Northwell Health Stern Family Center for Rehabilit

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 2/6/2025 and completed on 2/12/2025, the facility did not ensure that each resident's Advanced Directive wishes were formulated and clearly communicated. This was identified for one (Resident #374) of five residents reviewed for Advanced Directives. Specifically, Resident #374 completed a Medical Orders for Life-Sustaining Treatment (MOLST) form while in the hospital on 1/19/2025 indicating Do Not Attempt Resuscitation. Upon readmission to the facility, there was no Physician order placed for Do Not Resuscitate. In addition, the Social Work assessment dated [DATE] documented the resident was a Full Code (indicating resuscitation should be provided). The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 2/6/2025 and completed on 2/12/2025, the facility did not ensure that at the time each resident was admitted , the facility had physician orders for the resident's immediate care. This was identified for one (Resident #427) of two residents reviewed for Urinary Catheter. Specifically, Resident #427 was re-admitted to the facility on [DATE] and was utilizing an external urinary catheter at bedtime. The Physician's order was not obtained for the use of the external catheter until 2/11/2025. The finding is: Resident #427 was admitted with diagnoses that included a Right Femur Fracture, Osteoporosis, and Malnutrition. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 2/6/2025 and completed on 2/12/2025, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (Resident #222) of two residents reviewed for Hospitalization. Specifically, Resident #222's Discharge Minimum Data Set assessment dated [DATE] did not correctly reflect Resident #222's discharge location. The finding is: The facility's policy titled Minimum Data Set (MDS) Assessment last revised on 9/2024 documented that the Minimum Data Set is utilized by all disciplines responsible for the care of the resident. Each individual completing a portion of the assessment electronically signs and certifies the accuracy of that portion of the assessment. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification initiated on 2/06/2025 and completed on 2/12/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet medical and nursing needs. This was identified for one (Resident #130) of four residents reviewed for Skin Conditions. Specifically, Resident #130 had a Physician Order to apply Mupirocin (an antibiotic) ointment to the left large toe for an infection. There was no documented evidence that a care was developed to address Resident #130's left large toe infection. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/06/2025 and completed on 2/12/2025, 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 #109) of one resident reviewed for Edema. Specifically, Resident #109, had a physician's order to use the ace wrap (elastic bandage) for both lower legs daily for Edema (swelling caused by fluid buildup in the tissues). The resident refused to use the physician-ordered ace wrap and utilized their own compression socks instead. The Comprehensive Care Plan was not updated to include the resident's refusal of the physician-ordered ace wrap and the use of the resident's personal compression socks. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/06/2025 and completed on 2/12/2025, 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 #131) of three residents reviewed for Position and Mobility. Specifically, Resident #131 with a diagnosis of Diabetes Mellitus, utilized an Ankle Foot Orthosis (AFO) Brace (a brace that supports the foot) for their right dropped foot, without a Physician's order. The Ankle Foot Orthosis was brought from home by Resident #131. There was no documented evidence that a plan of care was developed for using the Ankle Foot Orthosis and that skin assessment was conducted according to the facility's policy related to the use of the Ankle Foot Orthosis. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 2/6/2025 and completed on 2/12/2025, the facility did not ensure that each licensed nurse had the specific competencies, and skill sets necessary to care for residents' needs and to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one (Resident #375) of five residents observed during Medication Administration. Specifically, on 2/7/2025 during the breakfast meal, Registered Nurse #1 handed the resident a souffle cup of oral medication tablets and left the room before the resident consumed the medications. Registered Nurse #1 then returned to the resident's room interrupted the resident's meal and administered a Lovenox (blood thinner) injection into the resident's abdomen. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2025 and completed on 2/12/2025, 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 two (Resident #525 and Resident #32) of three residents reviewed for Transmission Based Precautions. Specifically, Resident #525 was positive for COVID-19 (a contagious disease caused by the Coronavirus) infection and had a Physician's Order for Contact/Isolation Precautions; however, the signage posted outside Resident #525's door indicated Enhanced Barrier Precautions (EBP). Resident #32 was positive for COVID-19 infection and had a Physician's Order for Contact/Isolation Precaution; [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/30/2023 and completed on 11/3/2023, the facility did not ensure that each resident has a right to make choices about aspects of their life in the facility that are significant to the resident. This was identified for one (Resident #283) of three residents reviewed for Choices. Specifically, Resident #283 had a Physician's order to be weighed every day during the 11:00 PM-7:00 AM shift. The facility staff woke Resident #283 up at 4:00 AM to weigh the resident. Resident #283 refused the weights on multiple occasions and told the staff they did not want to be woken up early in the morning; however, the staff did not honor resident's choices and continued to wake the resident early in the morning to obtain the resident's weights. The finding is: [...]

Inspectors wroteBased on record review, observation, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00322792 and NY00317444), the facility did not ensure each resident received adequate supervision and assistance according to the plan of care to prevent accidents. This was identified for two (Resident #170 and #333) of five residents reviewed for Accidents. Specifically, 1) Resident #170's care plan documented the resident required two-person assistance for transfers. On 8/23/2023 Certified Nursing Assistant (CNA) #3 transferred Resident #170 from a shower chair to a wheelchair without utilizing assistance from a second person. Subsequently, Resident #170 fell sustaining an abrasion to the right knee; and 2) Resident #333 required extensive assistance of one person for toileting as per their Comprehensive Care Plan (CCP). [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification survey initiated on 10/30/2023 and completed on 11/3/2023, the facility did not ensure that all medications and biologicals were properly stored. This was identified in one (Unit 2 North West) of four medication rooms reviewed during the medication storage task. Specifically, on 11/3/2023 at 11:41 AM the Unit 2 medication refrigerator was observed with an internal temperature of 50 degrees Fahrenheit. Multiple medications and biologicals were observed being stored in the same refrigerator. The manufacturer's storage directions for all the items stored in the refrigerator were to be maintained between 36 degrees Fahrenheit and 46 degrees Fahrenheit. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/30/2023 and completed on 11/3/2023, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. This was identified for one (Resident #383) of three residents reviewed for Transmission-Based Precautions (TBP). Specifically, Resident #383 was on contact precautions for an infection in the surgical drainage tube. A contact precaution sign at the resident's doorway directed staff to wear a gown and gloves when providing care to the resident or when coming in contact with the resident's environment. On 10/30/2023 a Nurse Practitioner (NP) #1 was observed in Resident #383's room coming in contact with environmental surfaces. NP #1 was observed not wearing a gown or gloves. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 9/29/2021 the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #50) of 3 residents reviewed for Pain Management. Specifically, Resident #50 had a physician's order for an Aspercreme pain patch to be applied at 9 AM; however, the location to place the patch was not identified in the order, and on 9/27/2021 the patch was not applied until after 12 PM, when the resident returned from Rehabilitation Therapy (Rehab). The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey completed on 9/29/2021, the facility did not ensure that resident records were accurately documented in accordance with professional standards of practice. This was evident for one resident (Resident #143) of three residents reviewed for Respiratory Care. Specifically, the facility did not have documented evidence that Tracheostomy care was provided to Resident #143 as per the facility protocol. The finding is: The facility Tracheostomy Care policy, protocol, and procedure dated 12/2020 documented that unless otherwise directed, the inner cannula is removed and cleaned every 8 hours; use tracheostomy care kit. Tracheostomy Wound Care is done every 8 hours unless otherwise ordered; sterile technique/dressing. [...]