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 Premier Nsg & Rehab Center Of Far Rockaway during CMS and state inspections, most recent first.
The facility was cited for failing to maintain a safe, clean, and homelike environment across multiple units. Observations revealed dirt and rust on medical equipment, soiled wheelchairs, peeling paint, and damaged infrastructure. The facility acknowledged the need for renovations, with plans to remodel the second floor, but no proposals for other units. Maintenance and housekeeping challenges were noted, with staff acknowledging the issues but facing difficulties in addressing them.
The facility did not ensure corridors were protected from smoke passage, as required by NFPA standards. During a survey, it was noted that alcoves storing combustible items like linens were open to the corridor on all floors, including the basement, potentially allowing smoke to enter corridors during a fire. The Director of Maintenance confirmed these findings.
The facility did not ensure proper installation of sprinklers according to NFPA standards. On two resident floors and in the basement, issues were found: a missing sprinkler head in a fourth-floor alcove, and sprinkler heads on the second floor and basement installed too close to walls. The Director of Maintenance acknowledged these deficiencies.
A facility failed to develop a comprehensive care plan for a resident on palliative care, despite the resident's severe cognitive impairment and total dependence on staff. The deficiency was due to miscommunication among staff regarding responsibility for care plan development, resulting in the absence of a documented plan for the resident's comfort/palliative care.
The facility failed to provide necessary adaptive devices for residents with limited mobility. A resident with a hip replacement was not given an abductor wedge as ordered, and another resident was without heel protectors and a Lumbar Sacral Orthosis brace. Staff interviews revealed a lack of awareness and documentation, indicating a failure in communication and adherence to care plans.
A survey found that an LPN on Unit 2 left pre-poured medications unattended on an unlocked cart while obtaining a resident's blood pressure. Facility policy requires medication carts to be locked and medications not to be left unattended. Interviews with staff confirmed the policy and acknowledged the risk of wanderers accessing the medications.
During a survey, it was found that two LPNs left computer screens unlocked and unattended, exposing residents' private health information during medication administration. Interviews confirmed the facility's policy to protect such information, but the actions of the nursing staff compromised residents' privacy.
An LTC facility failed to report an alleged abuse incident within the required timeframe. An altercation occurred between two residents, where one was accused of hitting the other with a nebulizer, causing facial injuries. The Administrator was informed shortly after the incident but reported it to the state agency later than the mandated two-hour window, believing it was a peer-to-peer incident not meeting abuse criteria.
The facility failed to submit MDS assessments to CMS within the required 14 days after completion, affecting multiple residents. The policy lacked a submission timeline, and interviews revealed awareness of the issue, with ongoing discussions and plans to hire new assessors.
The facility did not conduct any emergency preparedness drills in the last 12 months. A document review revealed that the emergency preparedness policy and procedures lacked documentation of drills, and the Director of Maintenance confirmed the absence of such drills.
The facility failed to post conspicuous signage about COVID-19 vaccination availability, as required by a Dear Administrator Letter. Observations during a survey found no signage in key areas, and interviews revealed staff were unaware of the requirement. The DON noted signs were removed during renovations, and the Administrator confirmed vaccine availability but couldn't explain the lack of signage.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during a recertification survey. In Unit 2, multiple issues were noted, including dirt and dust accumulation on medical equipment such as sphygmomanometer stands and oxygen concentrators, rust on mechanical lifts, and dusty nurse stations. The dining room had dusty fans, rust-stained suction machine tables, and missing or torn window shades. Additionally, wheelchairs were soiled, floor mats were torn and dirty, and clothes bins were embedded with debris. The facility had a signed construction contract for remodeling the second floor, but the work was pending material availability. In Unit 3, several deficiencies were observed, including peeling chairs in the nurses' station, missing floor linoleum, and radiators with crusty brown substances. Rooms had peeling paint, broken window shades, and dirty walls. The Maintenance Director acknowledged the lack of a painter and the need for additional maintenance staff. The facility's administrator confirmed the building's age and the need for extensive renovations, with plans to remodel the second floor but no proposals yet for Units 3 and 4. Unit 4 also exhibited significant issues, such as holes in the common bathroom walls, peeling paint, chipped tiles, and brown stains on ceiling tiles. A resident expressed a desire for their room to be repainted. The porter responsible for cleaning acknowledged the issues but was unsure if they had been reported to maintenance. The administrator noted the challenges in maintaining cleanliness due to resident behaviors and confirmed the need for further renovations across the facility.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action a. Director of Environmental Services and Housekeeping Director did environmental rounds on 2nd, 3rd and 4th floor. b. All high touch surfaces, including nursing stations, closets, window sills, hand rails, fans, stands, lifts, suction machines checked and cleaned. Radiators, door frames cleaned and painted. c. Housekeeping Director checked all wheel chairs on the 2nd floor and scheduled cleaning. d. Director of Environmental Services made facility rounds noting which rooms need to be repainted. e. Director of Environmental Services made rounds of all window shades on 2nd and 3rd floor and replaced missing, torn, broken shades. f. Director of Environmental Services checked all chairs at nursing stations. All peeling and torn chairs, removed off unit, Administrator purchased new chairs. g. DON checked the condition of all binders. Old binders replaced with new ones. h. Director of Environmental Services repaired resident common bathroom including new tiles, paint and repaired holes. II. Identification a. Director of Environmental Services, Director of Housekeeping and Administrator made building wide facility rounds to identify areas of improvement. b. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator, Director of Housekeeping and Director of Environmental Services reviewed Safe and Homelike Environment Policy and found it to be compliant. b. Housekeeping Director in-serviced all housekeeping staff regarding the use of the Maintenance communication books at the nurses station when they see issues on the unit and in resident rooms. c. Director of Housekeeping and Director of Environmental Services to conduct weekly rounds on each unit. d. Full time maintenance employee hired. e. Full time housekeeper hired. Part time maid to be hired. IV. Monitoring a. Director of Environmental Services developed an audit tool for routine maintenance rounds to include window blinds, bathroom tiles, ceiling tiles, paint on radiators / ac units, walls, closets, windows, sinks. b. Administrator and Housekeeping Director developed an audit tool for cleanliness of units including nursing station, furniture, radiators, windows and more. c. Audit will be done weekly for 1 month, monthly for 3 months. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services and Housekeeping Director / designee. V. Responsibility: a. Director of Environmental Services and the Housekeeping Director will be responsible to ensure correction of this deficiency.
Corridor Smoke Protection Deficiency
Penalty
Summary
The facility failed to ensure that all corridors were protected from the passage of smoke, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that alcoves used to store combustible items, such as linens, were open to the corridor on all floors, including the basement. This configuration could allow smoke to pass into the corridor in the event of a fire. These findings were confirmed through observation and staff interviews, specifically with the Director of Maintenance.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K636 P(NAME) I. Immediate Corrections: a. Director of Environmental Services checked all alcoves where linens are stored on resident floors and noted half door partitions. b. Director of Environmental Services took measurements and will be installing full doors to ensure all corridors were protected from passage of smoke. II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed Fire Safety Policy. No Updates Necessary. b. Director of Environmental Services in-serviced all maintenance staff on protecting corridor from smoke in case of fire. IV. Monitoring: a. Director of Environmental Services developed an audit tool for alcoves to ensure proper closure and from passage of smoke. b. Audits will be done quarterly for one year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.
Sprinkler System Installation Deficiencies
Penalty
Summary
The facility failed to ensure that all sprinklers were installed in accordance with the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, it was observed that on two of the four resident floors and in the basement, the sprinkler system was not compliant. Specifically, on the fourth floor, an alcove off the corridor was missing a sprinkler head. On the second floor, a sprinkler head above the smoke barrier doors near a room was installed less than the required 4 inches from the adjacent wall. Similarly, in the basement laundry chute room, a sprinkler head was also less than 4 inches from the adjacent wall. These deficiencies were noted during the survey conducted between 9:30 am and 1:00 pm, and the Director of Maintenance acknowledged the need for correction.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrections: a. Director of Environmental Services checked all sprinklers in the facility across all four floors and basement. No negative findings. b. Administrator called Fire Safety Sprinkler Corp regarding the need to replace sprinkler heads on the second and fourth floor as well as the basement that are in question. c. Fire Safety Sprinkler Corp replaced 2 upright sprinkler heads next to the wall with vertical sidewall sprinkler heads near room [ROOM NUMBER] and in basement laundry chute room. d. Fire Safety Sprinkler Corp installed a new sprinkler head in the 4th floor alcove off corridor. II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed policy for Sprinkler System and found it to be compliant. b. Administrator in-serviced all maintenance staff on sprinkler coverage and need for sprinklers to be at least 4 inches from the wall. IV. Monitoring: a. Director of Environmental Services developed a sprinkler inspection audit to ensure all areas are sufficiently covered by sprinklers. b. Audits will be done weekly for quarterly for one year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.
Failure to Develop Comprehensive Care Plan for Palliative Care
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for a resident, specifically addressing comfort and palliative care needs. This deficiency was identified during a recertification survey, where it was found that a resident with severe cognitive impairment and total dependence on staff for daily activities did not have a care plan for comfort/palliative care, despite being on such care as per a nurse practitioner's notes. The resident was observed to be alert but non-responsive, with intravenous and oxygen support in place. Interviews with facility staff revealed a lack of clarity regarding responsibility for developing the care plan. A registered nurse indicated that it was the social worker's responsibility to create the care plan, while the Director of Social Services was unaware of this requirement, believing their role was complete after documentation. This miscommunication and lack of awareness led to the absence of a documented care plan for the resident's comfort/palliative care, violating the facility's policy and regulatory requirements.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. Resident 95 comprehensive care plan updated to reflect comfort care. II. Identification a. Audit of all residents with advanced directives done immediately on 3/5/25 to ensure appropriate care plans were in place. No negative findings. III. Systemic Changes a. Administrator and DON reviewed Comprehensive Care Plan Policy on 3/5/25 and found it to be compliant. b. Administrator in-serviced Social Work Director and Social Worker on responsibility of implementing care plans for comfort care measures. IV. Monitoring a. DON developed an audit tool to ensure all residents on comfort care have appropriate care plans. Any resident with Advanced Directives triggering comfort care measures will be sampled for audit. b. Audit will be conducted monthly x 12 months. c. Audits with negative findings will have immediate corrective action and reported to the Administrator for review and follow up. d. Audit findings will be presented to the QA committee quarterly by the Director of Nursing / designee. V. Responsibility a. The Director of Nursing will be responsible to ensure correction of this deficiency.
Failure to Provide Necessary Adaptive Devices for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion and mobility were provided with the necessary services, care, and equipment to maintain or improve their function. This deficiency was observed in three residents. Resident #22, who had a history of hip replacement, was not provided with an abductor wedge as per physician's orders. Despite multiple observations over several days, the resident was seen without the wedge while sitting in a wheelchair or participating in therapy. Interviews with staff revealed a lack of awareness and documentation regarding the use of the abductor wedge, indicating a failure in communication and adherence to the care plan. Similarly, Resident #92, who required heel protectors and a Lumbar Sacral Orthosis brace, was observed without these devices on multiple occasions. The resident was dependent on staff for assistance, yet the devices were not applied as ordered. Interviews with the CNA and LPN revealed a lack of awareness and responsibility for ensuring the resident used the prescribed adaptive devices. The Director of Nursing expressed surprise at the oversight, highlighting a gap in monitoring and execution of physician orders and care plans.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Action a. Resident #22 was evaluated by Director of Rehabilitation. b. Director of Rehabilitation in-serviced CNA’s on unit about the need to use abductor wedge. c. Director of Rehabilitation confirmed with Ortho to discontinue the abductor wedge. Care plan updated to reflect. d. DON reviewed Resident #92 care plan and confirmed physician orders [REDACTED]. e. Resident #92 counseled about the importance of wearing TLSO brace and heel protectors. II. Identification a. All residents with assistive devices audited to ensure accuracy with physician orders [REDACTED]. No negative findings. III. Systemic Changes a. Administrator, DON, Director of Rehabilitation reviewed Adaptive/Assistive Devices Policy on 3/7/35 and found it to be compliant. b. Director of Rehabilitation in-serviced all Rehab, nursing and CNA staff members on use of devices for resident safety. IV. Monitoring a. Director of Rehabilitation developed an audit tool to ensure devices ordered for residents are being used. b. Director of Rehabilitation/designee will observe 5 residents with devices at random weekly to ensure proper device compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2. d. Any negative audit findings will be presented to Administrator and immediately corrected. All audit findings will be presented to the QA committee quarterly by the Director of Rehabilitation. V. Responsibility a. The Director of Rehabilitation will be responsible to ensure correction of this deficiency.
Improper Medication Storage on Unit 2
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper storage of medications and biologicals on Unit 2. Specifically, a Licensed Practical Nurse (LPN) pre-poured medications for a resident and left them unattended on top of an unlocked medication cart. This occurred while the LPN entered the resident's room to obtain their blood pressure, leaving the medications vulnerable to access by others. Interviews conducted with the LPN, a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that facility policy mandates that medication carts must be locked when not in view of the nurse, and medications should not be left unattended. The LPN acknowledged the risk posed by wanderers who could potentially take the medications left on the cart. The RN and DON reiterated the importance of securing the medication cart at all times, regardless of the duration it is left unattended.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. DON gave 1:1 counseling to LPN 1 regarding following the facilities protocol and procedure of medication administration, including procedure when leaving med cart unattended. b. DON issued disciplinary action to LPN 1. II. Identification a. DON and ADON observed all LPN's doing medication pass. b. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Medication Administration Policy on 3/3/25 and found it to be compliant. b. DON and ADON in-serviced all RN and LPN on 3/2/25 staff on proper handling of medication, proper use and storage of medication cart when stepping away from the cart. c. RN and LPN's will receive performance review every 6 months, and quarterly medication pass review for all LPNs and RNs. IV. Monitoring a. DNS and ADON developed an audit tool to ensure nursing staff compliance with proper medication administration. All LPNs will be selected at random and rotated as part of the audit to ensure compliance. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The ADON will be responsible to ensure correction of this deficiency.
Breach of Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure residents' right to personal privacy and confidentiality of medical records during a recertification survey. This deficiency was observed in two of the four units surveyed. Specifically, licensed nurses left computer screens unlocked and unattended, exposing private medical information during medication administration. On Unit 2, a Licensed Practical Nurse left the computer screen open while attending to a resident's blood pressure, and on Unit 3, another Licensed Practical Nurse did the same while administering medications. Both nurses acknowledged the importance of maintaining confidentiality and admitted to not securing the computer screens. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the facility's policy and the legal requirement to protect residents' health information under the Health Insurance Portability and Accountability Act. The facility's policy emphasizes the responsibility of all employees to safeguard the confidentiality and integrity of resident information. Despite these policies, the observed actions of the nursing staff during medication administration compromised the privacy of residents' health information.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action LPN #1 and LPN #2 were given 1:1 education on HIPAA and protecting residents information. II. Identification a. DON and ADON observed all LPN’s give med pass on each unit. b. DON and ADON issued competencies to identify and potential issues. c. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Privacy Policy and Personal Health Information Pledge of Confidentiality on 3/3/25 and found it to be compliant. b. DON in-serviced all nursing staff on HIPAA and procedure when walking away from medication cart or electronic medical record kiosk. IV. Monitoring a. DON developed audit tool to ensure nursing personnel are properly following HIPAA protocols in the facility. Specifically, audit will focus on HIPAA and procedure when walking away from medication cart and or electronic medical record kiosk. b. DON/Designee will observe 5 nursing staff members at random weekly to ensure HIPAA protocol compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2 V. Responsibility The ADON will be responsible to ensure correction of this deficiency.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe during a Recertification and Complaint Survey. On January 29, 2025, at approximately 5:30 AM, a physical altercation occurred between two residents, where one resident was accused of hitting another in the face with a nebulizer machine. The incident resulted in the injured resident having redness, swelling, and a superficial cut on the face. The facility's Administrator was informed of the incident at 5:55 AM but did not report it to the New York State Department of Health until 2:28 PM, which exceeded the mandated two-hour reporting window for incidents involving potential abuse. The facility's policy on abuse prohibition requires that any suspected abuse be reported promptly, especially if it involves serious bodily injury. Despite the policy, the Administrator believed the incident was a peer-to-peer altercation and did not meet the criteria for abuse, thus assuming a 24-hour reporting window was applicable. This misinterpretation led to a delay in reporting the incident to the state agency, resulting in a deficiency citation for failing to adhere to the required reporting timeline.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action a. Administrator was re-educated regarding reporting guidelines and timeliness of reporting abuse by facility’s regional administrator. II. Identification a. Administrator reviewed reporting guidelines. b. The facility respectfully states that identified issue has been corrected. III. Systemic Changes a. Administrator and DON reviewed Abuse Prohibition policy on 3/7/25 and found it to be compliant. IV. Monitoring a. Administrator developed an audit tool to ensure any alleged violations involving abuse, neglect, exploitation or mistreatment are reported in a timely manner. b. Audit will be conducted monthly x 12 months. c. All negative findings will be immediately addressed to DOH. All audit findings will be presented to the QA committee quarterly by the Administrator. V. Responsibility a. Administrator is responsible to ensure correction of deficiency.
Delayed Submission 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 Data System within the required 14 days after completion. This deficiency was identified during a recertification survey, affecting 10 out of 37 sampled residents. The facility's policy on MDS assessments, reviewed in January 2025, did not specify a timeline for submission. The survey revealed that the MDS assessments for several residents were completed but not submitted within the mandated timeframe, with actual submission dates significantly delayed beyond the scheduled dates. Interviews with the MDS Coordinator and the Administrator highlighted awareness of the issue, with the Coordinator acknowledging the late submissions and the Administrator noting ongoing discussions about the problem. The facility recognized the delay in submissions during Quality Assurance meetings and was in the process of hiring new assessors to address the issue. Despite these discussions, the deficiency persisted, as evidenced by the late submission of MDS assessments for multiple residents, which was documented in the validation reports with warning messages indicating the records were submitted late.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action a. DON in-serviced MDS Coordinator regarding timely submission of MDS. II. Identification a. DON and MDS Coordinator reviewed all MDS submissions from start of 2025. b. The facility respectfully states that all identified issues have been corrected. III. Systemic Changes a. DON and MDS Coordinator reviewed and updated MDS Policy on 3/11/25 to indicate submission timeline for MDS submission. b. Administrator in-serviced all staff who complete portions of MDS on timely submission beginning on 3/7/25 and as new hires came on board. c. 2 per diem MDS assistants hired and given new schedules on 3/11/25. d. MDS case load divided by floor to ensure timely submission. IV. Monitoring a. DNS and MDS Coordinator developed an audit tool to ensure due MDS assessments are submitted in a timely manner. Audit tool will review all due MDS Assessments. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The MDS Coordinator will be responsible to ensure correction of this deficiency.
Failure to Conduct Emergency Preparedness Drills
Penalty
Summary
The facility failed to conduct any emergency preparedness drills within the last 12 months. During a document review on March 4, 2025, between 10:00 am and 12:00 pm, it was found that the facility's emergency preparedness policy and procedures lacked documentation of any emergency drills conducted in the specified period. The Director of Maintenance confirmed that no drills were conducted during this time.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I. Immediate Corrections: a. Director of Environmental Services reviewed Emergency Preparedness Plan and found there to be inadequate safety measures, specifically documentation and execution of necessary emergency drills within the last 12 months. b. Administrator registered facility for NYC Health Long Term Care Exercise Program to ensure compliance moving forward. c. Administrator registered facility for tabletop exercise on (MONTH) 22 and (MONTH) 23rd via NYC LTC Associates / NYC DOHMH II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed Emergency Preparedness Plan. b. Administrator in-serviced all maintenance staff on Emergency Preparedness requirements including the mandatory drills done in last 12 months. IV. Monitoring: a. Director of Environmental Services developed a Disaster Drill audit to maintain compliance over required 12 month period. b. Audits will be done quarterly for 1 year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.
Failure to Post COVID-19 Vaccination Signage
Penalty
Summary
The facility was cited for failing to ensure conspicuous signage was posted throughout the facility to remind residents and staff that COVID-19 vaccinations are available. This deficiency was identified during a Recertification Survey conducted from March 1, 2025, to March 7, 2025. The Dear Administrator Letter #23-15, dated March 13, 2023, required facilities to post such signage at points of entry, exit, and in each residential hallway. However, during observations conducted between March 4, 2025, and March 6, 2025, no signage was found in the lobby, hallways, or resident units. Interviews with facility staff revealed a lack of awareness and oversight regarding the signage requirement. The Infection Preventionist admitted to not posting the signage and was unaware of the need to do so. The Director of Nursing mentioned that the notifications had been posted previously but were removed approximately two years ago during renovations. The Administrator confirmed that COVID-19 vaccines are offered to residents and staff but could not explain the absence of the required signage.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Action: a. Administrator and Director of Nursing reviewed Covid-19 Comprehensive Policy and Procedure on 3/6/25. b. Administrator created and posted Covid-19 Vaccination signage available in lobby and on all units throughout the facility. c. Administrator in-serviced DNS and Infection Preventionist, and gave DNS and Infection Preventionist 1:1 educational counseling on signage posting regarding Covid-19 vaccine being available. II. Identification: a. On 3/6/25 Administrator and DNS reviewed signage on all units. b. Necessary Covid-19 vaccination signage noted missing. c. The facility respectfully states that all identified issues have been corrected. III. Systematic Changes: a. The Director of Nursing and Administrator reviewed and updated the Covid-19 Comprehensive policy and procedure to include posting of mandatory vaccination signage. b. DON in-serviced Infection Preventionist on 3/6/25. IV. Monitoring: a. Director of Nursing and Infection Preventionist created an audit to ensure Covid-19 vaccination signage is posted conspicuously throughout the facility. b. Administrator and DON will monitor all updates to Covid protocols by CDC and NYS. Any necessary signage will be added to policy and audit. Audits will be done quarterly for 1 year. Audits with negative findings will have immediate corrective action and reported to the Administrator for review and follow up. c. Audit findings will be presented to the QA committee quarterly by the Director of Nursing / designee. V. Responsibility: a. The Director of Nursing will be responsible to ensure correction of this deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 792 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Queens Nassau Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Far Rockaway Center For Rehabilitation And Nursing | 0.2 mi | ★★★★★ | 12 | 0 |
| Peninsula Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 3 | 1 |
| Bezalel Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 5 | 0 |
| Beach Gardens Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 1 | 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.