Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Far Rockaway Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Incomplete PASARR screening was identified for a resident admitted with dementia, bipolar disorder, and a right femur fracture. The Level I PASARR form documented no dementia diagnosis, but items needed to determine whether a Level II eval was required were left unanswered. Facility leaders stated the PASARR form should have been completed and reviewed accurately before admission, but the admission process involved uploading documents without reviewing their content.
Failure to implement a resident’s care plan for bilateral UE contractures: a cognitively intact resident with limited ROM and fisted hands was repeatedly observed without the ordered palm guards or gauze in place, despite care plan and CNA Kardex instructions requiring the adaptive devices. Staff reported the resident had a history of refusing the devices, but there was no documented refusal, and an LPN unit manager was unaware of recent nonuse.
A resident with dysphagia, gastrostomy status, and severely impaired cognition did not receive the full ordered amount of enteral formula. The feeding was started on the evening shift, but by the next morning the resident was no longer connected to the pump and only 800 mL of the ordered 1200 mL had been delivered. An LPN documented that the full amount had been given without verifying completion, and the overnight LPN reported the pump alarmed repeatedly, the feed was paused and resumed several times, and it was stopped early to silence the alarm.
Incomplete Enteral Feeding Documented as Completed: A resident with dysphagia, gastrostomy status, and severely impaired cognition was ordered continuous evening tube feeding for a total of 1200 mL. The LPN on duty reported repeated pump alarms and stopped the feeding early, then told the day nurse by phone to resume it. The unit manager initially signed the MAR as if the full amount had been delivered without verifying the pump or actual volume, and surveyors later found the resident disconnected with the pump off; the pump review showed only 800 mL had infused.
Surveyors found multiple insulin vials in a medication cart that were missing resident names or opening dates, and one vial was kept past the 28-day discard timeframe. An LPN, the unit manager, and the DON all stated insulin vials must be labeled with the resident name, dated when opened, and discarded after 28 days, but the cart still contained unlabeled, undated, and expired insulin.
An infection control deficiency occurred when an LPN handled sennosides tablets with bare hands during a med pass and then administered them with other oral meds to a resident with multiple chronic conditions and moderate cognitive impairment. In a separate event, an LPN cleaned a glucometer with alcohol prep pads instead of the required germicidal wipes after checking blood sugars for several residents, and the cart did not contain the proper disinfectant wipes.
The facility failed to maintain a safe and clean environment, with issues such as broken blinds, torn curtains, and rusty equipment observed in multiple areas. Staff reported environmental concerns verbally or in a log book, but the maintenance work book showed no evidence of these issues being logged. The Director of Housekeeping/Maintenance acknowledged challenges in maintaining the environment and stated that an exterminator visits regularly.
A facility failed to ensure a resident's representative was notified of Medicare Part A benefits termination. The Notice of Medicare Non-Coverage was not mailed on the same day as the phone notification, and there was no confirmation of receipt. Interviews revealed uncertainty among staff about the notice's delivery, indicating a breakdown in the notification process.
The facility breached resident privacy by conducting blood glucose monitoring and insulin administration in hallways, as observed during a survey. Two residents were involved, with LPNs performing these procedures in non-private settings, contrary to facility policy. Interviews revealed staff were either unaware or nervous, leading to this privacy violation.
A facility failed to create a comprehensive care plan for a resident with vision concerns, despite the resident's impaired vision and consultations with eye specialists. The oversight was acknowledged by the DON, who noted that care plans are usually managed by unit managers and RNs.
An LPN failed to administer insulin to a resident with diabetes as per the physician's order, mistakenly believing the resident was on a sliding scale. The resident's blood glucose levels were above the threshold for insulin administration, yet the LPN did not provide the prescribed dose. The LPN admitted to not reading the order before testing or administering insulin, leading to repeated errors.
A resident with a Stage 4 sacral pressure ulcer did not receive the prescribed treatment, and infection prevention standards were not maintained by an LPN. The LPN failed to apply the ordered bordered gauze and zinc ointment, and returned unused supplies to the treatment cart. The facility's protocol was not followed, as confirmed by the Assistant Director of Nursing and the Director of Nursing.
The facility failed to remove expired medications and improperly stored narcotics, as observed during a survey. Expired Lorazepam gel and Dronabinol were found in the medication room, and narcotics were stored in medication carts instead of double-locked cabinets. Staff interviews revealed a deviation from policy initiated by a former supervisor, which the current nursing leadership was unaware of.
A resident did not receive insulin as per physician's orders due to an LPN's misunderstanding of the insulin administration protocol. The LPN failed to administer 19 units of Novolog before meals unless the resident's blood glucose was under 100 mg/dL, mistakenly believing a sliding scale was in use. This error was repeated multiple times, with no documented evidence of insulin administration when required. Interviews revealed the LPN did not read orders before testing or administering insulin, highlighting a significant medication error.
A survey found that medications and biologicals were not properly labeled on a medication cart in an LTC facility. Open insulin vials and inhalers lacked the date opened and resident names. Interviews with staff revealed inconsistencies in labeling practices, despite existing guidelines.
A resident with specific dietary preferences and restrictions was repeatedly served incorrect food items, such as pineapple juice and mashed potatoes, despite facility policies requiring adherence to documented preferences. The meal assembly process failed to ensure accuracy, and staff interviews confirmed awareness of the issue.
During a survey, CNAs were observed assisting residents with hand hygiene without wearing gloves and not performing hand hygiene between residents. The DON confirmed that staff should use gloves and a receptacle for used wipes, while the Infection Control Preventionist noted a lack of specific training or policy on distributing hand wipes.
The facility was found to have environmental deficiencies, including soiled and damaged furniture in the North Unit Nurses Station, and disrepair in visitor and staff bathrooms. Observations noted rusted radiators, broken fixtures, and missing tiles. The Director of Housekeeping cited the building's age as a challenge, while the Administrator acknowledged the need for further improvements.
The facility was found deficient in its pest control program, as multiple flies were observed in resident rooms, the nurse station, dining room, and hallways during a survey. Despite regular exterminator visits and measures like replacing window screens and using ultraviolet lights, the fly issue persisted, indicating ineffective pest control.
Incomplete PASARR Screening Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately and was not completed prior to admission for one resident. Resident #74 was admitted with diagnoses of dementia, bipolar disorder, and a right femur fracture, and the admission MDS documented a BIMS score of 13, indicating intact cognition. The resident’s PASARR Level I screen dated 07/31/2024 was reviewed on 03/31/2026 and documented that the resident did not have a dementia diagnosis in item 22, but items 23 through 26 were indicated and left unanswered. These items were required to determine whether a Level II evaluation was needed. The facility policy stated centralized admission was to obtain the completed Level I screen before accepting the resident and that the social worker was to validate completion of the Level I and Level II PASARR documents upon admission. During interviews, the Director of Admission stated the offsite central admission department determined admission eligibility, received the pre-admission package, and uploaded documents without reviewing their content. The Director of Social Services stated the PASARR form was their responsibility to ensure it was received and completed accurately, and the DON and Administrator stated the screen should have been thoroughly reviewed and completed prior to admission to determine whether the resident was appropriately placed in the facility.
Failure to Implement Hand Positioning Devices for Resident with Bilateral Upper Extremity Contractures
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was implemented for Resident #5, including measurable objectives and timeframes to meet the resident’s medical and nursing needs. Resident #5 was admitted with diagnoses including major depressive disorder, generalized muscle weakness, and other abnormalities of gait and mobility, and the annual MDS documented a BIMS score of 14, indicating the resident was cognitively intact. The resident had bilateral upper extremity contractures and a functional limitation in range of motion in both upper extremities. A comprehensive care plan for bilateral upper extremity contractures was created on 5/14/2025 and included the use of bilateral gauze to prevent further closure of each hand. A later care plan for limited physical mobility related to bilateral upper extremity contractures documented the use of adaptive devices, including right and left hand palm guards to be removed during hygiene, ADLs, ROM, and grooming. However, during multiple observations, Resident #5 was found in bed without the required hand positioning devices in place, with both hands closed in a fisted position and fingers tightly closed into the palms. On one occasion, a palm guard was on the nightstand rather than on the resident’s hands, and the resident stated they were willing to use the device. The CNA Kardex also listed the palm guards as required interventions. During interviews, a CNA stated they had not yet provided morning care and were not aware the device was not in place, and an LPN unit manager stated the resident had a history of refusing the palm guards but did not know the resident had recently been refusing the adaptive device. There was no documented evidence of refusal of care.
Incomplete Enteral Feeding and Incorrect Documentation
Penalty
Summary
The facility failed to ensure that enteral feeding services met professional standards of quality for one resident receiving tube feeding. The resident had diagnoses including dysphagia, gastrostomy status, and adult failure to thrive, and the admission MDS documented severely impaired cognition. A physician order dated 03/25/2026 directed Isosource 1.5 to be administered via enteral tube at 65 mL/hour beginning at 6:00 PM for a total volume of 1200 mL each evening shift, with instructions to verify infusion every shift, keep the head of the bed elevated, stop the feeding when 1200 mL had infused, verify the pump setting, and document the total volume infused. The medication administration audit showed the enteral feed was started on 03/30/2026 at 5:04 PM. On 03/31/2026 at 9:07 AM, the resident was observed in bed with no feeding bag hanging, no connection to the feeding tube, and the pump screen off. At 9:16 AM, the unit manager documented that 1200 mL had been delivered, but later stated they had not verified completion before documenting and had assumed the feeding was finished because the setup was put away and the pump was off. On re-interview, the unit manager calculated that only 800 mL had been received. The overnight LPN stated the pump had alarmed several times, the feeding was paused, flushed, and resumed, and that the feeding was discontinued prematurely to silence the alarm; the LPN also stated the night nursing supervisor was not notified that the ordered amount had not been met.
Incomplete Enteral Feeding Documented as Completed
Penalty
Summary
Resident #20, who had dysphagia, gastrostomy status, adult failure to thrive, and severely impaired cognition, was ordered to receive Isosource 1.5 via enteral tube at 65 mL/hour beginning in the evening for a total volume of 1200 mL, with the head of bed elevated and the total volume verified before documenting completion. The care plan directed staff to administer tube feeding and water flushes per orders and to monitor for aspiration, tube dislodgement, infection, and tube dysfunction or malfunction. On the night shift, the assigned LPN reported that the feeding pump alarmed several times, requiring pauses, flushing, and resumption of the feeding. The LPN stated the feeding was discontinued prematurely to silence the alarm and that the day shift nurse was told by phone to resume the feeding, but the night nurse did not notify the nursing supervisor that the ordered amount had not been delivered. When the day shift began, the feeding setup had been put away and the pump was off, and the unit manager initially signed the MAR indicating that the full 1200 mL had been delivered without verifying the pump or the actual infused volume. During survey observation, the resident was in bed with the infusion pole at bedside, but no feeding bag was hanging, the resident was not connected to the tube, and the pump screen was off. The unit manager later reviewed the pump settings and determined that only 800 mL of the ordered 1200 mL had been infused. The unit manager stated the feeding should still have been infusing at the time of the earlier documentation and acknowledged that the MAR should not have been signed without confirming completion of the ordered tube feeding. The DON also stated that staff should not have documented the feeding as completed without confirming that the resident had received the full ordered amount.
Unlabeled and Expired Insulin Vials in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles on Unit 1. During an observation of the medication cart on 04/02/2026, surveyors found two opened vials of Novolog insulin with no resident name, one opened vial of Insulin Lispro for Resident #93 with no opened date, one opened vial of Novolin N insulin for Resident #62 dated 02/16/2026 and past the 28-day discard timeframe, and one opened vial of Lantus insulin for Resident #93 with no opened date. The report also noted two vials of insulin for Resident #93 without an open date and two vials of insulin that did not have resident names on them. The facility policy stated that insulin pens and cartridges are single-patient use and that opened multi-dose vials or injection pens must be dated and discarded within 28 days unless the manufacturer specifies otherwise. During interviews, the unit manager stated undated and unlabeled insulin vials had to be discarded, and the medication nurse stated the insulin vials should have resident labels and opening dates and should be discarded after 28 days, but the old insulin vials in the cart were not discarded. The DON stated insulin vials must have a resident name, be dated when first opened, and be discarded after 28 days, and that one vial of insulin is not used for multiple residents.
Infection Control Lapses During Medication Pass and Glucometer Cleaning
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to help prevent communicable diseases and infections during medication administration and medication storage tasks. During a medication pass for a resident with diabetes mellitus, cerebrovascular accident, seizure disorder, and moderate cognitive impairment, an LPN handled two sennosides tablets with bare hands after popping them out of the blister pack. The nurse then added those tablets to a cup containing other oral medications and administered all of the medications to the resident. The resident’s other oral medications were prepared from bottles and blister packs during the same pass, including amlodipine, aspirin, ferrous sulfate, Keppra, lamotrigine, and metformin. The report also identified improper cleaning of a blood glucose glucometer on Unit 2. An LPN stated and demonstrated that the glucometer was cleaned with an alcohol prep pad rather than a germicidal wipe effective against bloodborne pathogens. The nurse did not have germicidal wipes in the medication cart and stated they had used the glucometer to check blood sugars for four residents that day, cleaning the device after each use with alcohol prep pads. Facility policies required staff to follow infection control procedures during medication administration and to clean and disinfect blood glucose meters before and after each resident use with a disinfectant wipe based on manufacturer recommendations. Interviews with the Infection Preventionist, who was also the ADON and Nurse Educator, and the DON confirmed that touching medications with bare hands was an infection control concern and that alcohol prep pads were not sufficient for cleaning glucometers because they do not kill bloodborne pathogens.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during a recertification survey. On the South Unit, multiple deficiencies were noted, including broken blinds in Room #13, missing window slats in the dining room, and privacy curtains off the hook in Rooms #16 and another unspecified room. The Director of Maintenance and Housekeeping acknowledged awareness of these issues but stated that replacements for the broken blinds and missing slats were not available at the time. On the North Unit, several environmental concerns were identified, such as wheelchairs with torn armrests and encrusted dirt, rusty metal frames, and a corridor bathroom with a metal frame chair in disrepair. Additionally, the main dining room area had wobbly tables, rusty nails, and missing window slats, while the small TV area had a wall-mounted fan layered with dirt and dust. The maintenance work book for the North Unit showed no documented evidence of these concerns being logged, despite staff having the option to report issues verbally or in writing. Interviews with staff, including a CNA, LPN, and housekeeper, revealed that environmental concerns were communicated either verbally or through a log book. The Director of Housekeeping/Maintenance stated that an exterminator visits twice a week to address vermin issues, and maintenance staff review the log book at least twice daily. However, there was no set schedule for power washing resident equipment, and the Director acknowledged challenges in maintaining a safe environment due to some residents' behaviors.
Failure to Notify Resident's Representative of Medicare Coverage Termination
Penalty
Summary
The facility failed to ensure that a resident's designated representative was appropriately notified at the termination of Medicare Part A benefits. This deficiency was identified during a recertification survey, where it was found that the Notice of Medicare Non-Coverage was not mailed to the representative of a resident on the same day as the telephone notification. The resident was discharged from skilled services, and the representative was informed via a phone message about the last coverage date. However, there was no confirmation that the notice was mailed or received, as the certified mail receipt lacked a delivery date, and the tracking number provided no status update. Interviews with the facility staff revealed a lack of clarity and assurance regarding the delivery of the notice. The Minimum Data Set Director, responsible for issuing these notices, stated that they attempt to contact the representative by phone and involve the Administrator if they cannot reach them. Despite these procedures, the representative reported not receiving any letter, and the Administrator confirmed uncertainty about the notice's receipt. This indicates a breakdown in the facility's process for ensuring timely and documented notification of Medicare coverage termination.
Privacy Breach During Medical Procedures
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records during a recertification survey. Specifically, two residents were observed receiving blood glucose monitoring and insulin administration in the hallway, rather than in a private setting. Licensed Practical Nurses (LPNs) were seen conducting these procedures in the presence of other residents and staff, which compromised the residents' privacy. The facility's policy on Quality of Life/Dignity, revised in October 2023, mandates that residents should be cared for in a manner that promotes privacy and dignity, including during treatment procedures. Interviews with staff revealed a lack of adherence to the facility's privacy policies. One LPN admitted to performing the procedures in the hallway due to nervousness, while another LPN was unaware of the facility's privacy policy. The Assistant Director of Nursing and the Director of Nursing both confirmed that blood glucose monitoring and insulin administration should be conducted in private, within the residents' rooms, with doors or curtains closed to ensure confidentiality. The hallways were acknowledged as inappropriate locations for such medical procedures, indicating a deviation from best practices and facility policy.
Failure to Develop Vision Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident with vision concerns, as required by their policy. The deficiency was identified during a recertification survey, where it was found that there was no care plan created for a resident who had impaired vision and used corrective lenses. The facility's policy mandates that a comprehensive care plan should include measurable objectives and timetables to meet the resident's needs, incorporating their personal and cultural preferences. However, despite the resident's documented vision impairment and consultations with an optometrist and ophthalmologist, no care plan addressing these issues was initiated. The resident in question was admitted with diagnoses including anemia, malnutrition, and dry eye syndrome. Observations during the survey noted the resident wearing eyeglasses and engaging in activities such as writing. Despite these observations and previous consultations for eye-related issues, the facility did not have a documented care plan for the resident's vision needs. The Director of Nursing acknowledged the oversight, stating that care plans are typically managed by unit managers and registered nurse supervisors, but in this case, the vision care plan was inadvertently omitted.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the actions of a Licensed Practical Nurse (LPN) who did not administer insulin to a resident as per the physician's order. The resident, who had diagnoses including Parkinson's Disease and Diabetes Mellitus, was supposed to receive 19 units of Novolog insulin before meals unless their blood glucose was under 100 mg/dL. However, the LPN was observed conducting blood glucose monitoring and deciding not to administer insulin when the resident's glucose level was 114 mg/dL, mistakenly believing that the resident was on a sliding scale for insulin. The LPN admitted to not reading the physician's order before conducting blood glucose testing or administering insulin, leading to repeated failures to administer the prescribed insulin. The Medication Administration Record showed multiple instances where the resident's blood glucose levels were above 100 mg/dL, yet the insulin was not administered. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the LPN should have checked the order and consulted with a provider if there were any concerns. The physician confirmed that they had not been contacted to change the insulin orders and emphasized the importance of following the order's directions.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident #7, who was admitted with conditions including Peripheral Vascular Disease, wound infection, and malnutrition. The resident had a Stage 4 sacral pressure ulcer, and the care plan required specific treatments to promote healing and prevent infection. However, during an observation, it was noted that the resident did not receive the physician-ordered treatment, and infection prevention standards were not maintained by the LPN responsible for the care. During the wound care observation, the LPN did not apply the ordered bordered gauze to secure the dressing and failed to apply zinc ointment to the peri wound as prescribed. The LPN also returned unused supplies to the treatment cart, which is against the facility's protocol. The LPN admitted to not notifying the physician about the resident's skin breakdown from the adhesive of the bordered gauze, which could have warranted a change in the treatment order. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility's protocol was not followed. The Assistant Director of Nursing stated that the wound should always be covered with the ordered treatment and that any concerns with the treatment should be reported to the provider. The Director of Nursing confirmed that the LPN's practices during the wound care observation were not in line with the facility's standards, emphasizing that supplies taken into a resident's room should not be removed.
Expired Medications and Improper Narcotics Storage
Penalty
Summary
The facility failed to ensure the timely identification and removal of expired medications, as observed during a recertification survey. Specifically, a bag containing eight syringes of Lorazepam gel with an expiration date of 12/29/2021 and 44 capsules of Dronabinol with an expiration date of 01/26/2024 were found in the refrigerator narcotics box in the South Unit medication room. Additionally, it was noted that narcotics were not being stored in permanently affixed cabinets as required by the facility's policy. The facility's policy on medication storage, revised in January 2019, mandates that expired, discontinued, or contaminated medications be removed from storage areas and disposed of according to facility policy. Interviews with nursing staff revealed a lack of adherence to the facility's controlled substance management policy, which requires narcotics to be stored in a double-locked, wall-mounted cabinet during non-medication pass times. Instead, narcotics were being stored in medication carts, a practice that began approximately a year ago following a directive from a former supervisor. The Assistant Director of Nursing and the Director of Nursing were unaware of this deviation from policy. The Director of Nursing stated that discontinued medications should be given to them for proper disposal, but this process was not being followed. The facility's failure to adhere to its own policies and procedures regarding the storage and disposal of narcotics contributed to the deficiency identified during the survey.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during the recertification survey. Specifically, a Licensed Practical Nurse (LPN) did not administer insulin to a resident as per the physician's orders. The resident was supposed to receive 19 units of Novolog insulin before meals unless their blood glucose was under 100 mg/dL. However, the LPN did not provide insulin coverage if the blood glucose reading was less than 200 mg/dL, mistakenly believing the resident was on a sliding scale for insulin. This error was repeated multiple times, as evidenced by the Medication Administration Records for June and July, which showed no documented evidence of insulin administration when required. Interviews with the LPN revealed that they did not read the orders before conducting blood glucose testing or administering insulin. The Assistant Director of Nursing confirmed that orders should be checked every time medication is administered, and the Director of Nursing acknowledged the need for staff education to prevent future errors. The Nurse Practitioner and Physician both emphasized the importance of following medication administration orders and stated that the failure to administer insulin as ordered constituted a significant medication error. The Physician also noted that they had not been contacted to change insulin orders or informed of the resident not receiving insulin as ordered.
Medication Labeling Deficiency
Penalty
Summary
During a recertification survey, it was observed that the facility failed to store medications and biologicals in accordance with accepted professional principles. Specifically, on the South Unit medication cart, three open insulin vials were found without the date they were opened or the resident's name on the vials. Additionally, one opened vial of insulin lacked a resident's name on both the box and the vial. Furthermore, three inhalers were found without the date opened or the resident's name on the inhaler devices. Interviews with facility staff revealed inconsistencies in the labeling process. A Licensed Practical Nurse (LPN) stated that the nurse who opens a medication is responsible for labeling it, but the facility policy does not specify where to label each medication. The Assistant Director of Nursing indicated that insulin should be labeled with the resident's name and the date opened on both the vial and the box, while inhalers should be labeled with a sharpie. The Director of Nursing confirmed that the date a medication was opened should be listed on both the box and the vial, and that inhalers should be labeled with a sticker. Despite these guidelines, the survey found that the labeling was not consistently applied, leading to the observed deficiencies.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that Resident #80 received meals that accommodated their documented dietary preferences and restrictions. During the recertification survey, it was observed that Resident #80 was served food items that were explicitly listed as dislikes or restrictions on their meal ticket. For instance, the resident was served pineapple juice on multiple occasions despite their meal ticket indicating a restriction against pineapples. Additionally, the resident was served mashed potatoes, which were also listed as a restricted item. The facility's policy requires that food preferences and dislikes be documented and respected, with substitutions made as necessary. However, the process for assembling meal trays, which involves a caller reading out meal ticket instructions and another staff member plating the food, failed to ensure accuracy. The Director of Food Services acknowledged the responsibility of ensuring correct tray assembly but could not explain why the errors occurred repeatedly for Resident #80. Interviews with staff, including a Certified Nursing Assistant and the Registered Dietician, revealed that discrepancies in meal trays were a known issue for Resident #80. The Registered Dietician noted that the resident's dietary restrictions were based on recommendations from a previous hospitalization and had not been clinically evaluated at the facility. Despite this, the Registered Dietician confirmed that the meals should have adhered to the resident's stated preferences.
Infection Control Deficiency During Meal Observations
Penalty
Summary
During a recertification survey conducted from July 21 to July 25, 2024, it was observed that the facility failed to maintain proper infection control practices during lunch meal observations in the Main Dining Room. Certified Nurse Assistants (CNAs) were seen assisting multiple residents with hand hygiene without wearing gloves and did not perform hand hygiene between resident contacts. Specifically, CNA #6 was observed distributing and collecting sanitizing wipes with bare hands, moving from one resident to another without sanitizing their hands in between. Similarly, CNA #1 was observed assisting residents with hand hygiene without gloves and failed to perform hand hygiene between residents. Interviews with the staff revealed a lack of adherence to infection control protocols. CNA #1 stated they were trained to clean their hands before and after resident contact but could not recall performing hand hygiene between assisting residents. The Director of Nursing confirmed that staff were trained to perform hand hygiene before and after resident contact and should use gloves and a receptacle for collecting used wipes. The Infection Control Preventionist noted that there was no specific in-service training or policy on distributing hand wipes, emphasizing the need for a barrier to prevent cross-contamination.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for staff and the public during a recertification survey. Observations revealed that the North Unit Nurses Station had chairs that were soiled, dirty, and in disrepair. Additionally, visitor bathrooms across from the Dietician Office had rusted radiators, a broken toilet paper dispenser, a missing wall light cover, and a rusted wall light cover. The staff bathroom across from a specified room had missing and broken wall tiles behind the sink area. During a tour, the Director of Housekeeping acknowledged the building's age and stated their role in maintaining a safe and comfortable environment, prioritizing safety hazards. The Administrator mentioned plans to order new furniture for the nurse station and noted previous expenditures to improve the lobby, visitor bathroom, and staff bathroom, but acknowledged that additional areas of concern would be addressed.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was in place, as evidenced by the presence of multiple flies observed during a recertification survey. The flies were noted in various areas, including resident rooms, the nurse station, the dining room area, and hallways. Despite the facility's policy and procedure for pest control, which included maintaining an ongoing program and keeping service visit documentation on file, the presence of flies indicated a deficiency in the program's effectiveness. The Pest Control Log Book for the North areas documented regular exterminator visits from March to July 2024, with no reports of issues on the North Unit. However, observations during the survey contradicted these records, revealing a persistent fly problem. The Director of Housekeeping/Maintenance acknowledged the situation, stating that the exterminator visits twice a week and that efforts have been made to improve the situation, including replacing window screens and using ultraviolet lights with glue traps. Despite these measures, the presence of flies persisted, indicating a failure in the pest control measures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peninsula Nursing And Rehabilitation Center | 0 mi | ★★★★★ | 3 | 1 |
| Bezalel Rehabilitation And Nursing Center | 0 mi | ★★★★★ | 5 | 0 |
| Beach Gardens Rehabilitation And Nursing Center | 0 mi | ★★★★★ | 1 | 0 |
| Premier Nsg & Rehab Center Of Far Rockaway | 0.2 mi | ★★★★★ | 0 | 0 |
| Queens Nassau Rehabilitation And Nursing Center | 0.4 mi | ★★★★★ | 0 | 0 |
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