Inspection Reports for
Maria Regina Rehabilitation and Nursing
1725 Brentwood Rd - Bldg 1, Brentwood, NY, 11717
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
8.4 citations/year
Citations are regulatory findings recorded during state inspections.
65% worse than New York average
New York average: 5.1 citations/year
Citations per year
24
18
12
6
0
Inspection Report
Annual Inspection
Citations: 7
Date: Jan 28, 2025
Visit Reason
The survey was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including improper storage and self-administration of expired medications, failure to timely report injuries of unknown origin, inaccurate resident assessments, incomplete care plan updates, significant unaddressed weight loss in a resident, and insufficient nursing staff during a prior period in 2024. Corrective actions were noted for staffing deficiencies.
Citations (7)
F 0761: The facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. Resident #31 was observed self-administering expired eye drops stored unsecured on their bedside table.
F 0609: The facility did not ensure injuries of unknown origin were reported within 24 hours. Certified Nursing Assistant #6 failed to report a bruise on Resident #273's left forearm identified on 1/18/2025.
F 0641: The facility did not ensure an accurate assessment was completed. Resident #128's Quarterly Minimum Data Set assessment incorrectly documented the resident as comatose.
F 0657: The facility did not ensure comprehensive care plans were reviewed and revised to reflect resident preferences and status. Resident #102's care plan was not updated to reflect refusal and removal of hearing aids.
F 0692: The facility did not ensure residents maintained acceptable nutritional and hydration status. Resident #5 had an 8.48% weight loss in 90 days that was not addressed by the Clinical Dietitian.
F 0710: The facility did not ensure medical care was supervised by the physician. Resident #5's significant weight loss was not addressed by the Primary Physician, and weight changes were not documented in monthly visits.
F 0725: The facility did not ensure sufficient nursing staff were available on Unit 2 East during weekends in March 2024. Staffing was improved by the time of survey.
Report Facts
Weight loss percentage: 8.48
Bed capacity: 35
Resident census: 34
Resident census: 35
New hires: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | Medication Nurse | Named in finding regarding unawareness of expired medications stored in Resident #31's room. |
| Licensed Practical Nurse #4 | Stated Resident #31 should not have expired medications in room without physician order. | |
| Pharmacist | Stated expired eye drops should be discarded and not used. | |
| Director of Nursing Services | Stated Resident #31 should not have had expired medications in room without evaluation and order. | |
| Certified Nursing Assistant #6 | Failed to report bruise on Resident #273's forearm. | |
| Licensed Practical Nurse #6 | Unaware of bruise on Resident #273's forearm. | |
| Wound Care Registered Nurse | Noted no discoloration on Resident #273's forearm on 1/3/2025; noticed bruise on 1/24/2025. | |
| Registered Nurse #4 | Completed admission assessment for Resident #273 and did not document bruise. | |
| Licensed Practical Nurse Charge Nurse #2 | Notified about Resident #102's refusal to wear hearing aids but did not update care plan. | |
| Social Worker #1 | Responsible for Minimum Data Set Section B; admitted error documenting Resident #128 as comatose. | |
| Minimum Data Set Assessment Coordinator | Acknowledged error in Resident #128's assessment. | |
| Clinical Dietitian #1 | Did not address Resident #5's significant weight loss in a timely manner. | |
| Chief Clinical Dietitian | Described weight monitoring and reporting responsibilities. | |
| Licensed Practical Nurse #1 | Charge Nurse | Unaware of Resident #5's significant weight loss notification. |
| Primary Physician #1 | Primary Physician | Did not document weight change or address significant weight loss for Resident #5. |
| Medical Director | Stated physician should document weight loss and causes; noted failure in Resident #5's case. | |
| Administrator | Discussed staffing improvements since early 2024. | |
| Certified Nursing Assistant #1 | Reported prior understaffing on Unit 2 East. | |
| Certified Nursing Assistant #2 | Described care prioritization during understaffing. | |
| Staffing Coordinator | Described staffing requirements and weekend coverage responsibilities. | |
| Director of Nursing Services | Acknowledged prior understaffing and corrective actions. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 17
Date: Jan 28, 2025
Visit Reason
Multiple quality of care and life safety deficiencies identified, all corrected by March 19, 2025 or earlier.
Findings
Multiple quality of care and life safety deficiencies identified, all corrected by March 19, 2025 or earlier.
Citations (17)
Accuracy of assessments — quality of care
Care plan timing and revision — quality of care
Develop/implement comprehensive care plan — quality of care
Label/store drugs and biologicals — quality of care
Nutrition/hydration status maintenance — quality of care
Reporting of alleged violations — quality of care
Resident self-admin meds-clinically approp — quality of care
Resident's care supervised by a physician — quality of care
Sufficient nursing staff — quality of care
Develop ep plan, review and update annually — life safety code
Electrical systems - essential electric syste — life safety code
Electrical systems - other — life safety code
Fire alarm system - testing and maintenance — life safety code
Fire drills — life safety code
Fundamentals - building system categories — life safety code
Physical environment — life safety code
Sprinkler system - maintenance and testing — life safety code
Inspection Report
Complaint Investigation
Citations: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as an abbreviated survey triggered by a complaint (Complaint # NY000330281) regarding inadequate supervision leading to a resident ingesting a hazardous substance.
Complaint Details
The complaint investigation was substantiated. Resident #1 ingested hair dye due to inadequate supervision, causing swelling of lips and tongue and requiring emergency hospital admission. The incident was isolated, and staff were retrained with disciplinary action taken against Charge Nurse #2.
Findings
The facility failed to ensure adequate supervision to prevent accidents, resulting in Resident #1 ingesting hair dye left unattended at the nursing station, causing swelling and requiring emergency hospital transfer. The facility's policies on securing hazardous substances were found to be insufficiently followed, and corrective actions including staff retraining and disciplinary measures were implemented.
Citations (1)
F 0689: The facility did not ensure that each resident received adequate supervision to prevent accidents. Resident #1 ingested Wella Color Charm hair dye left unattended at the nursing station, resulting in actual harm and hospital transfer.
Report Facts
Residents reviewed for accidents: 3
Steroid dosage: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charge Nurse #2 | Named in relation to the incident and disciplinary action | |
| Certified Nurse's Aide #1 | Observed Resident #1 ingesting hair dye and reported the incident | |
| Nursing Supervisor #1 | Responded to the incident and assessed Resident #1 | |
| Medical Doctor #1 | Ordered treatment and hospital transfer for Resident #1 |
Inspection Report
Annual Inspection
Citations: 5
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with professional standards of quality, medication administration, respiratory care, nursing competencies, and drug labeling at Maria Regina Rehabilitation and Nursing.
Findings
The facility failed to ensure professional standards of quality in medication administration, respiratory care, and nursing competencies. Deficiencies included administering expired medication, failure to notify and document changes in resident condition, improper oxygen therapy administration, and inadequate competency of nursing assistants leading to resident injury.
Citations (5)
F 0658: The facility administered expired Vitamin B-1 to Resident #126 without checking the expiration date, violating medication storage policies.
F 0658: Licensed Practical Nurse #1 failed to notify nursing supervisor or physician about Resident #142's swollen hand and did not document the condition, delaying assessment and treatment.
F 0695: Residents #59, #84, and #118 did not receive oxygen therapy as prescribed; oxygen flow rates were set higher than ordered and nurses failed to verify orders and adjust accordingly.
F 0726: Certified Nursing Assistant #9 repositioned Resident #141 without assistance and in the dark, resulting in a laceration to the resident's head.
F 0761: Drugs and biologicals were not labeled according to professional standards; expired Vitamin B-1 was administered to Resident #126.
Report Facts
Deficiencies cited: 5
Medication expiration date: 8
Laceration size: 2
Oxygen flow rates observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Administered expired Vitamin B-1 without checking expiration date. |
| LPN #1 | Licensed Practical Nurse | Failed to notify supervisor or physician about Resident #142's swollen hand and did not document condition. |
| LPN #3 | Licensed Practical Nurse, Unit Charge Nurse | Observed oxygen flow rates set incorrectly and did not verify physician orders. |
| LPN #4 | Licensed Practical Nurse | Forgot to monitor oxygen flow rates as prescribed during shift. |
| CNA #9 | Certified Nursing Assistant | Repositioned Resident #141 without assistance and in the dark, leading to resident injury. |
| RN #1 | Registered Nurse, Nursing Supervisor | Responsible for ensuring oxygen therapy was administered as prescribed. |
| RN #2 | Registered Nurse | Assessed Resident #141 after injury and reported findings. |
| Director of Nursing Services | Director of Nursing | Interviewed regarding medication expiration and nursing reporting expectations. |
| Consulting Pharmacist #1 | Consulting Pharmacist | Confirmed medication expiration checks and removal procedures. |
| Medical Director | Physician | Provided expectations for oxygen therapy administration. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 7
Date: Sep 25, 2023
Visit Reason
Multiple Level 2 quality of care and life safety deficiencies identified, all corrected by November 15, 2023 or earlier.
Findings
Multiple Level 2 quality of care and life safety deficiencies identified, all corrected by November 15, 2023 or earlier.
Citations (7)
Competent nursing staff — quality of care
Label/store drugs and biologicals — quality of care
Respiratory/tracheostomy care and suctioning — quality of care
Responsibilities of providers; required notif — quality of care
Services provided meet professional standards — quality of care
Corridors - areas open to corridor — life safety code
Sprinkler system - maintenance and testing — life safety code
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Jan 3, 2022
Visit Reason
One Level 2 quality of care deficiency related to reporting to national health safety network, not corrected at time of report.
Findings
One Level 2 quality of care deficiency related to reporting to national health safety network, not corrected at time of report.
Citations (1)
Reporting - national health safety network — quality of care
Inspection Report
Annual Inspection
Citations: 4
Date: Sep 13, 2021
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for Maria Regina Rehabilitation and Nursing.
Findings
The facility was found deficient in ensuring accurate resident assessments, proper administration of respiratory care including oxygen therapy, and appropriate medication management for vision care. Specifically, oxygen therapy was not consistently administered as ordered for Resident #87, and Timolol eye drops were discontinued without proper physician reorder for Resident #116.
Citations (4)
F 0641: Ensure each resident receives an accurate assessment. Resident #87's MDS assessments did not document oxygen therapy despite a physician's order for continuous oxygen via nasal cannula.
F 0685: Assist a resident in gaining access to vision and hearing services. Resident #116 was not administered Timolol eye drops as recommended by the Ophthalmologist, resulting in eye redness and discharge.
F 0695: Provide safe and appropriate respiratory care for a resident when needed. Resident #87 was observed not using the nasal cannula and not receiving oxygen as ordered on two occasions.
F 0711: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders at each required visit. The attending physician did not reorder Timolol after it was stopped, despite ophthalmologist recommendations.
Report Facts
Residents reviewed for Respiratory care: 2
Residents reviewed for vision: 4
BIMS score: 12
BIMS score: 14
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Interviewed regarding omission of oxygen therapy documentation in MDS assessments. | |
| Director of Nursing Services | Interviewed regarding oxygen therapy documentation and medication discontinuation. | |
| Registered Nurse Charge Nurse #1 | Interviewed about Timolol administration and ophthalmologist consult. | |
| Attending Physician (MD) | Interviewed about medication management and ophthalmologist recommendations. | |
| Ophthalmologist | Interviewed about Timolol recommendations and medication discontinuation. | |
| Registered Nurse #6, Unit Charge Nurse | Interviewed about oxygen therapy administration for Resident #87. | |
| Certified Nursing Assistant #1 | Interviewed about oxygen therapy administration and nasal cannula use for Resident #87. |
Viewing
Loading inspection reports...
