Maria Regina Rehabilitation And Nursing
Maria Regina Rehabilitation and Nursing in Brentwood, NY — inspection on January 28, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on [DATE] at 11:14 AM, Licensed Practical Nurse #4 stated Resident #31 should not have had any medications including any expired medication in their room because they do not have a Physician's order to self-administer medication.
During an interview on [DATE] at 4:08 PM, the Pharmacist stated that Refresh eye drops should discarded after the manufacturer's expiration date.
The Pharmacist stated they do not recommend using any medication past the expiration date because the medication may become less effective.
During an interview on [DATE] at 11:22 AM, the Director of Nursing Services stated Resident #31 should not have had any eye drops stored in the resident's room without an evaluation and a physician's order to self-administer the medication.
The resident should not have had access to any expired medication. 10 NYCRR 415.18(e)(1-4)
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
During an interview on 1/24/2025 at 3:42 PM, the Wound Care Registered Nurse stated on 1/3/2025 they evaluated the resident's left elbow stage III pressure ulcer and did not recall the resident having any discoloration to their left forearm.
The Wound Care Registered nurse did not notice the discoloration until today, 1/24/2025.
During an interview on 1/27/2025 at 2:07 PM, Registered Nurse #4 stated they completed the admission assessment for Resident #273 on 1/2/2025.
Registered Nurse #4 stated they completed a head-to-toe assessment and the resident did not have any discoloration or a bruise on their left forearm.
Registered Nurse #4 stated when they completed their assessment if they had observed a discoloration on the resident's forearm that they would have documented the bruise in their skin assessment.
During an interview on 1/28/2025 at 12:01 PM, the Director of Nursing Services stated that Certified Nursing Assistant #6 should have reported the bruise to the charge nurse or the supervisor.
The Director of Nursing Services stated the supervisor should have then initiated an Accident/Incident Report to determine the root cause of the incident.
The Director of Nursing Service stated they had initiated an investigation as soon as they were informed on 1/24/2025 and abuse was ruled out. 10 NYCRR 415.4(b)(2)
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
During a subsequent interview on 1/24/2025 at 1:20 PM, Clinical Dietitian #1 stated when they enter a monthly weight into a resident's Electronic Medical Record, they do not look for a 7.5% weight loss in three months, but mainly for a 5% weight loss from month to month.
Clinical Dietitian #1 stated all resident weights have to be obtained by the tenth of the month; however, this month they ran the report for this month's weights on 1/22/2025.
The report indicated Resident #5 had an 8.48% weight loss in 90 days.
Clinical Dietitian #1 stated they did not have the time to write any significant weight loss notes yet for the month of January 2025.
Clinical Dietitian #1 stated the notes would be completed before the end of the month.
During an interview on 1/24/2025 at 1:50 PM, the Chief Clinical Dietitian stated on the first of every month, Certified Nursing Assistants start to take residents' monthly weights which are usually completed within 5 days and all reweighs have to be done by the tenth of the month.
The Chief Clinical Dietitian stated that all Clinical Dietitians are responsible for putting the weights into the Electronic Medical Record. If there is a weight gain or loss of five pounds from one month to the next, a reweigh must be obtained to ensure the accuracy of the weight.
The Chief Clinical Dietitian stated a significant weight loss was 5% in one month, 7.5% in three months, and 10% in six months.
The Chief Clinical Dietitian stated that Clinical Dietitian #1 may not have been looking for 7.5% weight losses in three months when entering monthly weights into the residents' Electronic Medical Records, but should have.
During an interview on 1/27/2025 at 10:10 AM, Licensed Practical Nurse #1, who was the Charge Nurse on Resident #5's unit, stated the Clinical Dietitian reviews all the weights and if they see that a resident had significant weight loss, they inform any Nurse on the unit who then contacts the resident's Primary Physician to inform them of the significant weight loss.
Licensed Practical Nurse #1 stated that Clinical Dietitian #1 never told them that the resident had a significant weight loss.
Licensed Practical Nurse #1 stated that if they had been informed, they would have contacted the resident's Primary Physician and written a Nursing Progress Note.
During an interview on 1/27/2025 at 11:10 AM, the Director of Nursing Services stated the Clinical Dietitians are responsible for identifying significant weight losses and reporting them to the Interdisciplinary Team (Nursing, Social Work, Rehabilitation, and Activities) during the morning report.
A Unit Nurse should also be made aware.
The nurse should notify the resident's Primary Physician of the significant weight loss to obtain any new orders to address the resident's weight loss, such as ordering blood work or nutritional supplements. 10 NYCRR 415.12(i)(1)
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
During an interview on 1/27/2025 at 10:10 AM, Licensed Practical Nurse #1, who was the Charge Nurse on Resident #5's unit, stated the Clinical Dietitian reviews all the weights and if they see that a resident had significant weight loss, they inform any Nurse on the unit who then contacts the resident's Primary Physician to inform them of the significant weight loss.
Licensed Practical Nurse #1 stated that Clinical Dietitian #1 never told them that the resident had a significant weight loss.
Licensed Practical Nurse #1 stated that if they had been informed, they would have contacted the resident's Primary Physician and written a Nursing Progress Note.
During an interview on 1/27/2025 at 10:25 AM, the resident's Primary Physician (Primary Physician #1) stated they should have documented the resident's weight in their monthly review.
Primary Physician #1 stated they did not realize they had left the monthly weight review section blank.
Primary Physician #1 stated they had only compared this month's weight with the resident's weight from the month before and did not see a significant weight loss.
Primary Physician #1 stated that the facility Dietitians and Nurses are pretty good in letting them know if a resident had a significant weight loss, but they were never informed that the resident had an 8.48% significant weight loss from October 2024 to January 2025.
During an interview on 1/27/2025 at 10:40 AM, the Medical Director stated, The dietitians are excellent in contacting the Physician about weight loss, but the Primary Physician can also look at the weights [themselves] to see if there have been any significant weight losses.
The Medical Director stated that the resident's Primary Physician was supposed to document the resident's weight in their monthly review and if a significant weight loss was identified, interventions such as supplements should be added.
The Physician should document the cause of the weight loss.
The Medical Director stated that all questions on a monthly visit template absolutely should be answered. 10 NYCRR 415.15(b)(1)(i)(ii)
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
1/28/2025 indicated sufficient nursing staff were available to care for the resident.
were no staffing complaints from the residents.
-The facility presented evidence of 100 newly hired staff which included nursing staff since March 2024 and hired sufficient staff by August 2024. -Interview with Resident Council members on 1/21/2025 confirmed improved staffing and staff responses to resident needs. -Interview with facility staff indicated improved staffing levels since March 2024. -During the survey frequent observations and review of the facility staffing level indicated compliance with F-F725. 10 NYCRR 483.35(a)(1)(2)
335837 01/28/2025
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
During an interview on [DATE] at 4:08 PM, the Pharmacist stated that Refresh eye drops should discarded after the manufacturer's expiration date.
The Pharmacist stated they do not recommend using any medication past the expiration date because the medication may become less effective.
During an interview on [DATE] at 11:22 AM, the Director of Nursing Services stated Resident #31 should not have had any eye drops stored in the resident's room without an evaluation and a physician's order to self-administer the medication.
The resident should not have had access to any expired medication. 10 NYCRR 415.18(e)(1-4)
During an observation and interview on [DATE] at 10:34 AM, Resident #31 was observed lying in bed with their bedside table placed directly in front of the resident. A plastic cup was observed on the bedside table containing four bottles of eye drops including two Refresh Liquigel bottles and two Systane eye ointments.
The resident took the Refresh Liquigel eye drops from the cup and self-administered the eye drops to the right eye.
The Refresh Liquigel eye drops documented an expiration date of [DATE].
The resident stated the nurses gave them the Refresh Liquigel to self-administer the eye drops.
335837
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 335837 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Maria Regina Rehabilitation and Nursing 1725 Brentwood Road Brentwood, NY 11717
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.