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 Promenade Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with depression and schizophrenia, initially assessed as not at risk for elopement and later identified as an elopement risk, eloped twice due to failures in supervision and access control. In the first incident, a housekeeping staff member used a back exit door with an alarm override key and did not ensure the alarmed door was properly secured and re-armed, allowing the resident to exit without triggering an alarm and without timely detection by nursing staff. In the second incident, despite a care plan and MD orders for a wander guard and frequent monitoring, required hourly checks were not documented, the resident removed the wander guard, left the unit via elevator, and was allowed out the front door by a security guard who did not confirm whether the individual was a resident or visitor and did not follow sign-in/sign-out procedures or promptly report the exit. These actions and omissions resulted in two unsupervised departures from the facility grounds.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as rusted and leaking air conditioners, peeling paint, and accumulated dirt observed across multiple units. Staff reported these issues, but there was a lack of effective follow-through and documentation. Facility leadership acknowledged the problems but had not yet implemented effective measures to address them.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment to the state health department. The resident's family reported finding the resident with a bloody nose, and the resident claimed to have been hit. Despite these allegations, the facility did not report the incident, as the Director of Nursing and Administrator did not observe physical evidence of abuse.
A facility failed to mail the Notice of Medicare Non-Coverage to a resident's representative after telephonic notification, contrary to its policy. The resident was discharged from skilled services, and the Minimum Data Set Coordinator confirmed that the notice was not mailed since the next of kin was informed by phone. The facility's policy requires mailing the notice if the resident cannot comprehend it, but this step was missed, leading to a deficiency.
A deficiency was identified when a nurse left a computer screen displaying a resident's personal health information open and unattended during a medication administration task, violating HIPAA guidelines. The nurse acknowledged the error, and both the RN Supervisor and DON emphasized the importance of maintaining confidentiality through proper training and monitoring.
A facility failed to ensure a resident was free from physical restraints, as the resident was observed with bilateral half side rails raised and was unable to use them independently. Despite a physician's order for side rails as enablers, the resident, who had severe cognitive impairments, could not follow commands to use them for mobility or transfers. Staff interviews revealed that the side rails were used to assist CNAs during care, contrary to the facility's policy. The facility's assessments and care plans did not accurately reflect the resident's inability to use the side rails, contributing to the deficiency.
A facility survey found that a nurse left medications and an open EMR unattended on a medication cart, breaching professional standards. The nurse admitted needing to slow down, and the DON confirmed this was against facility policy.
A medication cart was left unlocked and unattended during a medication administration task, contrary to facility policy. A nurse left medications on top of the cart while searching for apple sauce or pudding, posing a risk of unauthorized access. Staff interviews confirmed this practice was unsafe and against protocol.
A facility failed to maintain infection control practices, as observed during a survey. A respiratory therapist did not change gloves or perform hand hygiene while providing care to a resident with a tracheostomy, risking cross-contamination. Similarly, a nurse did not perform hand hygiene or change gloves during wound care for a resident with pressure ulcers. Both staff members acknowledged the lapses, and facility directors emphasized the importance of proper hand hygiene and aseptic techniques.
During a survey, it was found that handrails in the hallways of Units 2 and 6 were not firmly affixed to the walls. Despite daily cleaning routines and a system for reporting maintenance issues, the loose handrails were not addressed, indicating a lapse in communication and procedure adherence among staff.
A facility failed to update care plans for two residents, one with dementia and another with behavioral issues. The first resident's care plan was not revised after a significant change in condition, while the second resident's plan lacked interventions for verbally abusive and inappropriate sexual behavior. Staff interviews confirmed these oversights, with no explanations provided for the omissions.
Failure to Prevent Repeated Elopement Due to Door Alarm Misuse, Inadequate Monitoring, and Front Desk Lapses
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with depression and schizophrenia, resulting in two separate unsupervised exits from the building. On the first occasion, the resident had been assessed on admission as not at risk for elopement or unsafe wandering and had intact cognition, ambulating with supervision or touching assistance. On the day of the first incident, hourly rounding documentation at 5:00 PM recorded the resident as observed in bed awake. However, facility video later showed the resident walking down the hallway and exiting through the back exit door on the first floor at approximately 5:57 PM, without triggering an alarm. Staff did not realize the resident was missing until about 7:15 PM, when an LPN noted the resident was not in their room prior to medication administration and a search of the unit and facility was initiated. The first elopement was linked to the actions of a housekeeping staff member who used the back exit door to dispose of garbage and had the key to disable the door alarm. The facility’s policy on the delivery door alarm override limited use of the override key to authorized staff and required continuous supervision of the door and immediate re-arming of the alarm, with no prolonged disarming permitted. Housekeeping staff reported using the back door between 7:00 PM and 10:30 PM and stated they had the key to disable the alarm, believed they had locked the door and re-enabled the alarm, but acknowledged they may have forgotten to lock the door, allowing the resident to exit. The RN Supervisor confirmed that video surveillance showed the resident using the back exit door without triggering an alarm because the housekeeping porter had disarmed it, and the resident left the facility grounds unsupervised. The second elopement occurred after the resident had a documented history of elopement and was identified as at risk, with a care plan and physician’s orders for a wander guard and frequent monitoring. The MDS continued to show intact cognition and ambulation with supervision or touching assistance. An elopement evaluation documented that the resident had a history of elopement and voiced a desire to leave, and the Kardex indicated hourly rounds and a wander guard on the left wrist. Despite this, there was no documented hourly monitoring for the resident on the night of the second incident. Video surveillance showed the resident leaving the unit, taking the elevator, and later appearing at the front desk wearing a hat, blue jacket, and jeans. The security guard at the front desk pressed the button to unlock the front door and allowed the resident to leave, later stating that the individual did not look like a resident, had refused to sign in or out, and was nonetheless permitted to exit. The facility’s reception policy required all visitors to log in and out and directed reception/security staff not to allow anyone to leave without knowing whether the person was a visitor or a resident. The RN Supervisor and internal investigation documented that the security guard did not initially report the occurrence, and staff later found the resident’s wander guard cut off and left at the bedside, indicating the resident had removed it prior to leaving. These actions and inactions resulted in the resident exiting the facility unsupervised on two separate occasions without the facility’s knowledge at the time of departure. In both incidents, the facility’s systems and staff practices failed to prevent elopement despite existing policies and, in the second incident, a known elopement risk and specific monitoring and wander guard orders. In the first event, the back exit door alarm was disarmed and not properly managed, allowing the resident to leave without triggering an alarm and without timely detection by staff. In the second event, required hourly monitoring was not documented, the resident was able to remove the wander guard and leave the unit, and the security guard at the front desk did not verify the person’s identity as a resident or visitor before unlocking the front door, contrary to policy, and did not promptly notify nursing staff of the exit. These combined failures in supervision, door alarm management, and adherence to reception and elopement prevention policies led directly to the resident’s two elopements from the facility.
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. Multiple floors, including Units 3, 7, 2, 5, and 6, exhibited significant disrepair and cleanliness issues. Observations included rusted and leaking air conditioners, peeling paint, accumulated dust and dirt, and broken plaster. These deficiencies were noted in various rooms and common areas, such as dining rooms and corridors, indicating a widespread issue across the facility. Interviews with staff revealed that while there were protocols in place for reporting maintenance and housekeeping issues, there was a lack of effective follow-through. Housekeepers and nursing staff reported leaking air conditioners and other environmental concerns to maintenance, but the issues persisted. The maintenance log books did not contain documented evidence of the reported concerns, suggesting a breakdown in communication and documentation processes. Staff members, including Certified Nursing Assistants and Registered Nurse Supervisors, were aware of the issues but were unable to provide evidence of proper reporting or resolution. The facility's leadership, including the Administrator and Directors of Housekeeping and Maintenance, acknowledged the environmental issues and the need for repairs. They cited environmental factors, such as the facility's proximity to the beach, as contributing to the deterioration of the building. Despite awareness and acknowledgment of the problems, the facility had not yet implemented effective measures to address the deficiencies, resulting in ongoing safety and cleanliness concerns for residents, staff, and visitors.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the New York State Department of Health as required by their policy. The policy mandates that any alleged abuse should be reported immediately, but no later than two hours if it involves serious bodily injury, or within 24 hours if it does not. In this case, a family member of Resident #112 reported finding the resident with a bloody nose and a towel stained with blood. The resident, who has severe cognitive impairment due to aphasia and a cerebrovascular accident, indicated that they had been hit by someone, although they did not specify who. Despite these allegations, there was no documented evidence that the facility reported the incident to the state agency within the required timeframe. During interviews, the Director of Nursing and the Administrator both stated that they did not report the incident to the state because they did not observe any physical evidence of abuse, such as blood, swelling, or redness on the resident. The Director of Nursing mentioned that police officers had been called by the resident's family member regarding the incident, but the facility did not take further action to report it to the state. This inaction led to a deficiency being cited during the survey, as the facility did not comply with the regulatory requirement to report suspected abuse promptly.
Failure to Mail Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that a resident or their designated representative was provided with appropriate notification at the termination of Medicare Part A benefits. This deficiency was identified during a recertification survey, where it was found that the Notice of Medicare Non-Coverage was not mailed to the designated representative of a resident who was discharged from skilled services. The facility's policy requires that if a resident is unable to comprehend the notice, it must be delivered and signed by a representative, and a copy should be mailed via certified mail. However, in this case, the notice was not mailed after telephonic notification was made to the resident's next of kin. The Minimum Data Set Coordinator confirmed that the next of kin was notified over the phone about the discharge, but the Notice of Medicare Non-Coverage was not mailed as required. The coordinator stated that the notice is only mailed if the next of kin does not answer the phone, which was not in compliance with the facility's policy. Additionally, there was no documentation of the date and time of the notification or evidence that the notice had been mailed, highlighting a lapse in following the established procedures for beneficiary notification.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
During a recertification survey conducted from July 31, 2024, to August 7, 2024, a deficiency was identified at the facility regarding the maintenance of residents' personal privacy and confidentiality. Specifically, an incident was observed where a registered nurse left a computer screen displaying a resident's personal health information open and unattended during a medication administration task. This action was in direct violation of the facility's policy and procedure related to the Health Insurance Portability and Accountability Act (HIPAA), which mandates that computer screens should not be left unattended when displaying resident information. The incident involved Registered Nurse #1, who acknowledged the violation during an interview, stating that they were aware of the requirement to close the screen to protect residents' personal information. The nurse had received in-service training on HIPAA earlier in the year. Further interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the importance of closing computer screens to ensure confidentiality. The Director of Nursing emphasized that ongoing education and in-services are provided to staff regarding the protection of residents' personal health information.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the use of bilateral half side rails for Resident #10, who was unable to independently use or release them. The facility's policy required an assessment to determine the need for side rails, which should be documented in the resident's care plan. However, Resident #10, who had diagnoses including aphasia, hemiplegia, and cerebrovascular accident, was observed with side rails raised and was unable to follow commands to use them for mobility or transfers. Observations and interviews revealed that Resident #10 was dependent on staff for bed mobility and transfers, and the side rails were not documented in the Quarterly Minimum Data Set. Despite a physician's order for side rails as enablers, the resident could not hold onto them independently. Staff interviews indicated that the side rails were used to assist Certified Nursing Assistants during care, rather than for the resident's mobility, contradicting the Director of Nursing's statement that side rails should not be used for staff convenience. The facility's assessments and care plans did not accurately reflect Resident #10's inability to use the side rails, as the resident was nonverbal and unable to follow commands. The interdisciplinary team had recommended the use of side rails for enhancing bed mobility, but the assessments did not account for the resident's cognitive impairments and functional decline. The lack of a proper admission assessment upon the resident's return from the hospital further contributed to the deficiency, as the resident's needs and abilities were not adequately reassessed.
Medication Cart and EMR Left Unattended
Penalty
Summary
During a Recertification survey conducted from July 31, 2024, to August 7, 2024, it was observed that the facility failed to ensure that services provided met professional standards of quality. Specifically, a Registered Nurse left medications unattended on top of an open and unlocked medication cart. Additionally, the Electronic Medical Record (EMR) on the medication cart was left open, exposing a resident's confidential medical information. This incident occurred during a Medication Administration Task, highlighting a breach in maintaining the security and confidentiality of medications and resident information. The Registered Nurse involved acknowledged having been in-serviced on Medication Administration and the Health Insurance Portability and Accountability Act (HIPAA) but admitted to needing to slow down and consider the entire process and technique when administering medications. The Director of Nursing confirmed that the facility's policy does not permit leaving medication carts unattended or leaving the EMR screen open. The Director also stated that ongoing in-services are provided to nurses on proper medication administration procedures.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper storage and labeling of medications and biologicals. Specifically, a medication cart was left unlocked and unattended, with medications placed on top of it. This occurred during a medication administration task when a registered nurse removed several medications from the cart, crushed them, and placed them in separate cups. The nurse then walked away from the cart to find apple sauce or pudding, leaving the medications and the cart unsecured. Interviews with staff revealed that this practice was against the facility's policy, which mandates that medication carts be closed and locked when not in sight. The registered nurse acknowledged the oversight, recognizing the potential risk of unauthorized access to the medications. Both the registered nurse supervisor and the director of nursing confirmed that leaving medication carts open and unattended is not safe, as it could allow unauthorized individuals, including confused residents, to access the medications.
Infection Control Deficiencies in Respiratory and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed during a recertification survey. Specifically, a respiratory therapist did not adhere to hand hygiene protocols while providing respiratory care to a resident with respiratory failure and a tracheostomy. The therapist did not change gloves or perform hand hygiene after removing a soiled dressing and before applying a new one, which could lead to cross-contamination and infection. The therapist admitted to not changing gloves as required and had not received infection control training in over a year. Another incident involved a registered nurse who did not perform hand hygiene or change gloves while providing wound care to a resident with Alzheimer's disease and multiple pressure ulcers. The nurse failed to wash hands or don clean gloves before applying treatments to the wounds, which could introduce infection. The nurse acknowledged the oversight, attributing it to nervousness, and the nurse supervisor emphasized the importance of aseptic technique to prevent cross-contamination. Interviews with the Director of Respiratory Therapy and the Director of Nursing Services highlighted the facility's policy on annual infection control training and the critical role of hand hygiene in preventing infections. Both directors acknowledged the breaches in protocol and the potential risk of infection due to improper hand hygiene and glove use during care procedures.
Loose Handrails in Hallways
Penalty
Summary
During a Recertification Survey conducted from July 31, 2024, to August 7, 2024, it was observed that the facility failed to ensure that handrails in the hallways were firmly affixed to the walls. Specifically, on Unit 2, handrails outside the Oxygen Room and the Training Toilet were found to be loose, and on Unit 6, handrails outside a specific room were also not securely attached. These observations were made on multiple occasions, indicating a persistent issue with the maintenance of handrails in these areas. Interviews with facility staff revealed a breakdown in communication and procedure adherence. A housekeeper stated that cleaning and disinfecting handrails is part of their daily routine, and any loose handrails should be reported to the Maintenance Department. The Maintenance Director confirmed that they rely on reports from housekeeping to address such issues, and there is a Maintenance Log Book available for staff to report problems. However, despite these procedures, the loose handrails were not addressed in a timely manner, suggesting a lapse in the reporting and maintenance process.
Deficiencies in Care Plan Updates for Residents with Behavioral and Cognitive Issues
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised after each assessment for two residents, leading to deficiencies in care. Resident #38, diagnosed with Schizoaffective Disorder, Dementia, and Sepsis Pneumonia, had a care plan for Dementia that was not updated following a significant change in their condition as documented in the Minimum Data Set. The care plan, last revised in March 2024, did not reflect the resident's current needs, and the Registered Nurse Supervisor confirmed the oversight without providing an explanation. Resident #69, with diagnoses including Bipolar Disorder, Schizoaffective Disorder, and Quadriplegia, exhibited verbally abusive behavior and expressed inappropriate sexual desires towards staff. Despite multiple psychiatric consultations and nursing progress notes documenting these behaviors, the resident's care plan lacked specific interventions to address these issues. Interviews with staff revealed that the resident frequently cursed, shouted, and made inappropriate requests, yet the care plan was not updated to reflect these behaviors or provide guidance for staff on managing them. The Director of Nursing acknowledged the resident's inappropriate behavior but suggested that staff might be reluctant to document explicit language. The responsibility for updating care plans was attributed to the Registered Nurse Supervisor, who did not provide a reason for the omission. The facility's failure to update and revise care plans as required by their policy and regulations resulted in deficiencies in addressing the residents' needs and behaviors.
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 917 citations issued within 25 miles in the last 12 months — including the 15 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 Rockaway Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Nursing Home | 0 mi | ★★★★★ | 8 | 1 |
| Beacon Rehabilitation And Nursing Center | 0.1 mi | ★★★★★ | 4 | 0 |
| Ocean Gardens Care Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Resort Nursing Home | 2.3 mi | ★★★★★ | 0 | 0 |
| Lawrence Nursing Care Center, Inc | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Promenade Rehabilitation And Health Care Center.
100% money-back within 48 hours.
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.