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 Oceanview Nursing & Rehabilitation Care Center during CMS and state inspections, most recent first.
A significant medication error occurred when an LPN administered 150 mg of Methadone instead of the prescribed 35 mg to a resident with End Stage Renal Disease and other comorbidities. The error was discovered after the resident had left for hemodialysis, and the facility's policies on medication administration were not followed. The LPN did not provide a written statement and did not return to the facility.
The facility failed to ensure safe food storage practices, as outdated food items were found in the kitchen refrigerator during a survey. Expired snacks, including cottage cheese, skim milk, cut pears, and cranberry juice, were observed. Interviews with dietary staff revealed that these items were overlooked and should have been discarded, contrary to the facility's policy on food storage.
The facility was cited for failing to maintain a sanitary and comfortable environment, with issues such as mismatched paint, uneven floors, and damaged furnishings observed in resident rooms. The Director of Housekeeping and Maintenance acknowledged the deficiencies, citing ongoing building refresh efforts, while the Administrator highlighted the challenges of maintaining an older building.
The facility was cited for insufficient nursing staff on weekends, impacting resident safety and wellbeing. The deficiency was identified during a survey, revealing discrepancies between the facility's staffing policy and actual staffing levels. Interviews with residents and staff confirmed delays in assistance and staffing shortages, often due to call-outs. The DON was unaware of the issue, while the Administrator attributed it to CMS measure changes.
A resident with limited range of motion was observed multiple times without a prescribed left-hand roll, despite physician's orders and a care plan requiring its use. Staff interviews revealed that CNAs were responsible for applying the device, but it was not consistently done, leading to potential risks of contractures. The DON acknowledged the oversight responsibility of RNs and LPNs.
A resident with dysphagia was not provided with the ordered nectar thick liquids, leading to coughing episodes after consuming thin liquids. Staff interviews revealed inconsistencies in understanding responsibilities for administering thickened liquids, contributing to the deficiency.
The facility failed to maintain the dignity of two residents. A resident with an indwelling catheter had their urinary drainage bag uncovered and visible from the hallway, contrary to the facility's policy requiring dignity bags. Another resident, requiring total assistance for eating, was fed by an LPN who stood while feeding, necessitating the resident to raise their head to receive food. Both actions were against the facility's practices for maintaining resident dignity.
A facility failed to ensure that a storage structure attached to the building was protected by an automatic sprinkler system. The structure, made of combustible materials and containing cardboard boxes, was located near an egress door, posing a potential fire hazard.
The facility failed to transmit MDS assessments to CMS within the required 14-day period for five residents. The assessments were completed in early February but not sent until early March, as confirmed by the facility's validation report. The DON, also the MDS Coordinator, acknowledged the oversight.
The facility failed to include the total number of licensed and unlicensed nursing staff directly responsible for resident care in their daily nurse staffing information postings. Observations revealed that the postings only included the facility name, date, resident census, and actual hours worked by staff. Interviews with staff, including the DON and Administrator, indicated a lack of awareness about the requirement to include the total number of staff providing direct care.
The facility did not ensure the Medical Director's consistent participation in QAPI meetings, as required by policy. The Medical Director missed meetings in August 2024 and January 2025, with the last attendance recorded in 2024. The absence was confirmed by the DON and attributed to a cataract surgery by the Administrator.
A facility failed to ensure accurate MDS assessments for a resident's cognitive status. The MDS inaccurately documented the resident as independent, despite evidence of severe cognitive impairment. Staff interviews confirmed the resident's nonverbal status and need for assistance, highlighting discrepancies in the assessment process.
Significant Medication Error Involving Methadone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of an incorrect dosage of Methadone. On September 6, 2024, a Licensed Practical Nurse (LPN) administered 150 milligrams of Methadone to a resident instead of the prescribed 35 milligrams. The resident, who was alert and stable, was then escorted to a scheduled hemodialysis therapy session without any immediate complaints of pain or discomfort. The resident involved in the incident had a medical history that included End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, and a history of Opioid Use Disease. The resident was cognitively intact but required assistance with most activities of daily living. The error was discovered when the LPN reported the mistake to a Nurse Supervisor after the resident had already left for dialysis. The Methadone intended for another resident was mistakenly given, and the error was communicated to the dialysis center, the resident's family, and the attending physician. The facility's policies on medication administration, which were in place at the time, included guidelines to prevent medication errors, such as verifying the correct resident, dose, and time. However, the LPN did not adhere to these guidelines, leading to the administration of the wrong dosage. The Methadone bottles were stored in individual bags with visible labels, but the LPN was unsure of the name on the bottle used. The LPN left the facility without providing a written statement and did not return, complicating the investigation into the incident.
Deficiency in Safe Food Storage Practices
Penalty
Summary
The facility failed to ensure safe food storage practices, as evidenced by the presence of outdated food items in the kitchen refrigerator during a recertification survey. Specifically, during an initial tour of the kitchen, surveyors observed expired dietary prepared snacks, including 20 plastic cups of 4 ounces of cottage cheese, 8 plastic cups of 4 ounces of skim milk, 4 plastic cups of 4 ounces of cut pears, and 20 plastic cups of 4 ounces of cranberry juice, all with labeled dates indicating they were expired. Interviews with Dietary Aide #1 and the Dietary Supervisor revealed that the outdated food items were overlooked and should have been discarded, with the Dietary Supervisor acknowledging that expired food poses a health hazard and should not be consumed. The facility's policy on food storage and holding timeframes, which was last reviewed on a specified date, mandates that food items be dated, placed in a container, and discarded if not consumed, which was not adhered to in this instance.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 All foods that were out of date were discarded immediately. Element #2 A thorough inspection of the kitchen area will be completed by the food service Director to identify similar defective practices and any deficient practices will be addressed immediately. Counseling will be issued to all employees for noncompliance. Element #3 Dietary consultant will provide an in-service on when foods should be discarded. The policy for food storage will be reviewed by the food service director to ensure it states when food should be discarded. All kitchen staff will be in-serviced with the updated policy. Element #4 An audit tool will be developed by the Dietary consultant to ensure compliance with out of date food. The dietary service supervisor or designee will conduct weekly inspections of the kitchen area to verify the consistent to specific standards. Should the inspections find any issues necessitating corrective actions, the Food service Director will address them immediately. The Food service Director will submit a status report to the administrator on a weekly basis. The Food service Director will present the findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as observed during a recertification survey. Several deficiencies were noted, including mismatched paint, uneven floors, and damaged furnishings in resident rooms. Specifically, a room in the West Wing had a ripped door kick plate, while another had mismatched paint and a stained, uneven floor. The main dining room also had an uneven floor with discolored tiles. In the East Wing, one room had unpainted walls and a bedside table in disrepair, while another had broken bedside tables and a mattress in poor condition. Additionally, dirt and grime were observed on the baseboard in the hallway and the porter's closet. The facility's policy on environmental services, which outlines guidelines for cleaning and disinfecting resident rooms, was not adhered to, as evidenced by the lack of documentation in the maintenance and housekeeping logbook for necessary repairs. The Director of Housekeeping and Maintenance acknowledged the issues, stating that terminal cleaning is performed daily, but repairs and replacements were pending due to ongoing building refresh efforts. The Administrator also noted the challenges of maintaining an older building but emphasized the importance of addressing these concerns to ensure a proper living environment for residents.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: West wing room [ROOM NUMBER] kickplate will be replaced. West wing room #18 will be painted and the floor repaired; tiles will be replaced. Main dining room floor and tiles will be repaired and made even. East wing room #4 will be painted and the bedside table will be replaced. East wing #10 bedside table and mattress will be replaced. The baseboards in the hallway and porters’ closet will be thoroughly cleaned. Element #2: The Director of housekeeping will inspect all other areas to ensure there is no mismatched paint or tiles and no other tables and mattresses are in disrepair. The Director of housekeeping will inspect the entire premises for cleanliness. Element #3: Maintenance staff will be in-serviced on ensuring furniture, mattresses, and rooms are not in disrepair. The housekeeping staff will be in-serviced on proper cleaning of baseboards and porter closets. The maintenance manual on preventative maintenance will be updated to include specifically mattresses, furniture, mismatched or broken tiles, painting, and uneven floors. The policy and procedure for general cleaning was reviewed with the housekeepers and no revisions were made. Element #4: An audit tool will be developed by the housekeeping director to audit rooms, common areas, and nursing stations to ensure cleanliness and preventative maintenance. Audits will be done weekly by the housekeeping director for three months and then quarterly. All findings and corrective actions, if indicated, will be discussed with the administrator. The Director of housekeeping will submit a status report to the administrator on a monthly basis. The Director of housekeeping will present findings and corrective actions, if indicated, to the QAPI committee, and thereafter the QAPI committee will determine the frequency of reports. Element #5: Administrator 5/01/2025
Staffing Shortages on Weekends Lead to Deficiency
Penalty
Summary
The facility was cited for not ensuring sufficient nursing staff were available to provide necessary services to assure resident safety and wellbeing. The deficiency was identified during a recertification survey conducted from March 2, 2025, to March 7, 2025. The facility's staffing policy, last reviewed in September 2024, mandates adequate and competent staffing levels based on the facility assessment. However, the Payroll Based Journal Staffing Data Report for the fourth quarter of 2024 indicated excessively low weekend staffing, which was confirmed by reviewing the actual weekend staffing schedules. The facility assessment tool, updated in January 2025, outlined a staffing plan for a capacity of 102 residents, but discrepancies were noted in the actual staffing levels on weekends. The report detailed specific instances of staffing shortages on weekends from July to September 2024. These shortages included missing Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) on various shifts across the East and West Wings. Interviews with residents revealed that they experienced delays in receiving assistance, particularly at night, due to insufficient staffing. One resident mentioned that it took too long for staff to respond when they requested help, while another resident noted a lack of staff, especially during nighttime hours. Interviews with facility staff, including CNAs and the Staffing Coordinator, confirmed the occurrence of staffing shortages on weekends, often due to call-outs. The Director of Nursing (DON) stated they were unaware of the low weekend staffing or the Payroll Based Journal trigger for low staffing during the specified quarter. The Administrator acknowledged awareness of the Payroll Based Journal trigger but was unsure of the reasons, attributing it to changes in CMS measures rather than actual staffing level changes. The Administrator also mentioned that staffing levels had not changed significantly and had improved compared to previous years, despite the facility triggering worse under the updated measures.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 Residents #67 and #32 were interviewed about their concerns of short staffing on the weekends to efficiently address their concerns. Residents were updated on the plan of correction to ensure that the facility is fully staffed. Element #2 On weekends, the facility will schedule an extra CNA to each shift as padding to cover for call outs. The Staffing Coordinator and the Shift RN Supervisor will be educated that overtime may be used to cover call outs. Element #3 The facility will post ads to attract and hire more staff. The facility will update the policy that all weekend shifts will have padding of an extra CNA on all weekend shifts and overtime may be used to cover available shifts. All RN supervisors and the staffing coordinator will be in-serviced by the Director of Nursing on the new policy. Element #4 An audit tool will be developed by the Director of Nursing and completed weekly for three months to ensure the facility has sufficient weekend staffing. The Director of Nursing will submit a status report to the administrator on a weekly basis for three months. The Director of Nursing will present the findings and corrective actions if indicated to the QAPI committee, and thereafter the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25
Failure to Apply Prescribed Hand Roll for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, Resident #41, who had moderately impaired cognition and was dependent in all areas of activities of daily living, was observed multiple times without a left-hand roll in place as per physician's orders. The resident had a care plan focused on restorative nursing rehabilitation, which included the use of a left-hand roll to be worn at all times except for skin checks and hygiene. Despite these orders, the resident was observed without the hand roll on several occasions during the survey period. Interviews with facility staff revealed a lack of adherence to the prescribed care plan. Certified Nursing Assistant #8, who was responsible for the resident's care, admitted to not applying the left-hand roll and was unaware of its location. Registered Nurse #1 confirmed the resident's dependency on staff for activities of daily living and the necessity of the hand roll to prevent stiffness. The Director for Rehabilitation also noted the absence of the hand roll and stated that CNAs were responsible for its application. The Director of Nursing acknowledged the risk of contractures if the hand roll was not applied, emphasizing the responsibility of CNAs to apply the device and the oversight role of RNs and LPNs.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1 Resident #41 was immediately given a new hand roll. The CNA whom had resident #41 was disciplined for not providing the resident’s hand roll. Element #2 The Director of Rehabilitation reviewed all residents with assistive devices to ensure assistive devices are present and in use. Element #3 The nursing staff will be educated to use assistive devices that are ordered by the physician. The policy was reviewed and no revisions were made. Element #4 An audit tool will be developed by the Director of Rehabilitation to monitor the use of assistive devices. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Rehabilitation will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Director of Rehabilitation 5/01/2025
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided to a resident with a nutritional problem, as ordered by the healthcare provider. Specifically, a resident with intact cognition and a diagnosis of dysphagia was observed consuming thin liquids without the required thickener, despite having physician orders for nectar thick liquids. The resident's care plan, initiated due to impaired swallowing, included a diet of pureed food with moderately thick liquids. However, during a dining observation, the resident was provided with juice and a packet of thickener on the tray, but no staff was observed adding the thickener to the juice. Consequently, the resident consumed the juice without thickener and experienced coughing episodes. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities regarding the administration of thickened liquids. The Speech Language Pathologist confirmed the resident's need for nectar thick liquids due to the high risk of aspiration. A CNA stated that nurses were responsible for adding thickener to residents' drinks, while an LPN confirmed this responsibility. However, the Director of Nursing indicated that CNAs were responsible for adding the thickener when serving meal trays. This discrepancy in staff roles and responsibilities contributed to the failure to provide the resident with the appropriate therapeutic diet as ordered.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 The resident was immediately assessed by the RN supervisor and found to have no ill effects from the lack of thickener. Element #2 The facility purchased pre-thickened fluids to provide to residents that have orders for thickened liquid diet. The Director of Nursing will review all residents with thickened fluids orders to ensure residents are receiving pre-thickened fluids. Element #3 The nursing staff will be educated on the use of thickened fluids. The policy and procedure on thickened fluids will be updated to include the use of pre-thickened fluids and the responsibility of the LPN and CNA to ensure the resident receives thickened fluids. Element #4 An audit tool will be developed by the Director of Nursing to monitor the use of thickened fluids. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Director of Nursing 05/01/25
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents during the recertification survey. Resident #32, who had intact cognition and an indwelling catheter, was observed multiple times with their urinary drainage bag uncovered and visible from the hallway. This was contrary to the facility's policy, which mandates the use of dignity bags to cover catheter drainage bags at all times. Interviews with staff revealed a misunderstanding about the policy, with a Certified Nursing Assistant believing the dignity bag was only necessary when the resident was out of bed. The Director of Nursing confirmed that dignity bags should always be used, regardless of the resident's location. Resident #40, who had moderately impaired cognition and required total assistance for eating, was observed being fed by an LPN who remained standing while spoon-feeding the resident. This action required the resident to raise their head to receive food, which was inappropriate and against the facility's practice of ensuring dignity and proper feeding techniques. The LPN acknowledged the inappropriateness of their actions, and the Director of Nursing reiterated that staff should be seated while feeding residents to maintain dignity and ensure safety.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1 The CNA whom had resident # 32 was disciplined for not providing the dignity cover for the foley. The LPN whom fed resident # 40 resigned. It is the policy of the facility to ensure proper dignity to all residents. Element #2 All residents in the facility, with Foleys, were reviewed to ensure proper dignity bags are provided. All nursing staff will be in-serviced on proper use of dignity bags. All nursing staff will be in-serviced about not standing while feeding a resident. Element #3 The Director of Nursing reviewed the policy and procedure for dignity and updated accordingly to include and specify feeding a resident while standing and dignity bags for foleys. Element #4 Using a standardized audit tool, the Director of Nursing/designee will conduct an audit of: a) All residents, with foleys, will have a random check weekly for 4 weeks then monthly for 3 months to ensure dignity bags are in place. All findings will be reported to the quality assurance committee for the next two QAPI meetings. b) During meals, in the main dining room, there will be a random check weekly for 4 weeks then monthly for 3 months to ensure proper dignity while feeding a resident. All findings will be reported to the quality assurance committee for the next two QAPI meetings. Element #5 The Director of Nursing Date of completion 5/1/2025
Deficiency in Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that all areas of the building were protected by an automatic sprinkler system, as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, a storage structure attached to the back of the building was observed to be constructed with combustible materials, including wooden roof supports. This structure, measuring approximately 20 feet by 8 feet, was located within 10 feet of an egress door at the rear of the building and contained a large amount of cardboard boxes, which are considered combustible materials. The deficiency was identified during an observation at approximately 10:30 am on March 6, 2025. The lack of sprinkler protection in this area was confirmed through staff interviews, indicating a failure to comply with the required fire safety standards. The presence of combustible materials in a structure without adequate sprinkler coverage poses a potential fire hazard, which was not directly addressed in the report. The facility's administrator acknowledged the issue during the exit conference on the same day.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I. Immediate Corrective Actions 1. The facility maintenance department made a plan to demolish the storage shed near the egress. 2. The storage identified without a sprinkler will be completely removed. II. Identification of Other Residents 1. All residents have the potential to be affected by the deficient practice. 2. The maintenance department reviewed sprinkler coverage throughout the Facility and no additional areas were identified. III. Systemic Changes: 1. All Maintenance staff were informed and educated on (MONTH) 18th regarding sprinkler heads and their locations, as well as overview of requirements for sprinkler coverage as per K351. 2. The education concentrated on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. IV. QA Monitoring 1. The Maintenance staff has developed an audit tool to validate preventive maintenance and track compliance with all the sprinkler heads/locations. 2. Audits will be done weekly x4 initially by Maintenance/designee to inspect the sprinkler heads/locations, then monthly thereafter for compliance with our preventive maintenance plan. 3. Any sprinkler heads/locations identified with quality issues by these audits will be corrected by the Maintenance staff or Fire Safety Company staff as needed. 4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated. II. Responsible person: Director of Environmental Services Date of completion: 5/1/25
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) Data System within the required 14-day period after completion. This deficiency was identified during a Recertification Survey conducted from March 2, 2025, to March 7, 2025. The survey revealed that for five residents, the MDS assessments were completed but not transmitted within the mandated timeframe. Specifically, the assessments for these residents were completed in early February 2025 but were not transmitted until March 2, 2025, exceeding the 14-day requirement. The facility's policy, revised in May 2024, mandates that submissions should adhere to the Resident Assessment Instrument manual and federal and state guidance. Despite this, the Director of Nursing, who also serves as the MDS Coordinator, acknowledged the oversight in timely submission during an interview on March 7, 2025. The facility's validation report dated March 5, 2025, confirmed the late transmission of all five submissions, indicating a lapse in adherence to the established policy and regulatory requirements.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 F 640 Element #1: The MDS compliance consultant will educate the MDS coordinator on timely submissions. Element #2: The facility will review the last month's submissions to ensure they were submitted timely. Element #3: The policy and procedure for MDS completion will be updated to include timely submissions. The MDS consultant will in-service the MDS coordinator on the revised policy upon the completion of the update to the policy. Element #4: An audit tool will be developed by the Director of Nursing to monitor monthly for timely MDS submissions. Audits will be done for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5: Director of Nursing 5/1/25
Deficiency in Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, as observed during the Recertification Survey. The deficiency was identified when the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. The facility's policy, last reviewed in September 2024, mandates that nursing staff information, including the census, be posted daily at the beginning of each shift. However, during observations from March 2 to March 3, 2025, the posted information only included the facility name, date, resident census, and actual hours worked by nursing staff, omitting the total number of staff directly responsible for resident care. Interviews conducted on March 7, 2025, revealed a lack of awareness among staff regarding the requirement to include the total number of nursing staff in the postings. The Staffing Coordinator acknowledged knowing that the posting should include hours worked by LPNs, CNAs, and RNs, but admitted to not paying attention to the information as it was not their primary responsibility. Similarly, a Registered Nurse and the Director of Nursing were unaware of the requirement to include the total number of staff giving direct care. The Director of Nursing admitted to not realizing the guidelines had changed, and the Administrator also confirmed their lack of awareness regarding the need to include the total number of staff providing direct care.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1 The Nurse supervisors were immediately counseled on the proper requirements for the nurse staff posting. The facility immediately updated and posted the nurse staffing posting as required with the total amount of nurse staff hours, people and the census. The posting will be updated every shift. Element #2 The Director of Nursing reviewed the updated nurse staff posting to ensure it has all the required posting elements. The Director of Nursing educated all RN supervisors and the staffing coordinator of the required information needed on the daily nurse staffing posting. Element #3 The policy and procedure for the nurse staff postings will be updated to include the total amount of nurse staff hours, people and the census. The posting will be updated every shift. The Director of Nursing will educate all RN supervisors and the staffing coordinator of the updated policy. Element #4 An audit tool will be developed by the Director of Nursing to monitor the nurse staff posting. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of nursing will present findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the consistent participation of the Medical Director in the Quality Assurance & Performance Improvement (QAPI) meetings, as required by their policy. The policy, last revised in December 2024, mandates the involvement of the Medical Director in these meetings to study, plan, analyze, and validate specific areas for improvement in resident care outcomes. However, a review of the attendance sheets for the QAPI meetings revealed that the Medical Director did not attend the meetings held in August 2024 and January 2025. During interviews, the Director of Nursing confirmed that the Medical Director's absence was evident due to the lack of their signature on the attendance sheets. The Administrator stated that the Medical Director was invited to all meetings but missed one due to a scheduled cataract surgery. The last recorded attendance of the Medical Director was in an unspecified month in 2024.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1: The Medical Director was given the updated QAPI policy to reflect that if the medical director is unable to make a QAPI meeting, he must send a designee. Element #2: The medical director reviewed the last 2 QAPI minutes and reports. Element #3: The QAPI policy will be updated to reflect that if the medical director is unable to make a QAPI meeting, he will send a designee. Element #4: An audit tool will be developed by the administrator to ensure compliance of QAPI meetings. The administrator will audit the next 3 QAPI meetings to ensure the medical director attends. The administrator will present the findings and corrective actions if indicated to the QAPI committee and thereafter the QAPI committee will determine the frequency of reports. Element #5: Administrator 5/01/2025
Inaccurate MDS Assessment of Resident's Cognitive Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the cognitive status of a resident. Specifically, the MDS assessment for a resident did not accurately reflect their cognition, as it documented the resident's cognition as independent and without behaviors, despite evidence to the contrary. The facility's policy requires that MDS assessments accurately reflect the resident's status by collecting information from multiple sources. However, the resident's care plan indicated that the Brief Interview for Mental Status could not be completed, and the resident required cues and was unable to make needs known. Interviews with facility staff further highlighted the discrepancy in the resident's cognitive assessment. A Certified Nursing Assistant reported that the resident did not follow commands and sometimes needed assistance with feeding. The Social Worker Director confirmed that the resident was nonverbal and had impaired cognition, stating that the MDS should have reflected the resident's poor memory and cognitive impairment. The Director of Nursing, who also served as the MDS Coordinator, acknowledged that they sign off on the completion of the MDS, with each discipline attesting to the accuracy of their sections.
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Nursing homes near Far Rockaway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Lawrence Care Center, L L C | 0.1 mi | ★★★★★ | 0 | 0 |
| Brookhaven Rehab & Health Care Center L L C | 0.3 mi | ★★★★★ | 0 | 0 |
| Haven Manor Health Care Center, Llc | 0.4 mi | ★★★★★ | 1 | 0 |
| Queens Nassau Rehabilitation And Nursing Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Premier Nsg & Rehab Center Of Far Rockaway | 0.6 mi | ★★★★★ | 0 | 0 |
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