Below 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 Ocean Gardens Care Center during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, who required staff feeding and had a history of grabbing behaviors, grabbed a CNA’s breast during lunch. Staff gave conflicting accounts of the response, with one nurse describing the CNA angrily swinging the resident’s hand away and another CNA later stating the CNA hit the resident twice. The incident records and interviews did not consistently establish whether the resident was slapped or the hand was merely redirected.
A resident with dementia, seizure disorder, moderately impaired cognition, and dependence on staff for bed mobility and transfers sustained a second-degree burn on the thigh consistent with contact from a radiator. Nursing assessment described a 15 cm by 8 cm erythematous, blistered area whose pattern matched the radiator surface, and the MD indicated the wound was consistent with a burn from a hot surface and would be avoidable if caused by the radiator. CNAs reported the resident required extensive assistance, had poor awareness of bed boundaries, and was turned and provided incontinence care during the night and morning without observed redness, while also stating the bed was not close to the radiator. The facility’s investigation concluded the resident likely shifted or rolled toward the radiator due to poor boundary awareness and the alternating pressure mattress, demonstrating a failure to control environmental hazards and provide adequate supervision to prevent this avoidable accident.
Surveyors found that the facility failed to comply with state requirements that resident beds be kept at least three feet from radiators, resulting in harm to a resident whose bed had been placed too close to a radiator. During an abbreviated survey triggered by this incident, interviews and room measurements showed that multiple beds in sampled rooms were positioned less than 36 inches from radiators, confirming that resident equipment was not consistently maintained at the required distance.
A resident with dementia, seizure disorder, and COPD had a care plan indicating dependence for bed mobility with a need for total assistance from two staff, but the MDS assessment was inaccurately coded as requiring only partial/moderate assistance. Observation showed two staff providing total assistance for bed mobility, and interviews with an RN, a CNA, and the rehab director all confirmed the resident required total care with two-person assistance for bed mobility and transfers. The rehab department completed the MDS bed mobility section, and the rehab director later acknowledged the coding error, while the MDS coordinator stated they were unaware of the discrepancy despite their usual process of using assessments, staff interviews, and record review for MDS completion.
The facility failed to ensure immediate notification of residents’ representatives following significant changes in condition. In one case, a resident with severe cognitive impairment sustained an unwitnessed fall resulting in a facial laceration and hospitalization, yet documentation incorrectly indicated no next of kin and showed no attempt to contact the listed representative. In another case, a resident with dementia and Parkinson’s disease developed a new skin opening on the foot; although the MD was notified and treatment ordered, the RN only documented an attempted call and planned re-attempt, with no follow-up or evidence that the sibling was ever informed, and no handoff to other staff for continued notification efforts.
Surveyors found that the facility did not follow its own policy and state mandates requiring immediate (within 2 hours) reporting of alleged abuse, neglect, mistreatment, and injuries of unknown origin to the State Survey Agency. One resident with dementia and impaired cognition was discovered with significant facial discoloration, redness, and swelling while in a wheelchair, with no witnesses and no explanation for the injury; staff and the Administrator were aware, but the incident was not reported to the state until several hours later. Another cognitively impaired resident with dementia, Parkinson’s disease, and cerebrovascular disease was found in another resident’s room with a bleeding eyebrow laceration of unknown cause, later treated with Steri-Strips, and the facility’s investigation did not determine what occurred; this event was documented as a fall and was never reported to the state as an injury of unknown origin, despite leadership acknowledging it met criteria for such reporting.
The facility did not report multiple incidents of alleged abuse, neglect, and misappropriation within required timeframes. Events included physical altercations between residents with cognitive impairments, exposure of private areas, and a theft allegation involving a staff member. Reports to authorities were delayed, and law enforcement was not notified in a case of alleged misappropriation, despite facility policy and state regulations.
A resident with intact cognition reported being punched by a staff member, resulting in a black eye. The incident was not immediately reported or assessed by the staff involved. The facility's investigation concluded that there was reasonable cause to believe abuse occurred, as the resident consistently identified the staff member responsible. The lack of immediate action and communication among staff contributed to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a certified nursing assistant reacted to the resident grabbing her left breast during feeding in the dining room. The resident had diagnoses of dementia, anxiety, and bipolar disorder, and the Minimum Data Set documented severe cognitive impairment. The resident required assistance with most activities of daily living and was fed by staff. The resident’s behavior care plan noted a history of grabbing and inappropriate behaviors, with interventions to approach calmly, redirect, and step away. During the incident, staff gave conflicting accounts of what occurred. One nurse stated she saw the resident grab the CNA’s breast and saw the CNA angrily swing and knock the resident’s hand off her breast. The CNA stated she pushed or redirected the resident’s hand away and denied hitting or slapping the resident. Another CNA later stated they witnessed the CNA hit the resident twice after the resident grabbed her breast, while the nurse supervisor and other staff provided differing statements about whether the resident was slapped or the hand was pushed away. The facility’s records show the incident was reported and investigated, but the statements obtained were contradictory and did not consistently identify what occurred. The resident was interviewed and responded only that they were okay. The report also notes that no written statements were initially requested from the eyewitnesses at the time of the event, and later interviews continued to reflect conflicting versions of the incident.
Burn Injury from Radiator Due to Inadequate Hazard Control and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision and assistive devices to prevent avoidable accidents, resulting in a burn injury to one resident. The resident had diagnoses including dementia, anxiety disorder, and a seizure disorder, and the most recent Quarterly MDS documented moderately impaired cognition. The MDS and CNA documentation showed the resident required total assistance with transfers and toileting, used a Hoyer lift with two-person assistance for transfers, and needed substantial/maximal assistance with rolling in bed, indicating significant dependence for bed mobility and positioning. On the morning in question, the resident was observed with erythema on the left upper thigh extending to mid-thigh, approximately 15 cm by 8 cm, with irregular shape, uneven borders, bright pink to red coloration, and blistering in the mid-region. Nursing assessment documented that the resident appeared to have been lying with the thigh on a heating vent, although no staff witnessed this. The RN Supervisor later described the wound as a dark pink rectangular-shaped line on the left upper thigh with a small blister in the center, measuring 15 cm by 8 cm, and stated that the pattern of the lines on the resident’s thigh matched the line patterns on the top of the radiator. The physician who assessed the wound stated it could be a second-degree burn caused by a hot surface such as a radiator and that, if caused by the radiator, it would be avoidable. Staff interviews revealed that multiple CNAs and nursing staff had provided care and rounding for the resident before the burn was discovered, and that the resident was known to require extensive assistance with mobility and had poor awareness of bed boundaries. CNAs reported performing rounds and incontinence care during the night and early morning, stating that the resident’s bed was not close to the radiator and that they were able to walk around the bed. They also reported that the resident remained in the same position after being turned and that no redness was observed on the legs or thighs during earlier care. However, the facility’s incident investigation later concluded that, due to the resident’s poor awareness of bed boundaries and the alternating pressure of the air mattress, the resident likely shifted or rolled toward the radiator, resulting in the burn. This sequence of events demonstrates that the facility did not adequately control environmental hazards related to the radiator and did not ensure sufficient supervision and protective measures to prevent the resident from coming into prolonged contact with a hot surface.
Noncompliant Bed Placement Near Radiators Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to comply with N.Y. Comp. Codes R. & Regs. Tit. 10 § 713-1.3(h)(1), which requires that resident beds be placed so they can be approached from at least one side and one end and that no bed be closer than three feet to a window, radiator, or an adjacent bed. During an abbreviated survey conducted in response to an incident, surveyors determined that at least one resident’s bed had been positioned less than three feet from a radiator. This improper placement of the resident’s bed resulted in harm to that resident. The report identifies this as a failure to ensure compliance with applicable State and local laws governing the design and equipment of resident bedrooms for adequate nursing care, comfort, and privacy. Interviews and record review during the survey confirmed that the facility had not consistently maintained the required minimum three-foot distance between resident beds and radiators prior to the incident. The Maintenance Director reported that the bed in the involved room had been moved away from the radiator after the incident, preventing assessment of the original distance from the radiator. A sample of rooms measured by surveyors showed several beds with distances from the radiator to the mattress of less than 36 inches, including measurements of 32, 34, and 35 inches, indicating that the deficiency was not isolated to a single room. These findings support that the facility did not ensure resident equipment (beds) was kept at the minimum required distance from radiators, leading to the cited harm to a resident.
Inaccurate MDS Coding of Bed Mobility Assistance Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident. The facility’s policy on Resident Assessment, last reviewed on 10/25/2025, required comprehensive and accurate assessments using direct observation and communication with residents and direct care staff on all shifts. The resident, admitted with dementia, seizure disorder, and COPD, had a Comprehensive Care Plan effective 02/03/2026 documenting dependence for bed mobility (rolling left to right) with a need for total assistance of two staff. However, the MDS assessment dated [DATE] coded the resident’s bed mobility as requiring only Partial/Moderate assistance, indicating the helper did less than half the effort, which did not match the care plan or the resident’s actual needs. During observation on 03/11/2026 at 9:00 AM, the resident was seen receiving total assistance from two staff for bed mobility. In interviews, an RN stated on 03/10/2026 that the resident required total care with two people for bed mobility and turning/positioning, and a CNA reported that two staff had been providing total assistance for bed mobility since the resident’s readmission. The Director of Rehabilitation stated that the rehab department completed the MDS bed mobility section (GG0130), that the resident was on skilled therapy and required total care with assistance of two people for bed mobility and transfers, and acknowledged that the MDS coding was in error and should have been “dependent” rather than “partial/moderate.” The MDS Coordinator reported that they typically collect information from assessments, staff interviews, and medical record review and double-check records for accuracy before submitting MDS assessments, but stated they were not aware of the discrepancy in this resident’s MDS dated 02/12/2026.
Failure to Notify Representatives of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify residents’ representatives of significant changes in condition, including an accident with injury and a new skin opening, as required by facility policy and 10 NYCRR 415.3(f)(2)(ii)(c). For one resident with schizophrenia, anxiety, dementia, and severe cognitive impairment, an unwitnessed fall occurred in the evening, during which the resident was found sitting on the floor with a laceration to the left eyebrow that required hospitalization. The accident/incident report documented that family was not notified and indicated “No Next of Kin,” and a nursing progress note also stated there was no next of kin to notify. However, the resident’s face sheet contained next of kin contact information, and there was no documented evidence that staff attempted to call the designated representative. For another resident with non-Alzheimer’s dementia, Parkinson’s disease, cerebrovascular disease, and severely impaired cognitive skills, nursing documentation showed a new skin opening on the left dorsal foot, with the MD notified and treatment ordered. A subsequent nursing note recorded that the nurse called the resident’s next of kin to provide an update and would re-attempt contact later, but there was no documentation that the representative was ever successfully notified of this change in condition. The RN Supervisor who wrote the note later stated they did not recall if they actually reached the sibling, and they were out sick for at least a month afterward. The DON reported that next of kin notification is done by nursing or social work, that the RN Supervisor did not leave a voicemail per facility policy, and that the need for follow-up notification was not communicated in the end-of-shift report, leaving no evidence that the representative was informed.
Failure to Timely Report Injuries of Unknown Origin to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, mistreatment, and injuries of unknown origin were reported to the State Survey Agency immediately, and no later than two hours after discovery, as required by facility policy and state reporting mandates. The facility’s written policy, revised 05/06/2025, required that all alleged violations involving serious injuries of unknown source be reported and investigated immediately, with findings reported to the New York State Department of Health (NYSDOH) within two hours, as well as to law enforcement and other required agencies. Surveyors found that this policy was not followed for two residents whose injuries met criteria for injuries of unknown origin. For one resident with cellulitis, sepsis, and dementia, an Annual MDS documented moderately impaired cognitive skills and a need for supervision or assistance with activities of daily living. On 04/12/2024 at approximately 7:00 AM, this resident was observed in a wheelchair in the hallway with facial discoloration, redness to the right forehead and cheek, and ecchymosis and redness around both eyes, with mild swelling to the forehead and eyelids. The resident was unable to explain what happened due to cognitive impairment and a language barrier, and employee statements did not identify any witness to the injury. The Accident/Incident Report identified the event as an injury of unknown source, staff became aware at 7:00 AM, and the Administrator was notified at 9:00 AM. However, the incident was not submitted to NYSDOH until 1:57 PM, exceeding the two-hour reporting requirement. During interview, the Assistant DON confirmed the incident was reported but did not provide an explanation for the late submission. For another resident with non-Alzheimer’s dementia, Parkinson’s disease, and cerebrovascular disease, an Annual MDS documented short- and long-term memory problems and severely impaired cognitive skills for decision-making. On 11/21/2025 at 6:00 AM, this resident was found sitting in a wheelchair in another resident’s room with blood dripping from the left side of the face and a 2 cm laceration to the left eyebrow; the location of occurrence was unknown, and the resident could not state what occurred due to severely impaired cognition. The resident was sent to the hospital for evaluation and later returned with Steri-Strips and swelling to the left eyebrow. The facility’s incident report documented no conclusion as to what occurred, and there was no documented evidence that this injury of unknown origin was reported to NYSDOH. In interviews, the DON stated the incident was initially documented as a fall and acknowledged that, upon review, it could be considered an injury of unknown origin, and the Assistant DON stated the incident should have been reported as an injury of unknown origin because there was no clear evidence of a fall and did not recall any discussion about reporting it.
Failure to Timely Report Alleged Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported within the required timeframes to the appropriate authorities. Multiple incidents involving residents with varying degrees of cognitive impairment and mental health diagnoses were not reported immediately, or within the mandated two-hour or 24-hour windows, as required by state regulations and the facility's own policies. These incidents included physical altercations between residents, exposure of private areas, and allegations of theft by staff. For example, one incident involved a resident with intact cognition kicking and pulling the arm of another resident with severely impaired cognition after the latter wandered into their room. This event was not reported to the New York State Department of Health until more than a day later. In another case, a resident was found standing at the bedside of another resident, both with private areas exposed, but the incident was not reported until several hours after discovery. Additional incidents included a resident with impaired cognition being pushed by another resident, and a resident hitting another after being confronted for going through personal belongings, with delayed reporting in both cases. An allegation of theft was also not reported to local law enforcement as required. A resident with memory problems and poor decision-making reported that a housekeeper took their money, and although the facility's investigation found reasonable cause to believe misappropriation may have occurred, there was no documented evidence that law enforcement was notified. Interviews with facility leadership confirmed awareness of the reporting requirements, but the documented actions did not meet the mandated timelines.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a nursing home staff member. This incident involved a resident who was observed with a black eye, which they reported was caused by being punched by a staff member, specifically a Registered Charge Nurse. The resident, who had intact cognition, was able to identify the staff member involved in the incident. The facility's policy on the prohibition of resident abuse was not adhered to, as the staff member did not assess the resident or report the incident to the appropriate authorities. The incident occurred when the resident was redirected from entering a dining room with a wet floor, leading to an altercation where the resident reportedly slapped the staff member. The staff member did not report this altercation or the subsequent discoloration observed on the resident's face. Multiple staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, observed the discoloration but did not take immediate action to report or assess the situation. The Director of Nursing was eventually informed by an Occupational Therapist, who noticed the resident's condition and reported it. The facility conducted an investigation and concluded that there was reasonable cause to believe that abuse had occurred. The resident consistently reported being punched by the staff member, and the staff member failed to follow protocol by not reporting the incident or assessing the resident's condition. The lack of immediate action and communication among staff members contributed to the deficiency in protecting the resident from abuse.
Plan Of Correction
Plan of Correction: Approved April 29, 2025 Element #1: What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Residents #1 who was affected by this deficient practice was assessed by RN Supervisor (RNS), PMD and Psychiatrist. Right periorbital x-ray was ordered and result showed no fracture. Accused RN was immediately removed from duty. Completed 4/17/2025. Element #2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents under the care of accused RN had the potential to be affected by the deficient practice. Consequently, upon report of occurrence on 9/7/2023, the accused RN was immediately removed from duty and employment subsequently terminated. Cognitively intact residents who were under the care of accused RN will be interviewed and assessed for abuse or inappropriate interactions. Residents who are cognitively impaired, their NOK will be interviewed instead. Completed 6/3/2025. Element #3: What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Facility Abuse prevention policy and procedure was reviewed and revised to include that staff accused of abuse must be removed from duty immediately. All employees will be monitored by their respective department head to ensure they are not abusing residents. Specifically, unit CNA, LPN, and RN will be monitored by RN Supervisor. ADNS will supervise RNS for any inappropriate or abusive interactions with residents. Employees identified with behaviors or negative interactions that equate to abuse will be removed from duty immediately. All residents will be monitored by unit RN Supervisor and Social Worker to ensure they are not abused by staff. All staff who directly interact with residents—such as nursing, medical, housekeeping, social work, activities, rehabilitation, and administration—will be re-inserviced on abuse prevention by ADNS and/or their direct supervisor. Social Work Director and/or designee will attend monthly resident council meetings to educate residents on the procedure for promptly reporting abuse. DNS will monitor for sustained compliance of staff abuse prevention education and observation to ensure all residents are free from staff abuse. Completed by 5/31/25. Element #4: How the corrective actions(s) will be monitored to ensure the deficient practice will not recur—what quality assurance program will be put into practice Social Worker will audit/interview 5 residents weekly to assess comfort with caregivers and/or report of abuse and report to DNS and/or Administrator of their findings. Negative findings will be addressed promptly. ADNS will conduct weekly audits of direct staff interaction with residents on unit and report to DNS and/or Administrator of their findings; negative findings will be addressed promptly. Audit findings will be reported and reviewed at QAPI weekly x 2 weeks; monthly x 2 months, then quarterly thereafter. Completed by 5/31/2025. Element #5: The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing and/or designee Date: 6/3/2025
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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 Arverne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resort Nursing Home | 0.4 mi | ★★★★★ | 0 | 0 |
| Lawrence Nursing Care Center, Inc | 0.7 mi | ★★★★★ | 0 | 0 |
| Rockaway Care Center | 1 mi | ★★★★★ | 18 | 0 |
| Far Rockaway Center For Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 12 | 0 |
| Peninsula Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 3 | 1 |
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