDS Coordinator #1 | Interviewed regarding care plan updates for Resident #81 and Resident #130. | |
| Director of Nursing Services | DNS | Interviewed regarding care plan deficiencies, medication administration, and physician orders. |
| RN #2 | Unit Charge Nurse | Interviewed regarding awareness of Resident #130's hearing aids and Resident #200's care plan. |
| Licensed Practical Nurse #7 | LPN | Interviewed regarding Foley catheter insertion and physician orders. |
| Nurse Practitioner #1 | NP | Interviewed regarding oversight of physician orders for PICC line and Foley catheter. |
| Medical Director | Interviewed regarding physician orders and care for PICC line and Foley catheter. | |
| Certified Nursing Assistant #8 | CNA | Interviewed regarding Resident #200's removal of Miami J collar. |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding Resident #200's removal of Miami J collar and documentation. |
| Physician #1 | Attending Physician | Interviewed regarding Resident #87's medication self-administration. |
| Licensed Practical Nurse #8 | LPN | Interviewed regarding medication administration to Resident #87. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Nov 22, 2023
Visit Reason
Multiple health and life safety deficiencies including care plan timing, comprehensive care plan, accident hazards, physician supervision, and electrical systems; all corrected by January 2024.
Findings
Multiple health and life safety deficiencies including care plan timing, comprehensive care plan, accident hazards, physician supervision, and electrical systems; all corrected by January 2024.
Deficiencies (7)
Care plan timing and revision
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Resident's care supervised by a physician
Electrical systems - essential electric syste
Exit signage
Gas equipment - cylinder and container storag
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Sep 8, 2023
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulatory requirements, specifically focusing on the monitoring and documentation of resident bowel movements following a complaint or concern.
Findings
The facility failed to have an effective system to monitor and document bowel movements for Resident #1, who suffered from constipation leading to fecal impaction, septic shock, and death. Documentation inconsistencies, lack of timely notification to medical staff, and failure to follow bowel protocols were identified, resulting in immediate jeopardy and actual harm.
Deficiencies (5)
Failure to monitor and document bowel movements adequately for Resident #1, leading to undetected constipation and fecal impaction.
Inconsistent and incomplete documentation of bowel movements in CNA accountability records and high alert bowel monitoring forms.
Lack of documented evidence that medical staff were notified or assessments were conducted timely regarding Resident #1's condition.
Failure to administer ordered enema and follow up on x-ray results for Resident #1.
Missed documentation and communication failures among nursing staff and management regarding bowel movement monitoring and resident condition.
Report Facts
Documentation opportunities: 81
No bowel movement documented: 49
Documentation left blank: 19
Bowel movements documented with size: 12
Code 97 documented: 1
Episodes with six shifts without bowel movement: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported to complete high alert bowel form, did not administer ordered enema, and did not follow up on x-ray results |
| NP #1 | Nurse Practitioner | Ordered labs, x-rays, and enema; did not document assessments or interventions |
| NP #2 | Nurse Practitioner | Documented chest x-ray results and resident condition including lethargy |
| PP #1 | Primary Physician | Ordered enema and monitored labs and antibiotics; aware of resident decline |
| Director of Nursing Services | Director of Nursing Services | Provided information on documentation practices and communication processes |
| Unit Manager | Unit Manager | Responsible for checking CNA accountability records and completing high alert bowel monitoring form |
| Medical Director | Medical Director | Commented on physician practice independence and escalation protocols |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding bowel movement documentation and reporting |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding bowel movement documentation and reporting |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
One health deficiency related to quality of care with immediate jeopardy was found and corrected by October 2023; enforcement action included a stipulation and fine for quality of care.
Findings
One health deficiency related to quality of care with immediate jeopardy was found and corrected by October 2023; enforcement action included a stipulation and fine for quality of care.
Deficiencies (1)
Quality of care
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 22, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with professional standards of quality, rehabilitation services, activities of daily living care, and respiratory care at The Hamlet Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to rotate insulin injection sites for a resident on insulin therapy, failure to provide recommended Nursing Ambulation Program services leading to decline in ambulation for a resident, inadequate personal hygiene care with untrimmed and soiled fingernails for a resident requiring assistance, and improper oxygen administration exceeding physician orders for a resident on oxygen therapy.
Deficiencies (4)
Nursing staff did not rotate insulin injection administration sites for Resident #175 as required by facility policy.
Resident #100 did not receive Nursing Ambulation Program services as recommended, resulting in decline in ambulatory ability.
Resident #57 was observed with untrimmed, broken, and soiled fingernails despite requiring staff assistance for personal hygiene.
Resident #175 received oxygen at a flow rate higher than the physician's order without physician notification or order.
Report Facts
Insulin units administered: 46
Insulin units administered: 14
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 4
Oxygen flow rate observed: 3.5
Ambulation distance recommended: 40
Ambulation distance observed: 15
Ambulation frequency documented: 5
Ambulation frequency documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Administered insulin injections to Resident #175 without rotating sites and did not notify physician of resident's request |
| Assistant Director of Nursing Services | ADNS | Interviewed regarding insulin injection site rotation and care plan development |
| Director of Nursing Services | DNS | Interviewed regarding awareness of resident requests and care plan expectations |
| Physician #8 | Physician | Interviewed regarding expectations for insulin site rotation and lack of notification |
| CNA #9 | Certified Nursing Assistant | Interviewed regarding ambulation of Resident #100 |
| Anonymous CNA #10 | Certified Nursing Assistant | Interviewed regarding ambulation refusals during evening shift |
| PT #1 | Physical Therapist | Interviewed regarding functional decline and ambulation status of Resident #100 |
| RN Supervisor #3 | Registered Nurse Supervisor | Interviewed regarding notification of ambulation refusals and care plan development |
| CNA #8 | Certified Nursing Assistant | Interviewed regarding nail care responsibilities for Resident #57 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding nail care provision |
| RN Nurse Manager #2 | Registered Nurse Nurse Manager | Interviewed regarding documentation and expectations for nail care |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Interviewed regarding oxygen administration and resident requests |
| Physician #6 | Physician | Interviewed regarding oxygen administration and lack of notification of increased flow rate |
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