Nassau Rehabilitation & Nursing Center

Inspectors wroteBased on observation, staff interview and record review during an abbreviated survey (NY00373760), the facility failed to ensure food was prepared in a form designed to meet the resident's needs as documented on a hospital discharge summary for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 was admitted with a modified consistency diet of minced moist consistency and thickened liquids. The facility diet order documented chopped consistency with thin liquids. Resident # 1 was found unresponsive in the dining room during breakfast on 09/10/2024. This resulted in Resident #1 being transported to the hospital with upper airway obstruction from food and subsequently expired. This deficient practice has the potential to affect all 102 residents in the facility with a modified consistency diet that is Immediate Jeopardy. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for two (Resident #78 and Resident #155) of the two residents reviewed for Dignity. Specifically, during a lunch meal observation on 4/21/2025, Occupational Therapist Assistant #1 was observed standing over Resident #78 while they assisted the resident with the lunch meal. During the same lunch meal observation, Transporter #1 was also observed standing over Resident #155 while they assisted the resident with their lunch meal.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #232) of one resident reviewed for Bowel and Bladder Incontinence. Specifically, Resident #232's room was observed with a strong urine smell. Staff Interviews and record review revealed the resident did not receive staff assistance with incontinence care and assistance with personal hygiene as per the resident's plan of care. The finding is: The facility's policy titled Activities of Daily Living, dated 10/1/2024, documented to provide Activities of Daily Living care to all residents based on assessment of needs. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that residents received care consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for two (Resident #176 and Resident#196) of four residents reviewed for Skin Conditions. Specifically, 1) Resident #176 had a history of a pressure ulcer to the mid-back and utilized an air mattress for pressure relief. During multiple observations, Resident #176 was observed in bed with their air mattress weight setting at 450 pounds. Resident #176 weighed 114.4 pounds on 4/02/2025. 2) Resident #196 required the use of an air mattress to decrease the risk of skin breakdown. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure all drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #28) of five residents reviewed for Accident Hazards. Specifically, Resident #28 was observed with an unlabeled, clear bottle of Safetussin Cough and Chest Congestion (medication for cough and congestion) on their nightstand with no nursing staff within the vicinity of Resident #28's room. Additionally, there was no Physician's Order for the Safetussin Cough and Chest Congestion medication, and Resident #28 was not assessed to self-administer medications. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit in the facility and for each shift, such as day, evening, and night. This was identified during the Sufficient and Competent Nurse Staffing Review Task. Specifically, the Facility Assessment, last updated on 3/5/2025, did not specify the number of Certified Nursing Assistants and Licensed Practical Nurses required to care for the resident population. Additionally, the facility assessment staffing plan did not specify the nursing staffing needs per unit per shift. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024 the facility did not ensure each resident received adequate supervision to prevent accidents. This was identified for one (Resident #26) of three residents reviewed for Accidents. Specifically, Resident #26 was assessed as a high risk for falls, required extensive assistance of one person for transfers and toileting needs, and was to be placed in a high visibility area when awake as per the resident's Comprehensive Care Plan. On multiple occasions, the resident was observed going into the bathroom unassisted in their room to toilet themselves. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that each resident who is fed by enteral means received treatment and services to prevent complications of enteral (tube) feeding including but not limited to aspiration pneumonia and vomiting. This was identified for one (Resident #184) of one resident reviewed for Tube Feeding. Specifically, Resident (#184), who was fed by enteral means, had a Physician's order to elevate the head of the bed at a 45-degree angle during and one hour after the tube feeding. Resident #184 was observed lying flat on their back 45 minutes after receiving the bolus (administration of a limited volume of enteral formula over a brief period) feeding. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that the medical care of each resident was supervised by the Physician, including monitoring changes in the resident's medical status. This was identified for one (Resident #75) of four residents reviewed for Nutrition. Specifically, Resident #75 had an 8.5% significant weight loss in 30 days identified in November 2023. The significant weight loss was not addressed by the resident's Primary Care Physician or Nurse Practitioner in the resident's Electronic Medical Record. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This was identified for one (Resident #75) of five residents reviewed for Unnecessary Medications. Specifically, Resident #75 was started on Risperdal (Risperidone-an antipsychotic medication) on 8/21/2023 in an attempt to reduce the resident's non-compliant behavior of refusing to take their medications which is not the appropriate indication for the use of Risperdal. The finding is: [...]

Inspectors wroteBased on the observation, record review, and interviews during the Recertification survey completed on 12/21/2021, the facility did not ensure that each resident environment remained free from accident hazards. This was identified for one (Resident #124) of seven residents reviewed for Accidents. Specifically, Resident #124's room was observed with sharp metal that was protruding out of the heating/ventilation unit. The finding is: The Facility Environmental Maintenance Policy reviewed on 11/28/2021 documented that all staff should report any issues regarding equipment that may need repair to the Maintenance Director, so the problem can be addressed in a timely manner. Resident #124 was admitted with diagnoses including Depression and Hypertension. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 12/21/2021, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and their comprehensive person-centered care plan. This was identified for one (Resident # 494) of one resident reviewed for Respiratory care. Specifically, Resident #494 was observed receiving oxygen at a flow rate of 4 liters per minute (L/min) via a nasal cannula (tubing used to deliver supplemental oxygen) without a Physician's order. The finding is: The facility policy and procedure for oxygen, revised in October 2020 documented to ensure there is a Physician's order for oxygen use. Resident #494 was admitted with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Hypertension. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey and the Abbreviated Survey (Complaint #NY00259905) completed on 12/21/2021, the facility did not ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day for one (Resident #88) of 5 residents reviewed for Food and Nutrition. Specifically, Resident #88 verbalized that the time between dinner and breakfast next morning was too long and they (Resident #88) did not consistently get a midnight snack and felt hungry at night. The finding is: An undated document titled Meal Delivery documented the mealtimes were approximate to when the trays/meals would arrive on the 3rd floor: Supper: Unit 3 North: 5:00 PM Unit 3 South: 5:30 PM Breakfast: Unit 3 North: 8:00 AM Unit 3 South: [...]

Inspectors wroteBased on observation and interviews during the Recertification Survey completed on 12/21/2021, the facility did not make staffing information readily available to residents and visitors. Specifically, daily staffing was not observed posted in a prominent area in the facility on 12/16/2021. The finding is: During a tour of the facility on 12/16/2021 from 10:35 AM to 10:45 AM the Nursing Staffing information was not observed posted at a prominent area in the facility including the entrance lobby, receptionist desk, and the elevators. The Staffing Coordinator was interviewed on 12/16/2021 at 11:50 AM and stated they (staffing coordinator) were not aware of the requirement to post the daily nursing staffing in a prominent area that was accessible to residents and visitors at all times. [...]