Momentum at South Bay for Rehabilation and Nursing

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure a comprehensive person-centered care plan was implemented for each resident to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #57) of twelve (12) residents reviewed for Infection Control. Specifically, Resident #57 had a physician's order for Contact Precautions dated 08/12/2025; however, there was no Comprehensive Care Plan developed for Contact Precautions with measurable goals and interventions. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team to reflect the resident's current status. This was identified for one (1)(Resident #1) (1)of one resident reviewed for Pressure Ulcers. Specifically, Resident #1's Comprehensive Care Plan was not updated to indicate the changes in the interventions related to offloading the resident's heels (both extremities). The finding is: The facility's policy, titled Pressure Ulcer Prevention and Care, dated 10/30/2024, documented to Avoid positioning the resident on a pressure injury. If unavoidable, attempt to limit the duration of the pressure on these areas. [...]

Inspectors wroteBased on observation, record review, and interviews, during the Recertification Survey and Abbreviated Survey (800725) initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (1) (Resident # 92) of three (3) residents reviewed for Pain Management. Specifically, Resident #92 had a diagnosis of Spinal and Hip Fractures and had a physician's order for Acetaminophen (pain reliever) for 14 days on 08/05/2025. The pain medication order was not renewed after 14 days. [...]

Inspectors wroteBased on observation, record review, and interviews, during the Recertification Survey and Abbreviated Survey (800725 ) initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure that the medical care of each resident was supervised by a Physician, including monitoring changes in the resident's status and the need for changes in the treatment. This was identified for one (1) (Resident #92) of three (3) residents reviewed for Pain Management. Specifically, Resident #92 had a diagnosis of Spinal and Hip Fractures and had a physician's order for Acetaminophen (pain reliever) for 14 days on 08/05/2025. The pain medication order was not renewed after 14 days. The resident was evaluated by Pain Management Nurse Practitioner #2 on 09/07/2025 and recommended to continue Acetaminophen for pain management without reviewing the resident's physician's orders. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/09/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #57) of twelve (12) residents reviewed for Infection Control, and two (2) (Resident #19 and Resident #156) of two (2) residents reviewed during the Medication Storage task. Specifically, 1) Resident #57 had a physician's order for Contact Precautions due to Clostridium Difficile (a bacterium that causes severe diarrhea and intestinal inflammation) infection. Certified Nursing Assistant #4 was observed entering and exiting Resident #57's room without putting on and removing Personal Protective Equipment. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00330563) initiated on 06/04/2024 and completed on 06/11/2024 the facility did not ensure Intravenous antibiotics were administered consistent with professional standards of practice and in accordance with physician's orders and the comprehensive person-centered care plan. This was identified for one (Resident #98) of one resident reviewed for Peripheral Intravenous Catheter. Specifically, Resident #98 was observed with a Peripheral Intravenous Catheter in their right arm. There were no physician orders for the placement of the Peripheral Intravenous Catheter and monitoring of the Peripheral Intravenous Catheter site. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 6/4/2024 and completed on 6/11/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #90) of three residents reviewed for Infection Control. Specifically, Resident #90 had a physician's order for Contact Enteric Isolation due to Clostridium Difficile (C-Diff-bacteria that causes inflammation of the colon) infection. On 6/7/2024, Certified Nursing Assistant #4 was observed providing perineal care to Resident #90 after a bowel movement. When the perineal care was completed, Certified Nursing Assistant #4 removed their dirty gloves and put on a new pair of gloves without performing hand hygiene. [...]

Inspectors wroteBased on observation and staff interviews during the Recertification Survey started on 9/28/2022 and was completed on 10/5/2022, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness. Specifically, on 9/29/2022 at 2:20 PM, the dish machine was observed running with a Wash temperature of 148 degrees Fahrenheit (F) and a Rinse temperature of 174 degrees F when the manufacturer specifications stated that the Wash temperature should be a minimum of 160 degrees F and the Rinse temperature be a minimum of 180 degrees F. The finding is: The facility's policy titled Sanitation of Dishware dated 1/12/2011 documented to take dishmachine temperatures three times per day to enable proper washing and sanitation. Procedures included: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey started on 9/28/2022 and completed on 10/5/2022 the facility did not ensure that its medication error rate was not 5 percent or greater. This was identified for 2 of 33 opportunities during the medication pass observation, resulting in a 6 % medication error rate. Specifically, during the medication pass observation 1) Registered Nurse (RN) #1 administered a Sucralfate tablet (a medication used to treat and prevent gastric and intestinal ulcers) to Resident # 91 while the resident was eating breakfast; however, the Physician ordered the medication to be administered on an empty stomach. 2) Licensed practical Nurse (LPN) #1 administered Gabapentin (a medication used to treat nerve pain) to Resident # 302 at the wrong time. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 9/28/2022 and completed on 10/5/2022, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on one of four medication carts reviewed during the Medication Storage and Labeling Task. Specifically, Resident #80's two Admelog insulin vials were observed opened with no date to indicate when the insulin vials were first opened. The finding is: The Facility's Medication Labeling Policy and Procedure dated 8/2021 documented that upon opening insulin pens/vials, the licensed nurse will write the date opened. Resident #80 was admitted with diagnoses that included Diabetes Mellitus, Hyperlipidemia, and Malnutrition. [...]