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 Peninsula Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and aspiration risk, requiring supervision during meals, was found unresponsive with food lodged in the airway after wandering unsupervised. Staff failed to provide adequate supervision and did not follow established aspiration precautions, resulting in the resident's death from choking.
A resident with severe cognitive impairment and aspiration risk was not properly supervised and was able to access and consume food unsupervised. When found unresponsive, staff did not immediately assess or initiate CPR, and there was a delay in contacting EMS. Upon EMS arrival, the resident was found with food obstructing the airway and was later pronounced deceased. The facility failed to follow professional standards and the resident's care plan, resulting in actual harm.
A resident with severe cognitive impairment and aspiration risk was found unresponsive with food lodged in their airway. Staff provided inconsistent accounts regarding supervision and the presence of food, and the DON did not conduct a thorough investigation or fully document the incident as required by policy.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling medical devices and during wound care, as observed during a survey. Two residents with catheters did not have the required precautions, and a CNA did not perform hand hygiene between assisting residents in the dining room. These lapses indicate a gap in staff training and awareness of infection control protocols.
The facility failed to provide timely notification of Medicare Part A benefit termination to two residents' representatives. Notices of Medicare Non-Coverage were not mailed on the same day as the telephone notifications, contrary to facility policy. Interviews revealed uncertainty about the mail pickup process, leading to delays.
The facility failed to ensure proper physician review and documentation of care for intravenous catheter lines for two residents. A nurse was observed changing a PICC line dressing for a resident, which was overdue by one day, without a documented physician order for dressing change frequency. Similarly, another resident's Midline catheter dressing was changed without a documented order. Interviews revealed lapses in the process of documenting and verifying physician orders for catheter care.
A resident with Alzheimer's and other conditions did not receive a timely annual dental evaluation as required by facility policy. Despite expressing a need for dentures, there was no documented follow-up after the last dental consult. Staff interviews revealed unclear processes and communication issues regarding the scheduling of dental consults, contributing to the deficiency.
Failure to Prevent Choking Death Due to Inadequate Supervision and Aspiration Precaution
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who was at risk for aspiration and choking and required supervision during meals, was found unresponsive in a hallway late at night. The resident had a documented history of wandering, taking other residents' food, and required a puree and nectar thick liquid diet with soft sandwiches. The resident wore a green charm indicating aspiration risk and was supposed to be closely supervised, especially during meals and when in common areas. Despite these precautions, the resident was last seen in the hallway and was later found unresponsive in their wheelchair with food, including peanut butter and meat, lodged in their airway. Staff interviews and documentation revealed that the resident was not being adequately supervised at the time of the incident. Certified Nursing Assistants and nurses on duty were either unaware of the resident's whereabouts or did not recognize the need for immediate intervention when food was observed in the resident's mouth. The staff did not perform appropriate emergency measures such as suctioning the airway, and there was confusion about the timeline and actions taken during the emergency response. The facility's policy required close observation and intervention for residents with aspiration risk, but these protocols were not followed, as evidenced by the lack of supervision and failure to prevent the resident from accessing and consuming unsafe food. The incident resulted in the resident's death due to choking and aspiration, as confirmed by emergency medical services who found large amounts of food obstructing the airway. The facility's documentation and staff statements indicated gaps in monitoring, supervision, and adherence to established aspiration precautions. The deficiency was identified as Immediate Jeopardy due to the actual harm and death of the resident and the potential for serious harm to other residents at risk for aspiration.
Removal Plan
- Hold a Quality Assurance Performance Improvement meeting addressing the immediate jeopardy citation (F689), root cause and scope determination, immediate corrective actions, directed plan of correction and monitoring and validating plan.
- Reeducate the Nursing staff, Dietary and Speech Therapists regarding resident safety and supervision, aspiration precautions and emergency response.
- Conduct a chart audit on residents to ensure residents are assessed for aspiration and wandering behavior. Implement physicians' orders and update care plans.
- Review Policies and Procedures on Cardiopulmonary Resuscitation and Heimlich Maneuver.
- Revise the Cardiopulmonary Resuscitation policy and procedure to include not to move the resident to the bed or another area, begin cardiopulmonary resuscitation where the resident is found.
- Revise the Heimlich Maneuver policy and procedure to include to lower resident to a firm surface and activate Emergency Medical Service (911), begin cardiopulmonary resuscitation starting with compressions, before delivering breaths during cardiopulmonary resuscitation cycles, open mouth and look for visible object, remove only if seen, do not perform blind finger sweeps.
- Reevaluate all locations of nourishment and snacks on the units to ascertain if current measures to secure said nourishment is adequate.
- Initiate in-service education to Certified Nursing Assistants, Licensed Nurses, Speech Therapist and Dieticians regarding residents at risk for aspiration, facility safety practices, policy update, rounding and documentation, and environmental safety measures.
- Provide staff in-service on resident safety and supervision, aspiration precautions and emergency response.
Failure to Provide Timely Assessment and Supervision for Resident on Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, severe cognitive impairment, and a known risk for aspiration and choking was found unresponsive in a hallway. The resident was on aspiration precautions, wore a green charm indicating swallowing difficulty, and required supervision during meals. Despite these documented risks and care plan interventions, the resident was not adequately supervised and was able to access and consume food unsupervised, which was not consistent with their prescribed dietary and safety requirements. When the resident was discovered unresponsive in their wheelchair, staff did not immediately assess the resident or initiate cardiopulmonary resuscitation (CPR) as required by facility policy. There was a delay in both the assessment and the initiation of emergency procedures, including calling Emergency Medical Services (EMS), which occurred approximately 15 minutes after the resident was found. Documentation and interviews revealed inconsistencies in staff awareness and response, with some staff noting the presence of food in the resident's mouth and others not recognizing or acting upon this critical finding. Upon EMS arrival, the resident was found to have a large amount of food, including peanut butter and meat, lodged in their airway, which required clearing and suctioning before further resuscitation efforts. The resident was pronounced deceased after unsuccessful resuscitation attempts. The facility failed to provide care and treatment in accordance with professional standards, the resident's care plan, and the resident's known preferences and goals, resulting in actual harm.
Failure to Investigate Resident Death Related to Aspiration
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a severely cognitively impaired resident who was at risk for aspiration and required supervision during meals. The resident, who had a history of wandering and taking other residents' food, was found unresponsive in a hallway late at night. Emergency services were called, and upon their arrival, the resident was found to have food, including peanut butter and meat, lodged in their airway, which required clearing and suctioning before intubation. The resident was pronounced deceased shortly after. Facility policy required that all incidents be documented with a summary of circumstances, including staff and witness statements, and submitted to the Director of Nursing within 24 hours. However, the investigation into this incident was incomplete. Staff interviews revealed inconsistent accounts regarding the presence of food in the resident's mouth and a lack of awareness about the resident's aspiration risk and behaviors. Some staff observed food on the resident's lap and in their mouth, while others denied knowledge of these details. The Director of Nursing collected staff statements but did not conduct a thorough investigation, believing staff had responded appropriately and was unaware of the food found in the resident's airway. The deficiency was cited because the facility did not ensure a comprehensive investigation into the circumstances leading to the resident's death, particularly regarding supervision, aspiration precautions, and the presence of food in the resident's airway. The required documentation and reporting procedures were not fully followed, and the results of the investigation were not adequately reported to the administrator or other officials as required by state law.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling medical devices and during wound care, as observed during the recertification survey. Specifically, two residents with indwelling catheters did not have the required precautions in place. Registered Nurse #3 did not wear a gown while performing a dressing change for a resident with a Peripherally Inserted Central Catheter, and there was no signage indicating the need for Enhanced Barrier Precautions. Similarly, Registered Nurse #4 did not wear a gown while administering intravenous antibiotics to a resident with a midline catheter, and there was no signage for Enhanced Barrier Precautions. Additionally, the facility did not maintain proper hand hygiene practices in the dining room. A Certified Nursing Assistant was observed assisting multiple residents with hand hygiene without performing hand hygiene themselves between residents. This lapse in protocol was acknowledged by the Certified Nursing Assistant, who admitted to not cleaning their hands between assisting different residents, potentially leading to cross-contamination. The facility's failure to adhere to its own policies and the new CMS guidance on Enhanced Barrier Precautions and hand hygiene protocols resulted in deficiencies. The Infection Control Preventionist and Director of Nursing confirmed the necessity of these precautions, yet they were not consistently implemented, indicating a gap in staff training and awareness.
Deficiency in Timely Notification of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents or their designated representatives were provided with appropriate notification at the termination of Medicare Part A benefits. This deficiency was identified during a recertification survey, affecting two residents out of the three reviewed for beneficiary notification. Specifically, the Notices of Medicare Non-Coverage for these residents were not mailed out on the same day as the telephone notifications to their representatives, as required by the facility's policy. The policy mandates that such notifications be sent at least two business days before the last covered day, with certified mail receipts maintained in the MDS office. For one resident, the telephonic notification was made on May 24, 2024, but the certified mail was not sent until May 29, 2024. Similarly, for another resident, the telephonic notification occurred on January 3, 2024, but the mail was not sent until January 5, 2024. Interviews with the Minimum Data Set Assessors revealed that while they dropped off the notices at the front desk for mailing on the same day as the phone calls, they were unsure when the mail was actually picked up. The facility's process lacked a verification step to ensure that the mail was sent out on the same day as the notification, leading to a delay in the mailing of the notices.
Deficiency in Physician Review of Intravenous Catheter Care
Penalty
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, specifically regarding the maintenance of intravenous catheter lines for two residents. For Resident #377, a registered nurse was observed changing a dressing for a Peripherally Inserted Central Catheter (PICC) and administering an intravenous antibiotic. The dressing was overdue for a change by one day, as it had been last changed eight days prior. There was no documented physician order specifying the frequency of dressing changes for the PICC line, despite a physician order for the administration of Vancomycin. Similarly, for Resident #50, a registered nurse was observed changing a dressing for a Midline catheter and administering an intravenous antibiotic. Again, there was no documented physician order specifying the frequency of dressing changes for the Midline catheter. Interviews with the Director of Nursing and the Medical Director revealed that there should be documentation of physician orders for intravenous line care and maintenance, including dressing changes. The Director of Nursing acknowledged the absence of a dressing change order for Resident #50 and was uncertain about the order for Resident #377. The Attending Physician stated that they rely on nurses to enter orders when they are not in the building and that they verify and sign these orders afterward. However, the Attending Physician admitted not checking for a dressing change order for Resident #50, indicating a lapse in the process of ensuring proper documentation and review of physician orders.
Failure to Provide Timely Dental Evaluation for a Resident
Penalty
Summary
The facility failed to ensure that a resident received a timely annual dental evaluation and care, as required by their policy. Resident #92, who was admitted with Alzheimer's Disease, Non-Alzheimer's Dementia, and Seizure Disorder, did not receive an annual dental evaluation after the last documented consult on 5/25/2023. Despite orders for an initial dental consult and follow-up as needed, there was no evidence of a dental evaluation after this date. The resident expressed a need for dentures to staff, but no follow-up was documented. Additionally, there were no records of the resident refusing dental services on 5/23/2024 and 5/30/2024, or being seen on 7/2/2024, as noted in the Dental Orders and Progress Notes. Interviews with facility staff revealed a lack of clarity and communication regarding the scheduling of dental consults. Registered Nurse #4 indicated that issues with dental care are reported to nursing supervisors, who are responsible for scheduling appointments. Nursing Supervisor #1 stated that dental consults are scheduled annually, but was unsure how the scheduling for Resident #92 was missed. The Director of Nursing mentioned that the contracted dental company tracks annual consults and notifies them via email, but was uncertain about the process and whether notifications had been received. This lack of documented follow-up and unclear processes contributed to the deficiency in providing necessary dental care for Resident #92.
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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 Far Rockaway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Far Rockaway Center For Rehabilitation And Nursing | 0 mi | ★★★★★ | 12 | 0 |
| 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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