Massapequa Center Rehabilitation & Nursing

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #146) of two residents reviewed for Activities of Daily Living. Specifically, Resident #146 was observed with long and yellow fingernails on their contracted right hand on multiple occasions. The finding is: The facility's policy and procedure titled Activities of Daily Livings (ADLs) last reviewed 1/2024 documented that residents who are unable to carry out Activities of Daily Living independently will receive the necessary services including but not limited to hygiene such as bathing, dressing, grooming and oral care. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #120) of two residents reviewed for Skin Conditions and for one (Resident #93) of one resident reviewed for Communication-Sensory. Specifically, 1) Resident #120 was observed with a dressing on the left side of the forehead on 12/3/2024 and 12/5/2024; however, there was no physician's order for any assessment treatment for the left side of the forehead lesion. Additionally, the facility did not initiate a care plan for the left side of the forehead lesion. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #46) of one resident reviewed for Accident Hazards. Specifically, Resident #46 was observed with a Calcitonin (Salmon) spray bottle on their overbed table and there was no staff in the vicinity. Additionally, Resident #46 was not assessed to self-administer their medication. The finding is: The facility's policy and procedure titled, Medication Storage, last revised on 1/2024, documented that medications must be stored in accordance with the manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. This was identified for one (Resident #14) of two residents reviewed for Skin Conditions. Specifically, there was no documented evidence that Resident #14, with a diagnosis of a chronic infected wound on the right hip, was placed on Enhance Barrier Precautions as per the facility's policy. The finding is: The facility's policy and procedure titled Enhanced Barrier Precaution, dated 4/1/2024 documented the facility will implement Enhanced Barrier Precaution to include any resident with chronic wounds (e.g. [...]

Inspectors wroteBased on observation, interviews and record review during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. Specifically, one (Resident #548) of three sampled pooled residents, requested to take a nutritional supplement purchased by the resident. Resident #548 was not assessed by the facility staff to determine if the resident was a candidate to self-medicate.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 5/4/2021, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for 1 of 1 resident reviewed for Dignity. Specifically, the facility did not investigate an allegation of a Certified Nursing Assistant (CNA) attempting to photograph Resident #174 while disrobed. The finding is: The facility's Abuse, Neglect, and Mistreatment policy dated 1/5/2018 (revised on 1/2021) documented that the policy ensures that all patients will be treated with dignity, consideration, and respect at all times by employees. Any patient that reports fear or signs of abuse shall be evaluated by provider team as appropriate when a Patient verbalizes abuse, neglect or mistreatment. A full investigation of the incident will be done by the facility, immediately. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey completed on 05/04/2021, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being for one (Resident #550) of three residents reviewed for Quality of Care. Specifically, Resident #550 had a Pulmonary Consult dated 4/23/2021 that was not addressed by the attending physician in a timely manner. The findings is: Resident #550 has diagnoses that include Hypertension (HTN) and Coronary Artery Disease (CAD). The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) Score of 15 indicating the resident's cognitive status was intact. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that the attending Physician must document in the resident's medical record that an irregularity identified by the Pharmacy consultant was reviewed and a rationale was documented for disagreement with the pharmacy consultant. This was identified for 1 (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, the Pharmacy Medication Regimen Review (MRR) documented a recommendation to stop the use of Diphenhydramine (Benadryl) for Resident #222. The medical record lacked documented evidence of a Physician's rationale to address continued use of Benadryl for Resident #222. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident remains free of psychotropic drugs unless the medication is necessary. This was identified for 1 (Resident #498) of 6 residents reviewed for unnecessary medications. Specifically, Resident #498 with a diagnosis of Dementia was prescribed Seroquel (an antipsychotic medication) XR (extended release) for Agitation for behavior management. The finding is: The facility's policy, dated 9/4/2018 and revised on 10/2020, documented that residents displaying symptoms of a psychiatric disorder and/or behavioral symptoms shall have non-pharmacological interventions planned and carried out prior to psychiatric intervention. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 5/04/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, Resident #222 had a Physician's order for a Psychiatry consult dated 3/13/2021 and the Psychiatry consult was not completed until 4/29/2021, more than six weeks after the consult was ordered. The finding is: Resident # 222 was admitted with diagnoses that include Generalized Anxiety Disorder, Depression and Agoraphobia (fear of open spaces) with panic disorder. The Minimum Data Set Assessment (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident's cognitive status was intact. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not maintain accurate Electronic Medical Records (EMR) for one (Resident # 550) of 70 sampled resident records. Specifically, EMR system used by the facility erroneously deleted a consultation note that was written by the Pulmonologist consultant on 4/23/2021 when a correction update to the consult was made by the Pulmonologist on 4/28/2021. The finding is: Resident #550 has diagnoses that include Hypertension (HTN) and Coronary Artery Disease (CAD). The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognitive status was intact. Review of Nursing progress notes documented Resident #550 was seen by the Pulmonologist on 4/23/2021 with recommendations. [...]