Maria Regina Residence Inc

F-F725.

10 NYCRR 483.35(a)(1)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 335837 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50423 Residents Affected - Few Based on observations, interviews, and record review during the Recertification Survey initiated on [DATE REDACTED] and completed on [DATE REDACTED], the facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. This was identified for one (Resident #31) of four residents reviewed for Vision and Hearing. Specifically, a plastic cup containing two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment medications were observed on Resident #31's bedside table on [DATE REDACTED]. The Refresh Liquigel eye drops expiration date was documented as ,d+[DATE REDACTED] and the resident was observed to self-administer the expired eye drops.

The finding is:

The facility policy titled Storage of Medication dated ,d+[DATE REDACTED] documented that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Compartments containing drugs and biologicals shall be locked when not in use. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

Resident #31 was admitted with diagnoses including Dry Eye Syndrome of both eyes and Cataract. The Quarterly Minimum Data Set assessment dated [DATE REDACTED] documented a Brief Interview for Mental Status score of 15, indicating the resident's cognition was intact. The Minimum Data Set assessment documented

the resident had adequate vision and used corrective lenses.

A Comprehensive Care Plan titled Sensory Deficit: Visual Deficit dated [DATE REDACTED] documented interventions including Ophthalmology and Optometry consults as appropriate, encourage the resident to ask for assistance as needed, and maintain eyeglasses.

There was no documentation in the resident's medical record of an assessment or a comprehensive care plan to self-administer medications.

A Physician's order dated [DATE REDACTED] last renewed on [DATE REDACTED] documented to administer Systane Nighttime 95 percent to 3 percent eye ointment to both eyes at bedtime.

During an observation and interview on [DATE REDACTED] 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 REDACTED]. The resident stated the nurses gave them the Refresh Liquigel to self-administer the eye drops.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 335837 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview on [DATE REDACTED] at 11:09 AM, Licensed Practical #5, the medication nurse, stated they were not aware Resident #31 had a plastic cup with four bottles of eye medications available to them in the room. Level of Harm - Minimal harm or Licensed Practical Nurse #5 stated the resident did not have a physician's order to self-administer any potential for actual harm medication and these medications should not be stored in the resident's room, especially the expired medication. Residents Affected - Few

During an interview on [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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)(,d+[DATE REDACTED])

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 335837