Maria Regina Rehabilitation and Nursing

Inspectors wroteBased on observation, interviews, and record review during survey, the facility failed to ensure an assessment accurately reflected each resident's status. This was identified for one (1) (Resident #4) of one (1) resident reviewed for catheter. Specifically, Resident #4 was admitted without an indwelling urinary catheter (a flexible tube inserted through the urethra or abdominal wall into the bladder to continuously drain the urine into an external bag). The admission 5-Day Minimum Data Set assessment dated [DATE] inaccurately documented that the resident had an indwelling catheter.

Inspectors wroteBased on observation, record review, and interview during the survey, the facility failed to ensure that a resident who needs respiratory care is provided with such care, consistent with professional standards of practice. This was identified for one (1) (Resident #146) of three (3) residents reviewed for respiratory care. Specifically, Resident #146 had physician's orders for oxygen therapy via nasal cannula two liters per minute as needed for the treatment of chronic obstructive pulmonary disease. On 4/30/2026 the oxygen tubing label was dated 4/21/2026.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's current medical and nursing needs was developed in a timely manner. This was identified for one (Resident #272) of two residents reviewed for Antibiotic use; for one (Resident #3) of two residents reviewed for Activities of Daily Living; and for one (Resident #19) of one resident reviewed for Respiratory Care. Specifically, 1) Resident #272 was readmitted to the facility on [DATE] with a Peripherally Inserted Central Catheter line to the Right Upper Arm; [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. This was identified for one (Resident #31) of four residents reviewed for Vision and Hearing. Specifically, a plastic cup containing two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment medications were observed on Resident #31's bedside table on [DATE]. The Refresh Liquigel eye drops expiration date was documented as 8/2024 and the resident was observed to self-administer the expired eye drops. The finding is: The facility policy titled Storage of Medication dated 3/2023 documented that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that injuries of unknown origin were reported by the covered individual including the Certified Nursing Assistants within 24 hours of identifying the injury. This was identified for one (Resident #273) of three residents reviewed for Skin Condition (non-pressure). Specifically, Certified Nursing Assistant #6 did not report a bruise of unknown origin on the back of Resident #273's left forearm when they identified the bruise on 1/18/2025. The finding is: The facility's Abuse Prevention policy dated 10/2022 documented that the facility staff are trained regarding the facility policies related to Abuse Prevention and Reporting at the time of orientation and at least annually thereafter. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure an assessment was completed to reflect the resident's status accurately. This was identified for one (Resident #128) of four residents reviewed for Dementia Care. Specifically, the Quarterly Minimum Data Set assessment for Resident #128 dated 1/6/2025 inaccurately reflected the resident as comatose. The finding is: The facility's policy titled Minimum Data Set Completion Assignment, last reviewed on 10/18/2023 documented that interdisciplinary care team members are assigned to specific Care Area Assessment which they have to document key findings regarding the resident's status based on the triggered care area. The care area assessment summary must be completed at the time of Minimum Data Set completion. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #102) of six residents reviewed for Communication. Specifically, Resident #102 had a Physician's order to use bilateral hearing aides daily. The resident exhibited noncompliance and frequently removed the hearing aids; however, the comprehensive care plan for the hearing deficit was not updated to indicate the resident's behavior. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #5) of five residents reviewed for Nutrition. Specifically, Resident #5 had an 8.48% significant weight loss in 90 days, from October 2024 to January 2025, which was not addressed by the Clinical Dietitian. The finding is: The facility's undated policy titled, Weight Monitoring documented, once weights have been recorded in the Electronic Medical Record (EMR), the unit Clinical Dietitian will review the resident's weight status over the specified period of time to identify any residents who have experienced a significant weight change. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, 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 #5) of five residents reviewed for Nutrition. Specifically, Resident #5 had an 8.48% significant weight loss in 90 days, from October 2024 to January 2025, which was not addressed by their Primary Physician. The finding is: The facility's undated policy titled, Weight Monitoring documented, once weights have been recorded in the Electronic Medical Record (EMR), the unit Clinical Dietitian will review the resident's weight status over the specified period of time to identify any residents who have experienced a significant weight change. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and abbreviated Survey (Complaint # NY 00337758) initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident. This was identified for one ( Unit 2 East) of six nursing units during the Sufficient Staffing Task. Specifically, a review of the daily staffing sheets and grievance reports indicated that Unit 2 East did not have sufficient nursing staff available during the weekends to care for residents in March 2024. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. This was identified for one (Resident #31) of four residents reviewed for Vision and Hearing. Specifically, a plastic cup containing two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment medications were observed on Resident #31's bedside table on [DATE]. The Refresh Liquigel eye drops expiration date was documented as 8/2024 and the resident was observed to self-administer the expired eye drops. The finding is: The facility policy titled Storage of Medication dated 3/2023 documented that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. [...]

Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey (Complaint # NY000330281) the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically, Resident #1, who has a diagnosis of dementia, was observed by Certified Nurse's Aide #1 sitting in their reclining wheelchair next to the nursing station drinking from a brown bottle labeled Wella Color Charm hair color which had been left unattended at the nursing station. Subsequently, Resident #1 was transferred to the hospital for swelling to the lips and tongue via 911 and admitted to the hospital on [DATE]. This resulted in actual harm that is not immediate jeopardy.

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for three (Resident #59, Resident #84, and Resident #118) of four residents reviewed for Oxygen use. Specifically, on 9/18/2023 Resident #59, Resident #84, and Resident #118 were observed on two different occasions not receiving Oxygen therapy as prescribed by the Physician.

Inspectors wroteBased on observations, record review and staff interviews conducted during the Recertification and Abbreviated Survey (NY 00317788) initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure that services provided by the facility meet professional standards of quality. This was identified on 1) one (1 East) of four nursing units during the medication administration task and 2) one (Resident # 142) of five residents reviewed for accidents. Specifically, on 9/19/2023 Licensed Practical Nurse (LPN) #6 administered Vitamin B-1 to Resident #126 without checking the expiration date on the bottle. The Vitamin B-1 bottle had an expiration date of 8/2023. 2) On 6/1/2023 LPN #1 did not notify the nursing supervisor or a Physician regarding a change in condition for Resident #142 who was identified with a painful swollen hand.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00316441) initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure that nurse's aides were able to demonstrate competency in skills and techniques necessary to care for resident needs. This was identified for one (Resident #141) of five residents reviewed for accidents. Specifically, on 5/10/2023 Certified Nursing Assistant (CNA) #9 repositioned the resident without utilizing the assistance of two staff members as per the resident's plan of care. Additionally, CNA #9 did not turn the room lights on when they (CNA #9) repositioned the resident. Subsequently, Resident #141 was identified with a laceration to the back of the head. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey initiated on [DATE] and completed on [DATE] the facility did not ensure that drugs and biologicals are labeled in accordance with currently accepted professional standards and include the expiration date when applicable. This was identified on one (1 East) of four nursing units during the medication administration observation task. Specifically, on [DATE] Licensed Practical Nurse (LPN) #6 administered Vitamin B-1 to Resident #126 without checking for the expiration date on the bottle. The Vitamin B-1 bottle had an expiration date of 8/2023. The finding is: The facility's policy for Storage and Maintenance of Medications dated 12/07 documented medication should be checked regularly for expiration dates and deterioration. Expired (outdated) medications are removed from use and destroyed. [...]