Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grand Pavilion For Rhb & Nrsg At Rockville Ctr during CMS and state inspections, most recent first.
A resident with a Stage 3 pressure ulcer experienced unmanaged pain due to inadequate communication and coordination among staff at an LTC facility. Despite frequent complaints of pain, the resident did not receive appropriate pain management, and the prescribed positioning wedge was not used correctly to alleviate pressure. The facility's failure to adhere to its pain management policy resulted in actual harm to the resident.
The facility failed to maintain privacy for residents with urinary catheters, as their catheter bags were not covered with privacy pouches, making them visible from the hallway or doorway. This deficiency was observed in three residents, despite the facility's policy requiring privacy covers to promote residents' rights and dignity. Staff interviews confirmed the oversight, and the Director of Nursing emphasized the importance of using privacy bags.
The facility failed to complete annual MDS assessments for two residents within the required 14-day timeframe, as identified during a survey. The MDS Director and DON were aware of the delays, which were attributed to staffing turnover.
The facility did not complete Quarterly MDS assessments within the required time frames for three residents, with delays ranging from three to five days. The MDS Director and DON were aware of the issue, attributing it to staffing turnover, which affected timely assessment completion.
The facility failed to develop comprehensive care plans for residents requiring specific medical interventions. A resident with intravenous hydration therapy had no care plan for catheter use. Another resident received an incorrect dosage of calcium with vitamin D due to unavailability of the prescribed dose. A third resident with an intravenous midline catheter lacked a care plan for its use. Staff acknowledged these oversights.
A resident, unable to perform activities of daily living due to medical conditions, was observed with long, untrimmed fingernails despite expressing a desire for assistance. The facility's policy required staff to assist with grooming tasks, but confusion among staff about their responsibilities led to a delay in providing necessary nail care.
A resident with a Stage 3 pressure ulcer did not receive proper care as the facility failed to use a positioning wedge for pressure relief. The wedge was not used correctly, and staff were unaware of its purpose, leading to the resident experiencing pain. The care plan lacked an intervention for the wedge, and there was a communication breakdown among staff regarding its use.
A resident with Alzheimer's and other conditions experienced significant weight loss due to the facility's failure to provide a therapeutic diet and monitor weight as ordered. Despite recommendations for weekly weight checks, there was no documentation of such monitoring. The resident's care plan was not adjusted in response to the weight loss, and staff interviews confirmed lapses in following the facility's nutritional management policy.
The facility failed to ensure the safe administration of IV antibiotics for two residents, as per professional standards and physician's orders. One resident had a Midline IV Catheter without proper monitoring and flushing orders, and the other lacked documentation of required assessments and flushes. Nursing staff interviews revealed lapses in obtaining necessary orders and documenting assessments, leading to a deficiency in care.
A resident experienced ten falls during a short-term stay, including one that required hospitalization, due to inadequate supervision and fall prevention measures. Despite being identified as a fall risk, the facility's interventions were insufficient, and there was no formal fall prevention program in place. The facility relied on family involvement for managing the resident's fall risk, which was not effective.
Inadequate Pain Management for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a Stage 3 pressure ulcer, resulting in actual harm. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was admitted with several diagnoses, including cellulitis and malnutrition. Initially, the resident had an order for Oxycodone for pain management, which was discontinued without a follow-up plan for pain management. Despite the resident's frequent complaints of pain, there was no documented evidence of a comprehensive pain assessment or effective pain management plan. The resident's complaints of pain were consistently reported by various staff members, including Certified Nursing Assistants and an Occupational Therapist, yet these complaints were not adequately addressed. The resident was observed in pain multiple times, with facial grimacing and verbal complaints, but the facility staff failed to communicate these observations effectively to the physician or ensure that appropriate pain management interventions were in place. The facility's policy required ongoing communication between the prescriber and staff for optimal pain management, which was not adhered to in this case. Furthermore, the facility did not utilize the prescribed positioning wedge correctly to alleviate pressure on the resident's sacral area, which could have helped reduce pain. The lack of coordination and communication among the nursing staff, rehabilitation department, and medical providers contributed to the resident's unmanaged pain. The Director of Nursing Services acknowledged that the staff should have reported the resident's pain and utilized the positioning wedge as recommended. The attending physician also noted that pain medication orders should have been in place given the resident's condition.
Failure to Maintain Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to ensure that residents with urinary catheters were treated with respect and dignity, as their urinary catheter bags were not covered with privacy pouches, making them visible from the hallway or doorway. This deficiency was identified during a recertification survey for three residents. The facility's policy required that urinary catheter bags be maintained in privacy pouches to promote residents' rights and privacy, but this was not adhered to in the cases observed. Resident #335, who had intact cognition, was observed with a visible urinary catheter bag while sitting in a wheelchair. The Certified Nursing Assistant (CNA) responsible for transferring the resident admitted to not placing the urinary catheter bag in a privacy pouch, which was confirmed by the Unit Manager and the Director of Nursing. Similarly, Resident #283, who had moderate cognitive impairment, was found with an uncovered urinary catheter bag attached to the bedside. The CNA acknowledged that the night shift did not cover the bag, and the resident was unaware of the need for a privacy cover. Resident #284, also with moderate cognitive impairment, was observed with an uncovered urinary catheter bag while sleeping in bed. The CNA stated that the night shift did not cover the bag, and the Registered Nurse Manager mentioned that new bag covers had been ordered due to the previous ones being soiled. The Director of Nursing Services reiterated that all residents with urinary catheters should have privacy bags to cover the drainage bags, as per facility policy.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive assessments of residents were conducted within the required time frames, as mandated by the guidelines provided in the Resident Assessment Instrument Manual. Specifically, two residents, identified as Resident #67 and Resident #37, did not have their annual Minimum Data Set (MDS) assessments completed within 14 days of the Assessment Reference Date. Resident #67's assessment was completed 7 days late, while Resident #37's assessment was completed 6 days late. This deficiency was identified during a Recertification Survey conducted from January 5 to January 10, 2025. Interviews conducted during the survey revealed that the Minimum Data Set Director was aware of the late completion of the assessments and acknowledged that the assessments should have been completed within the 14-day requirement. The Director of Nursing Services also confirmed awareness of the late assessments, attributing the delay to staffing turnover. The facility's policy, dated December 10, 2024, clearly states that all MDS assessments are to be completed and submitted as per the guidelines, with the MDS Coordinator responsible for ensuring compliance.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for three residents during the Recertification Survey. Specifically, the MDS assessments for three residents were not completed within 14 days of the Assessment Reference Date, as required by the facility's policy and the guidelines provided in the Resident Assessment Instrument Manual. The assessments for these residents were completed three to five days beyond the required time frame. Interviews conducted during the survey revealed that the Minimum Data Set Director and the Director of Nursing Services were aware of the late completion of the MDS assessments. The Director of Nursing Services attributed the delay to staffing turnover, which impacted the timely completion of the assessments. The facility's policy, dated December 10, 2024, clearly outlines the responsibility of the Minimum Data Set Coordinator to ensure timely completion and submission of MDS assessments, which was not adhered to in these instances.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents requiring specific medical interventions. Resident #233, who was admitted with conditions including hypertension, diabetes mellitus, and depression, had a physician's order for intravenous hydration therapy. However, there was no comprehensive care plan developed for the insertion, care, and use of the intravenous catheter. This oversight was acknowledged by the Registered Nurse Unit Manager and the Director of Nursing Services, who confirmed that a care plan should have been initiated. Resident #68, diagnosed with vitamin D deficiency, hemiplegia, and seizures, was administered an incorrect dosage of calcium with vitamin D. The prescribed dosage was 600 milligrams-200 International Units, but the resident was given two tablets of calcium 250 milligrams with vitamin D3 due to unavailability of the correct dosage in the medication cart. The LPN involved admitted to administering the closest available dose and stated they would have documented a partial dose if the resident had not refused the medication. The Unit Manager and the Director of Nursing Services confirmed that the LPN should have checked with Central Supply or contacted the physician for an alternative order. Resident #285, with diagnoses including urinary tract infection and chronic kidney disease, had a physician's order for an intravenous midline catheter and antibiotic therapy. Despite this, there was no comprehensive care plan for the catheter's use, and the existing care plan for the urinary tract infection did not include interventions related to the catheter. The Registered Nurse Unit Manager and the Director of Nursing Services acknowledged that a care plan should have been developed for the catheter when it was ordered and placed.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain personal hygiene. This deficiency was identified for a resident who was observed on multiple occasions with long, untrimmed fingernails. The resident, who was admitted with diagnoses including cancer, vertebra fracture, and muscle weakness, was dependent on facility staff for personal hygiene due to numbness in their hands. Despite the resident's expressed desire to have their fingernails trimmed, the facility did not provide the necessary assistance in a timely manner. The facility's policy on Activities of Daily Living Care required staff to assist residents with grooming tasks, including nail care. However, there was confusion among staff regarding whether Certified Nursing Assistants (CNAs) were permitted to trim fingernails, particularly for non-diabetic residents. This confusion contributed to the delay in providing the necessary care. Interviews with staff, including a CNA, an LPN, and the Director of Nursing Services, revealed inconsistencies in understanding and implementing the facility's policy, resulting in the resident's unmet need for nail care.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a Stage 3 pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for bed mobility and transfers, was observed without the proper use of a positioning triangle wedge intended for pressure relief. The wedge was found against the bed's side rail instead of being used to offload pressure from the sacral area, as ordered by the physician and documented by the physical therapist. The facility's policy required a comprehensive assessment and documentation of pressure ulcers, including the use of pressure-reducing devices. However, the care plan for the resident did not include an intervention for the positioning wedge, and the direct care staff were unaware of its intended use for pressure relief. Observations revealed that the resident was in pain, and the staff did not reposition the resident or use the wedge correctly, despite being informed of its purpose by the Rehabilitation Department. Interviews with staff, including the Registered Nurse Unit Manager, Certified Nursing Assistant, and Physical Therapist, highlighted a lack of communication and understanding regarding the use of the positioning wedge. The Director of Nursing Services acknowledged that the nursing staff should have known the purpose of the wedge and utilized it to offload the wound area. This deficiency indicates a failure in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Provide Therapeutic Diet and Monitor Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with a nutritional problem was offered a therapeutic diet as ordered by the healthcare provider. Resident #54, who had diagnoses including Alzheimer's Disease, Atrial Fibrillation, and Depression, experienced a significant weight loss of 10% over one month and an additional 7% in the following month. Despite the Registered Dietician's recommendation for weekly weight monitoring, there was no documented evidence that the resident's weights were obtained weekly to monitor further weight loss. The facility's policy required the Clinical Dietitian to place residents on weekly weights if their weight loss was unplanned or undesirable, and to notify the Physician of any significant weight changes. However, the medical record lacked documented evidence of weekly weights in November and December 2024. The resident was on a mechanically altered therapeutic diet and required assistance for eating, but the interventions in the care plan, such as monitoring weights and oral intake, were not effectively implemented. Interviews with facility staff revealed that the Registered Dietician did not change the resident's plan of care despite the significant weight loss, and the Chief Dietician acknowledged that changes should have been made to the nutritional plan. The Primary Physician was aware of the weight loss but did not document a weight change in their notes. The deficiency was identified during a Recertification Survey, highlighting the facility's failure to adhere to its policy and ensure proper nutritional management for the resident.
Failure to Ensure Safe Administration of IV Antibiotics
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) antibiotics for two residents, Resident #336 and Resident #285, as per professional standards and physician's orders. Resident #336 had a Midline Intravenous Catheter in the left arm, but there were no physician orders for monitoring and flushing the catheter until several days after its insertion. The facility's policy required IV sites to be checked every four hours for signs of infection or inflammation, and to be flushed with saline. However, there was no documentation of such assessments or flushes in Resident #336's records before 1/8/2025, despite the resident receiving IV medication. Interviews with nursing staff revealed that they forgot to obtain the necessary orders and failed to document the required assessments. Resident #285 also had a Midline Intravenous Catheter, but there was no documentation of the required assessments, monitoring, or flushing of the catheter in the Medication Administration Record or Treatment Administration Record. Observations showed that the catheter site appeared clean and dry, but the necessary physician's orders for site assessment and flushing were missing. Interviews with nursing staff confirmed that they were expected to assess and document the catheter site condition and perform flushes, but these actions were not consistently documented. The Director of Nursing Services stated that the facility's policy required IV catheter sites to be assessed for signs of infiltration and infection every shift, with documentation in the resident's progress notes. However, this was not adhered to for both residents, leading to a deficiency in the administration of IV antibiotics. The lack of proper documentation and adherence to physician's orders and facility policy resulted in a failure to provide safe and appropriate care for the residents involved.
Inadequate Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident who experienced multiple falls during a short-term stay. The resident, who had a history of falls and was identified as a fall risk upon admission, sustained ten falls between March and May 2024. Despite the implementation of some interventions such as a low bed, bilateral floor mats, and keeping the environment well-lit and free of clutter, the resident continued to experience unwitnessed falls, one of which resulted in hospitalization due to a non-traumatic subdural hemorrhage. The facility's policy on managing falls and fall risks was not effectively implemented, as evidenced by the lack of new interventions following the resident's readmission after hospitalization. The resident's care plan included goals to prevent falls with injury, but the interventions were insufficient to prevent further incidents. The facility's Director of Nursing acknowledged the absence of a defined fall program and stated that falls were discussed during morning reports without a formal policy or timeline for addressing them. Interviews with facility staff revealed that the facility relied on family involvement to manage the resident's fall risk, suggesting that the family visit more frequently or provide a private companion, which the family refused. The facility's approach to fall prevention was reactive, with new strategies being tried individually after each fall, rather than having a comprehensive and proactive fall prevention program in place. The lack of a formal policy and consistent interventions contributed to the repeated falls experienced by the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rockville Centre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockville Skilled Nursing & Rehabilitation Center, | 0.1 mi | ★★★★★ | 0 | 0 |
| Mount Sinai South Nassau T C U | 1.3 mi | ★★★★★ | 1 | 0 |
| Lynbrook Restorative Therapy And Nursing | 1.3 mi | ★★★★★ | 5 | 0 |
| Oceanside Care Center Inc | 1.7 mi | ★★★★★ | 5 | 0 |
| North Shore - Lij Orzac Center For Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.