Queens Nassau Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint- survey, the facility did not ensure that residents are informed and provided information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This was evident for 1 (Resident # 84) of 3 residents reviewed for Advance Directives out of a total sample of 38 residents. Specifically, the facility failed to discuss the resident's right and option to formulate an advance directive for Resident # 84.

Inspectors wroteBased on interviews and record review conducted during the Recertification and survey, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 1 (Resident #159) out of 2 residents reviewed for Accident. Specifically, the facility did not report Resident #159 was found with injuries of an unknown source to the New York State Department of Health (NYSDOH) within 2 hours.

Inspectors wroteBased on record review and interview during the Recertification survey, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for 1 (Residents #96) of 8 residents investigated for Pressure Ulcer/Injury out of 38 total sampled residents. Specifically, there was no comprehensive care plan developed to address at risk for skin breakdown and potential to develop pressure ulcers for Resident #96.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that resident's Comprehensive Care Plans were reviewed and revised. This was evident for 1 (Resident #63) of 8 residents reviewed for Pressure Ulcer out of 38 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plans for Skin Integrity and Pressure Ulcer were reviewed and revised after the last quarterly Minimum Data Set assessment was completed, or after Resident #63's Stage 3 pressure ulcer re-opened. The finding is: The facility policy and procedure titled Comprehensive Care Plan dated 2/2025 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that drugs and biologicals were stored in accordance with professional standards. This was evident in 1 Unit (2 South Unit) of 3 units observed for Medication Storage. Specifically, the 2 South Unit medication refrigerator was observed to contain one opened multi-dose insulin vial that was undated and three opened, dated multi-dose insulin vials that had not been discarded within 30 days.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 1 (Resident #22) of 8 residents observed for Pressure Ulcer/Injury out of 38 sampled residents. Specifically, Registered Nurse #5 failed to follow Enhanced Barrier Precautions by not donning a gown while performing a wound care dressing change.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey, the facility did not ensure resident's Minimum Data Set assessments accurately reflect the resident's status. This was evident for 1 (Resident #63) of 8 residents investigated for Pressure Sores, 1 (Resident #79) of 5 residents investigated for Mood and Behavioral Symptoms, and 1 (Resident #93) of 2 residents investigated for Activities of Daily Living out of 38 total sampled residents. Specifically, 1. The Minimum Data Set assessment did not document Resident #63's use of hand mittens. 2. There was no documentation of Resident #79 use of Wander Guard Device on the Minimum Data Set assessment. 3.) The Minimum Data Set assessment did not capture that Resident #93 had a Stage 3 pressure ulcer.

Inspectors wroteBased on observation, interviews and record review conducted during an Abbreviated Survey (NY00323188), the facility failed to protect the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of five residents (Resident #1) sampled for abuse. Specifically, on 09/02/23, Resident #1 was hit on the right side of the forehead during incontinent care, on the 3:00pm to 11:00pm shift, by Certified Nursing Assistant (CNA) #1. The physical abuse was witnessed by CNA #2. Resident #1 was assessed by Registered Nurse Supervisor (RNS) #3 with discoloration and swelling to the right side of the forehead. Resident #1 was transferred to emergency room (ER) for evaluation. Resident #1 returned to the facility on [DATE].

Inspectors wroteBased on observation, interviews, and record review during an abbreviated and partial extended survey (NY00322953), the facility failed to ensure a resident, identified as an elopement risk and had a history of previous elopement, received adequate supervision to prevent elopement from facility. This was evident in 1 of 5 residents sampled (Resident #1). Specifically, on 08/29/2023, Resident #1, who was cognitively impaired and had a wander alert device in place, left the building undetected. Resident #1 returned to the facility from a clinic appointment on 08/29/2023 at 3:42 PM. There was no documented evidence that Resident #1 was monitored by staff every 15 minutes, as an intervention to prevent elopement, after 3:45 PM on 08/29/2023. Subsequently, Resident #1 was identified missing at 5:40 PM. [...]

Inspectors wroteBased on observation, record review and interview, during the recertification survey of 3/9/23 to 3/16/23, the facility failed to ensure food was storeed, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, multiple items were observed in the dairy and meat walk-in refrigerators without proper labeling and dating. Two expired food items were observed in the emergency storage area. An employee was observed without a hair restraint or beard restraint, with hair exposed.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure each resident remained free from physical restraints. This was evident for 2 out of 6 residents reviewed for Physical restraints out of a sample of 35 residents. (Resident #54 and #141). Specifically, Resident #141 had a lap tray restraint in use without a medical justification, assessment, evidence of less restrictive alternatives tried, and ongoing evaluation for continued use. Resident #54 had a lap tray restraint in use without a medical justification, assessment, care plan, evidence of less restrictive alternatives tried, and ongoing re-evaluation for continued use.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that all alleged violations, including injuries of unknown origin, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve serious bodily injury, to the State Survey Agency. This was evident for 1 of 4 resident reviewed for Accident. (Resident #59). Specifically, the facility did not report Resident #59's left distal tibia fracture of unknown origin to New York State Department of Health (NYSDOH) within 2 hours. The finding is: The facility policy titled Accident/Incident Reporting dated 08/2022 states All accidents/incidents/episodic events will be investigated thoroughly, documented and reported to the NYS DOH as appropriate. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey from 03/09/23 to 03/16/23, the facility did not ensure that the Minimum Data Set (MDS) assessments accurately reflects the resident's status. This was evident for 2 out of 6 residents reviewed for Physical restraints and 1 out of 3 residents reviewed for close records, out of a sample of 35 residents. Specifically, 1.) the MDS assessments did not accurately document trunk restraints were used for 2 residents with a lap tray (Resident # 54 and Res #141) who were unable to release the lap trays independently due cognitive and disability impairment. 2.) Resident #179 was discharged to the community and the discharge MDS dated [DATE], documented discharge assessment return not anticipated, discharge status to acute hospital.

Inspectors wroteBased on record review and interview, during the recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's medical, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. This was evident for 3 of 35 sampled residents (Resident #s 93, 54, and 128). Specifically, a CCP for Activities was not developed for Resident #93 upon readmission. A restraint CCP was not developed to address Resident #54's lap tray. A CCP was not developed to address the care needs for Resident #128's midline catheter placement and use to administer Intravenous (IV) medication.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 2 (Resident #45 and Resident #66) of 7 residents reviewed for Limited Range of Motion from a sample of 35 residents. Specifically, Residents #45, a resident with left hand contractures, was observed without a left palm guard in place, as ordered, and Resident #66, a resident with left hand contractures, was observed without a left resting hand roll in place, as ordered.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 3/9//23 to 3/16/23, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (3 North Unit). Specifically, two bottles of expired Bisacodyl tablets were stored in 3 North Unit medication room.