Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 N Y S Veterans Home In N Y C during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer's disease, and Parkinson's disease fell during a transfer with a Hoyer lift and sustained a laceration. While the incident was initially reported to the NYSDOH as required, the facility did not submit the results of the investigation within five working days, as mandated. Interviews with nursing leadership confirmed the omission and revealed that facility policies did not specify this reporting requirement.
Two residents experienced physical abuse by staff in separate incidents. One resident was restrained by a security guard after attempting to exit through an emergency door, while another resident was allegedly hit by a CNA during personal care. Both incidents were confirmed through staff statements and video evidence, highlighting a failure in the facility's abuse prevention policy.
The facility failed to store and label food according to safety standards, with milk and eggs stored at 51°F and expired instant mashed potatoes found in storage. A food service worker admitted to not labeling the potatoes with an expiration date.
A resident with severe cognitive impairment fell while transferring to a wheelchair. An LPN and a CNA failed to report the incident to the RN supervisor or Medical Doctor, delaying necessary evaluation and assessment. The facility's policy requiring such reporting was not followed, leading to a delay in care.
A resident with severe cognitive impairment fell while transferring to a wheelchair, but the incident was not reported to the RN supervisor by an LPN, delaying necessary assessment. The facility's policy requires reporting such incidents to ensure timely evaluation and care.
Two residents experienced safety and supervision deficiencies in an LTC facility. One resident, requiring two-person assistance, was transferred by a CNA alone, resulting in a fall and injuries. Another resident, with a history of wandering, was found outside unsupervised and later missing for over an hour. The facility failed to monitor the resident adequately, with incomplete logs and non-functioning security alarms contributing to the incidents.
A resident with schizoaffective disorder and anxiety did not receive their prescribed Ativan dose due to a medication error. An LPN incorrectly signed the Medication Administration Record, indicating the medication was given, but the blister pack count showed otherwise. The DON confirmed the resident did not receive the medication, and the facility's policy was not followed.
A resident with dementia and unhealed pressure ulcers did not receive the physician-ordered treatment for their great toes, as observed during a survey. The RN applied treatments to the resident's heels but neglected the toes, which was later acknowledged as an oversight. The DON confirmed the failure to follow orders, highlighting a lapse in the facility's pressure ulcer prevention policy.
During a survey, CNAs on two units failed to perform hand hygiene and sanitize blood pressure cuffs between resident uses, despite knowing infection control standards. Nursing staff confirmed the expectation for equipment sanitization, and monitoring by the Infection Control Preventionist and RN supervisor was noted.
Failure to Submit Investigation Results to State Agency Within Required Timeframe
Penalty
Summary
The facility failed to ensure that the results of an investigation into a resident incident were reported to the New York State Department of Health (NYSDOH) within five working days, as required by regulation. Specifically, after a resident with diagnoses including dementia, Alzheimer's disease, and Parkinson's disease fell during a transfer with a Hoyer lift and sustained a forehead laceration, the initial incident was reported to NYSDOH on the same day. However, there was no documented evidence that the results of the subsequent investigation were submitted to NYSDOH within the mandated five-day period. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that while the initial incident was reported promptly, the required five-day follow-up report containing the results of the investigation was not submitted. The facility's policies did not specify the requirement to submit the investigation results to the Department of Health within five working days, and staff could not provide an explanation for the omission during interviews.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving staff and residents. In the first incident, a security guard physically restrained a resident by grabbing their collar and holding them against a wall. This occurred after the resident attempted to exit through an emergency door, and the security guard reacted to being punched by the resident. The incident was captured on surveillance video, although the footage was unclear. Staff members present during the incident confirmed the security guard's actions, and the resident was subsequently transferred to a hospital for evaluation. In the second incident, a certified nursing assistant (CNA) was reported to have hit a resident during personal care. The resident, who had a history of aggressive behavior, attempted to kick the CNA, who then allegedly struck the resident's hand. A registered nurse present during the incident corroborated the account of the CNA hitting the resident. The resident was assessed afterward, with no visible injuries or complaints of pain, but the incident was still classified as physical abuse. Both incidents highlight a failure in the facility's policy to prevent abuse and ensure the safety of residents. The facility's investigation into these events confirmed the occurrence of physical abuse, as staff statements and video evidence supported the allegations. The involved staff members were removed from their duties pending further investigation, but the incidents underscore significant lapses in maintaining a safe environment for residents.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. **Corrective Action for Affected Resident/Area** A. Immediately after the incident, Resident #1 was assisted to safety on the Unit for RN Assessment. Resident #1 refused the body check, but the Supervisor reported that no visible injury was noted and there were no complaints of pain. The Designated Representative was informed and the Physician ordered to transfer the Resident out to the Hospital for further evaluation of uncontrolled agitative behavior. The Security Guard, who did not follow the Facility’s Policy and Procedure for “Abuse Prohibition,” was immediately removed from duty and his assignment at the Home was terminated by the Contract Vendor. B. Immediately after the incident, Resident #4 was assessed by the RN. There were no visible signs of injury or complaints of pain reported. The Certified Nursing Assistant who did not follow the Facility’s Policy for “Abuse Prohibition” was immediately removed from direct Resident care duties and placed on Administrative Leave pending an Investigation. II. **Identification of other Areas/Residents Potentially Affected** The Facility respectfully states that no other residents were identified with Abuse, Neglect, or Mistreatment concerns. The Director of Nursing/Designee performed an Audit of all other residents, to ensure that they have an Abuse Prevention/Prohibition and Resident Centered Care Plan in place. Any Resident identified with missing alleged Abuse Care Plans will be promptly updated. The Facility will provide comprehensive “Abuse prohibition” re-training for all staff members to effectively manage and support residents exhibiting behaviors associated with dementia and other behaviors. Rein-service/Competency will continue until all employees are re-trained. III. **Address what measures will be put in place or Systemic Change made to ensure that the Deficient practice will not Recur/System change and Measure to prevent Recurrence** The Facility changed the Systems for monitoring “Abuse Prohibition” to include a process that during Shift Change Huddles, the Charge Nurse will also reinforce adherence to the “Abuse Prohibition” Policy and practices and remove triggers for residents who have potential for escalating verbal outburst or violent physical aggression. The Home will select front-line staff to serve as ambassadors in specialized Dementia Care and Behavioral Management, who will provide support and guidance to other team members. The Facility’s Policy and Procedure for “Abuse Prohibition” was reviewed by the Acting Administrator and was found to be compliant. All current employees will be rein-serviced immediately on the Policy and annually thereafter. New employees will be In-service during Orientation. Lesson Plan will include, but will not be limited to: - The Facility will not knowingly and intentionally hire individuals found guilty of Abuse, Mistreatment of [REDACTED]. - Employees shall adhere to the reporting mechanism as outlined in the law and regulations. - Employees are made aware that any derogatory language or remarks towards Residents and any other potential Abuse, Neglect issues will lead to immediate suspension/termination. - The Facility will train staff to safely care for combative residents, emphasizing de-escalation techniques and ensuring that they do not retaliate to physical aggression. - The Facility requires that Potential Abuse cases are reported and investigated immediately once brought to the attention of a Supervisor. - Employees are instructed on appropriate and safe interventions of care to be used with aggressive residents with behaviors. - Employees shall report occurrences that may be interpreted as acts of Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. - Ensuring staff understanding of Residents’ behaviors that could lead to physical violence, and Behavioral Management measures to de-escalate such behaviors. - Licensed staff members are educated on how to document and fully describe unusual events that could be interpreted as a situation of Potential Abuse. - Administrative Management and Supervisory personnel monitor staff interaction with residents on an ongoing basis to ensure residents’ safety. In-service and Competencies will be filed in the employees Personnel History Folder for reference and validation. IV. **How does the Facility plan to monitor its performance to make sure that Solutions are Sustained/Monitoring of Corrective Actions** The Director of Nursing and the Director of Social Services developed an “Abuse Prohibition Compliance Audit Tool” to identify high risks resident for alleged potential abuse, and staff interventions for such behaviors. The Audit Tool will be used Daily by the Associate Director of Nursing/Designee and the Social Workers/Designee, to monitor and document alleged cases of Potential Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. Any case found out of compliance will warrant an immediate on the spot correction/rein-service by the Supervisor, followed by a formal Report, employee Statements, and an Investigation. The Director of Nursing and the Director of Social Services will review the Audit Tool Weekly for compliance. The Tool will be filed in a Binder in the Nursing Administration Office after it is reviewed, for reference and validation. **IV. QA Monitoring** The person responsible to correct this issue is the Director of Nursing and the Director of Social Services. The Associate Director of Nursing/Designee will report findings Monthly to the QAPI Committee for 12 Months.
Food Storage and Safety Deficiency
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety, which could potentially lead to foodborne illness. During a kitchen observation, it was noted that milk and eggs were stored in Refrigerator #3, which had a thermometer reading of 51 degrees Fahrenheit, exceeding the safe temperature of 41 degrees Fahrenheit. Additionally, expired food was found in the dry storage room, specifically six 5-pound bags of instant mashed potatoes with an expiration date that had passed. The facility's policy on Food Service Sanitation Guidelines requires that potentially hazardous food exceeding 41 degrees Fahrenheit for more than two hours should be discarded. However, this policy was not adhered to, as evidenced by the temperature of the refrigerator. Furthermore, during an interview, a food service worker admitted to forgetting to label the instant mashed potatoes with an expiration date, which is a critical step in ensuring food safety.
Failure to Report Resident Fall Incident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by an incident involving a resident with diagnoses of cerebral infarction and atrial fibrillation, who had severely impaired cognition. The resident experienced a fall while attempting to transfer to their wheelchair. Despite the fall being reported by the resident and their roommate, the Licensed Practical Nurse (LPN) involved did not inform the Registered Nurse (RN) supervisor or the Medical Doctor, delaying the necessary evaluation and assessment of the resident's condition. The facility's investigation revealed that the LPN and a Certified Nursing Assistant (CNA) did not follow the facility's policy, which required reporting such incidents to ensure timely assessment and care. The CNA confirmed assisting the LPN in transferring the resident back to bed without notifying the RN supervisor. The Director of Nursing stated that the staff were responsible for reporting falls to ensure proper assessment, but this protocol was not followed, resulting in a delay in care for the resident.
Failure to Report Resident Fall Delays Assessment
Penalty
Summary
The facility failed to ensure that a resident received quality care following a fall incident. Resident #24, who had diagnoses of cerebral infarction and atrial fibrillation and was documented to have severely impaired cognition, fell while attempting to transfer to their wheelchair. The incident was not reported to the Registered Nurse supervisor by Licensed Practical Nurse #5, which delayed the necessary assessment of the resident's condition and potential injuries. The facility's policy requires that nursing staff report such incidents to ensure timely evaluation and care. The incident was discovered when Resident #24 and their roommate reported the fall to Registered Nurse #3 the following day. Certified Nursing Assistant #10 confirmed that they assisted in transferring the resident back to bed after the fall, as instructed by Licensed Practical Nurse #5, who initially denied the fall occurred. The Director of Nursing stated that the staff failed to follow the facility's policy by not reporting the fall to the Registered Nurse and Medical Doctor, which is essential for ensuring the resident receives an appropriate assessment.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, leading to significant deficiencies. One resident, who required two-person assistance for transfers, was transferred by a Certified Nursing Assistant (CNA) without assistance, resulting in the resident falling from a reclining chair. The CNA did not follow the facility's policy on safe patient handling, which mandates two caregivers for such transfers. Despite being trained on safe patient handling, the CNA proceeded alone, leading to the resident sustaining skin injuries. Another resident, with a history of wandering and severely impaired cognition, was found outside the facility unsupervised and later missing for over an hour. The resident was known to wander and had a high risk for elopement, yet the facility failed to monitor the resident adequately. On one occasion, the resident was found outside with injuries after falling, and on another, the resident was found sleeping in an unoccupied bed on a closed unit. The facility's monitoring logs were incomplete, and there was no evidence of the required 15-minute checks being conducted. The facility's policies on wandering and elopement were not effectively implemented, as evidenced by the lack of proper monitoring and supervision. The security measures, such as door alarms, were not functioning correctly, contributing to the resident's ability to leave the building unnoticed. The facility's failure to adhere to its own policies and procedures resulted in these deficiencies, compromising the safety and well-being of the residents involved.
Medication Error: Resident Missed Dose of Ativan
Penalty
Summary
The facility failed to ensure that all residents were free from significant medication errors, as evidenced by the case of Resident #109. This resident, who had diagnoses of schizoaffective disorder and anxiety and was cognitively intact, did not receive their prescribed dose of Ativan, an antianxiety medication, on the evening of March 24, 2024. The facility's investigation revealed that the blister pack count for Ativan remained unchanged, indicating the medication was not administered as ordered. Licensed Practical Nurse #2 erroneously signed the Medication Administration Record, confirming the administration of Ativan, which did not occur. The Director of Nursing Services confirmed that the medication was not given, as reported by Resident #109, and the facility's policy on medication administration was not followed.
Failure to Follow Physician-Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with pressure ulcers, as observed during a recertification survey. Specifically, the facility did not follow the physician-ordered treatment for a resident with unhealed pressure ulcers and dementia. The resident was identified as being at risk for developing pressure ulcers, and a physician's order was in place to cleanse the resident's left and right great toes with normal saline, apply Betadine 10% solution, and cover with non-woven gauze. However, during an observation of wound care, the registered nurse applied treatments to the resident's heels but neglected to perform the ordered treatment for the great toes. The registered nurse later acknowledged forgetting to perform the treatment as ordered. The Director of Nursing confirmed that the nurse did not follow the physician's wound treatment orders and emphasized the importance of reviewing orders before performing treatments. This deficiency was identified for one resident out of 38 sampled during the survey, highlighting a lapse in adhering to the facility's policy on pressure ulcer prevention and intervention, which aims to prevent infection and promote healing.
Infection Control Deficiencies in Equipment Sanitization
Penalty
Summary
During the recertification survey conducted from May 9 to May 16, 2024, the facility was found to have deficiencies in infection control practices on the Pine and Maple Units. Specifically, Certified Nursing Assistant #6 was observed failing to perform hand hygiene and sanitize the blood pressure cuff between uses on multiple residents in the Pine Unit. This occurred despite the availability of sanitizer wipes on the unit and the acknowledgment by the CNA that they were aware of the infection control standards requiring such practices. Similarly, on the Maple Unit, Certified Nursing Assistant #7 was observed not sanitizing the blood pressure cuff and not performing hand hygiene between resident uses. The CNA admitted to forgetting to sanitize the equipment between uses. Interviews with the nursing staff, including a Licensed Practical Nurse and a Registered Nurse, confirmed that the expectation was for equipment to be sanitized before and after each resident use. The Infection Control Preventionist and Registered Nurse supervisor were noted to monitor staff compliance with infection control protocols.
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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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Nursing homes near Jamaica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silvercrest | 2.2 mi | ★★★★★ | 0 | 0 |
| Jamaica Hospital Medical Center T C U | 2.4 mi | ★★★★★ | 0 | 0 |
| Jamaica Hospital Nursing Home Co Inc | 2.6 mi | ★★★★★ | 0 | 0 |
| Hollis Park Manor Nursing Home | 2.8 mi | ★★★★★ | 0 | 0 |
| Holliswood Center For Rehabilitation And Healthcar | 2.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.