Rego Park Nursing Home

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00355639), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made to the State Survey Agency in accordance with State law through established procedures. This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 09/20/2024 at 7:30 AM, Resident #1 was observed with an abrasion and redness without any active bleeding on the left forearm. The facility investigated the incident and did not report the injury of unknown origin to the New York State Department of Health.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 3 (Residents #46, #294, and #295) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required, did not ensure that notices were mailed on the same day telephone notification was made, and did not provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form for residents after discharge from skilled services.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/08/2024 to 10/16/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #52) of 2 residents reviewed for positioning / mobility. Specifically, Resident #52 has been observed on 2 occasions without the hand rolls applied in both hands as per physician orders.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 4/3/23 to 4/11/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit 6) of 6 units. Specifically, Unit 6 was observed with wheelchairs (WC) with torn armrests, torn and frayed mesh on shower chairs, the dining room floor in disrepair, resident closets and bedside tables in disrepair, missing molding, and a bathroom door in disrepair.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure a resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #61) of 2 residents reviewed for Discharge out of 35 total sampled residents.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure the participation of the resident and the resident's representative in the development of the comprehensive care plan (CCP), and the review and revision of the CCP after each assessment. This was evident for 2 (Residents #135 and #61) of 38 total sampled residents. Specifically, 1) Resident #135's CCP related to altered respiratory status was not revised to reflect the resident's oxygen use, and 2) Resident #61 was not invited to their CCP meeting.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure treatment and care were provided in accordnace with professional standards of practice. This was evident for 1 resident (Resident #84) reviewed for Infection/Transmission-Based Precautions out of 35 total sampled residents. Specifically, the facility did not ensure Resident #84 received care for a right upper arm intravenous (IV) midline.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 4/3/23 to 4/11/23, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for 1 resident (Resident #84) reviewed for Infection/Transmission-Based Precautions out of 35 total sampled residents. Specifically, the physician did not evaluate Resident #84 for the continuation of a right upper arm intravenous (IV) midline upon admission, and there were no physician's orders for care of the IV midline.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 4/3/23 to 4/11/23, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This was evident for 1 (Residents # 136) of 5 residents reviewed for Unnecessary Medications out of 35 total sampled residents. Specifically, non-pharmacological interventions were not used to address Resident #136's behaviors and an antipsychotic medication was administered without attempting a Gradual Dose Reduction (GDR).

Inspectors wroteBased on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure that: residents' Comprehensive Care Plans (CCPs) were reviewed and revised after a Fall; and the facility did not ensure cognitively intact cognitively intact residents were invited to participate in the development of their plan of care. Specifically: (1) The residents' CCPs were not reviewed and revised to determine effectiveness of interventions and include new interventions after falls (Resident #51 and #115). (2) Residents were not invited to participate in the care plan meeting (Resident #31 and #48). This was evident for 4 out of 35 residents reviewed in the investigation sample (Resident #s 51, 115, 31, and 48).

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) A nurse was observed administering eye drop during medication pass without wearing gloves; (2) oxygen tubing was observed on the floor; and (3) Staff were observed assisting multiple residents without performing hand hygiene between residents or after touching dirty items during the dining preparation and service. This was evident for 1 of 4 residents observed for Med Admin; 2 of out of 31 residents reviewed in the investigation Sample; and random observations on 1 out of 4 units observed for Dining (Unit 6).

Inspectors wroteBased on record reviews and interviews conducted during the Recertification survey and abbreviated survey (NY00252328), the facility failed to notify a resident's representative when there was a need to alter treament significantly. Specifically, a resident's representative was not informed when the resident was started on a new medication, Ambien, at bedtime. This was evident for 1 of 2 residents reviewed for Notification of Change (Resident #336). The finding is: The Facility Policy titled Change in a resident's condition dated February 2020 documented the nurse will notify the resident's representative when there is significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications will be made within 24 hours of a of change occurring in the resident's medical/mental condition or status. [...]

Inspectors wroteBased on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure that all alleged violations were thoroughly investigated within 5 workdays and reported to the administrator or his or her designee. Specifically, Accident/Incident (A/I) investigations were not fully completed to rule out neglect. This was evident for 2 of 2 residents reviewed for Fall (Resident #51 and # 115).

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's Minimum Data Set 3.0 (MDS) assessment documented the resident had a trunk restraint used in the chair or out of bed when the resident had no restraint. This was evident for 1 of 1 resident reviewed for MDS accuracy (Resident #123). The finding is: The CMS RAI Version 3.0 Manual (Dated October 2018), titled Procedure: General Information documented The RAI, MDS 3.0 process requires input from the health care team to complete the designated areas in a timely and accurate fashion in accordance with State and Federal regulations. Resident #123 was admitted to the facility with diagnoses that included Hypertension, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. [...]

Inspectors wroteBased on record review and staff interview during the Recertification and Abbreviated survey (NY00273390), the facility did not ensure adequate supervision and assistance was provided to a resident to prevent an accident. Specifically, a resident identified as high risk for fall/injury, with severely impaired cognition, had fall with injury while trying to use bathroom. The resident's care plan was not reviewed and revised with interventions to prevent additional falls. The resident was readmitted from the hospital and had another fall while attempting to use the bathroom. This was evident in 1 of 2 residents reviewed for Accident/Fall (Resident #51). The finding is: (1) Resident #51 had diagnoses which include Non-Alzheimer's Dementia, Peripheral Vascular Disease, and Hypertension. [...]