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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Queens For Rehabilitation & Nursin during CMS and state inspections, most recent first.
Failure to notify the MD and resident representative of a significant BiPAP setting change. A resident with CHF, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema had a physician order for BiPAP 28/5 with FiO2 40%. The RT changed the settings to 25/5 because the machine could not tolerate higher settings, but did not notify the MD, nursing supervisor, or representative, and did not document the change.
A resident with CHF, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema did not receive ordered BiPAP at bedtime because the machine was not obtained until the next day. The RT Director ordered the device using initial settings without checking the MD order, later changed the BiPAP settings from the ordered parameters without a physician order or notification, and did not document the change; nursing staff and the MD were unaware of the missed delivery and unauthorized setting change.
A resident with CHF, rheumatic heart disease, chronic respiratory failure with hypercapnia, and acute pulmonary edema had ordered BiPAP settings of 28/5, but the DRT changed the machine to 25/5 without a physician order and did not document the change in the chart. The RN was unaware of the change, and the MD was not informed that the BiPAP was delayed and the settings were altered.
The facility experienced significant staffing shortages on weekends, particularly on the 2nd floor Ventilator unit, as revealed by a Recertification Survey. Despite attempts to use staffing agencies and overtime, the facility failed to meet required staffing levels, leading to deficiencies in resident care and safety.
The facility failed to adhere to food safety standards, as kitchen staff were observed not wearing beard restraints and the Food Service Director did not follow proper hand hygiene after touching a trash can. The facility's policies require hair and beard nets to prevent contamination, but staff either forgot or were not informed of the requirement. The Infection Preventionist did not conduct regular kitchen rounds, contributing to the oversight.
The facility failed to maintain a clean and homelike environment, with multiple units having unclean wheelchairs and environmental deficiencies. Observations revealed wheelchairs with dirt and debris, and interviews with staff highlighted inconsistencies in cleaning schedules. Additionally, Unit 4 had chipped window sills, mismatched paint, and a dusty heating system, indicating a lack of adherence to the facility's policy for a safe environment.
The facility failed to maintain proper infection control practices, as observed during a survey. A housekeeper did not wear the required PPE while cleaning a room under contact and droplet precautions. A CNA assisted multiple residents with hand hygiene without cleaning their hands between residents, risking cross-contamination. Additionally, several nurses did not perform hand hygiene appropriately during medication administration and failed to clean blood pressure cuffs between residents.
A resident with hypertension, anxiety disorder, and diabetes mellitus was found with a bruise on their nose. The facility failed to notify the resident's family promptly, as required by policy. Although the charge nurse and supervisor were informed immediately, the family was not notified until three days later. Staff interviews revealed inconsistencies in the reporting process, with no documentation to support claims of timely notification.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage at least two days before the end of Medicare Part A services, as required. The notice was given only one day prior to discharge, and there was no documentation of the resident requesting early discharge. Staff interviews confirmed awareness of the 48-hour notice requirement, but the necessary documentation was missing.
A resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation and heart failure, was taking Eliquis without a comprehensive care plan in place. The facility's policy required such a plan, but it was not developed, leading to a deficiency noted during a survey. Staff observed skin discoloration on the resident's legs, but this was not addressed in a care plan, and the oversight was acknowledged by a nurse.
The facility failed to update comprehensive care plans for two residents after assessments. One resident with anxiety and depression did not have their psychotropic medication care plan updated, while another with pain issues had their pain management plan overlooked after readmission. Staff interviews revealed lapses in the process of reviewing and updating care plans, despite existing policies.
The facility failed to label medications according to professional standards, as observed on two resident units. On the 5th Floor, opened insulin and eye drops lacked dates on their labels, with dates only on the bags. A nurse focused on bag labels rather than the medication itself. On the 3rd Floor, insulin and eye drops were undated, with one insulin vial exceeding the 28-day limit. Staff relied on bag dates, and the pharmacy labeled only the box. The Assistant DON stressed the importance of immediate labeling and discarding expired medications.
The facility failed to follow menus as per residents' dietary needs and preferences, leading to discrepancies in meal service for four residents. Meals served did not match tray tickets, with missing items and unlisted substitutions. Staff interviews revealed inadequate communication and documentation regarding menu changes.
The facility failed to properly dispose of garbage and refuse, as observed during a survey. Recycling bins were overflowing and left open, contrary to policy. Staff interviews revealed a lack of coordination and oversight in waste management, contributing to the deficiency.
The facility did not ensure the Nurse Staffing Information was posted in a prominent and accessible location, as required. Observations showed the information was either missing or incomplete, and interviews revealed staff were unaware of the posting requirements.
Failure to Notify Physician and Representative of BiPAP Setting Change
Penalty
Summary
The facility failed to immediately consult the resident’s physician when a treatment was significantly altered. Resident #1 was admitted with congestive heart failure, rheumatic heart disease complicated by mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema. The Minimum Data Set documented moderately impaired cognition, and the resident required continuous oxygen therapy and non-invasive mechanical ventilation (BiPAP). A physician’s order dated 07/15/2026 specified BiPAP settings of IPAP 28 and EPAP 5, with FiO2 40 percent at bedtime as tolerated and removed in the morning. On 07/16/2026, the Director of Respiratory Therapy changed the BiPAP settings from 28/5 to 25/5 because the machine could not tolerate settings over 25/5. The Director of Respiratory Therapy stated they did not review the physician’s order before ordering the BiPAP machine, did not notify the physician, nursing supervisor, or the resident’s representative of the change, and did not document the events in the medical record. The resident’s representative stated they were not notified of the change, the RN stated they were not informed that the settings had been changed, and the Medical Doctor stated they were not aware the BiPAP machine had not been delivered on 07/15/2026 or that the ordered settings had been changed.
BiPAP Not Available at Bedtime and Settings Changed Without Order
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with physician orders and the resident’s care plan for one resident who was admitted from the hospital with congestive heart failure, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema. The resident’s Minimum Data Set documented moderately impaired cognition and the need for continuous oxygen therapy and non-invasive mechanical ventilation (BiPAP) on admission and while a resident. A physician’s order dated 07/15/2026 directed BiPAP use at bedtime with IPAP 28, EPAP 5, FiO2 40%, with application at 9:00 PM and removal at 8:00 AM, along with monitoring of oxygen saturation and respirations. The BiPAP machine was not available for the resident’s bedtime use on 07/15/2026. The Director of Respiratory Therapy stated the facility was notified on 07/15/2026 that the resident would need oxygen and a BiPAP machine, but the BiPAP was not ordered until 07/16/2026 and arrived at about 8:00 PM that day. The Director of Respiratory Therapy also stated they ordered the machine using initial settings of 12/6 without checking the physician’s order, then changed the settings to 25/5 after reviewing the order because the machine could not tolerate the ordered settings of 28/5. The Director stated they did not notify a nursing supervisor or physician of the change and did not document the change in the medical record. Nursing staff and the physician stated they were not aware the BiPAP had not been delivered on 07/15/2026 or that the settings had been changed without an order.
Incomplete Documentation of BiPAP Setting Change
Penalty
Summary
Medical records were not completed and accurately documented in accordance with accepted professional standards when the Director of Respiratory Therapy changed Resident #1’s BiPAP settings without a physician’s order and without documenting the change in the resident’s record. Resident #1 was admitted with congestive heart failure, rheumatic heart disease complicated by mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema. The Minimum Data Set documented moderately impaired cognition, and Section O noted continuous oxygen therapy and non-invasive mechanical ventilator use on admission and while a resident. A physician’s order dated 07/15/2026 specified BiPAP settings of IPAP 28 and EPAP 5, with FiO2 40 percent at bedtime as tolerated and removal in the morning. The Treatment Administration Record showed BiPAP settings of 28/5, and the RN signed the record when the BiPAP was applied. The Director of Respiratory Therapy stated they ordered the BiPAP, initially set it at 12/6 before checking the physician’s order, then changed the machine to 25/5 because the ordered settings could not be tolerated. The Director stated they did not notify a nursing supervisor or physician and did not document the change in the medical record. The RN stated they were not aware of the change, the ADON stated the change should have been communicated to the RN, and the MD stated they were not aware the BiPAP was not delivered on the first day or that the settings had been changed.
Weekend Staffing Shortages in LTC Facility
Penalty
Summary
The facility was found to have insufficient nursing staff during weekends, which compromised the safety and well-being of residents. The Recertification Survey conducted from November 13 to November 20, 2024, revealed that the facility did not maintain adequate staffing levels to meet the needs of its residents. The review of the Daily Staffing and Payroll Based Journal Staffing Data Report confirmed that the facility experienced short staffing on weekends, particularly on the 2nd floor, which is designated as the Ventilator unit. The facility's staffing plan outlined specific numbers of Registered Nurse Supervisors, Licensed Practical Nurses, and Certified Nursing Assistants required for each shift, but these numbers were not met consistently. The report detailed specific instances of staffing shortages over several weekends in April 2024. For example, on April 6, 2024, there was a shortage of 1 Registered Nurse Supervisor, 5 Licensed Practical Nurses, and 7 Certified Nursing Assistants across various shifts, with no replacement staff available. Similar shortages were documented on subsequent weekends, with the 2nd floor frequently experiencing the most significant deficits. The facility's inability to provide a staffing policy further highlighted the lack of preparedness in addressing these staffing issues. Interviews with the Director of Nursing and the Staffing Coordinator revealed that the facility attempted to mitigate staffing shortages by using nursing staffing agencies and relying on per diem and overtime work. However, these measures were insufficient to meet the required staffing levels consistently. The Director of Nursing admitted to personally covering shifts when necessary, indicating a reactive rather than proactive approach to staffing management. Despite these efforts, the facility failed to meet the staffing requirements as per the Payroll Based Journal guidelines, leading to the deficiency noted in the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was served and dishware was handled in accordance with professional standards for food service safety. During the recertification survey, it was observed that several kitchen staff members were not wearing beard restraints while preparing and assembling food. This was contrary to the facility's policy, which mandates the use of hair and beard nets to prevent contamination. Interviews with the dietary aides revealed that they either forgot to wear the beard nets, were not informed of the requirement, or neglected to wear them due to being busy. The Director of Food Service acknowledged the issue and stated that they conduct daily kitchen tours to ensure staff compliance with attire requirements, but noted that the problem persisted, particularly with union employees. Additionally, the Food Service Director was observed not following proper hand hygiene protocols. While checking food temperatures on the tray line, the director touched the lid of a trash can with gloved hands and continued to handle food items without changing gloves or washing hands. This action was inconsistent with the facility's policy, which requires handwashing after contact with potentially contaminated surfaces. The director admitted to not recalling the incident but acknowledged the importance of maintaining cleanliness. The Infection Preventionist stated that they do not conduct regular rounds of the kitchen, with the last round occurring before the survey began. They confirmed that staff should wear hair and beard nets to prevent contamination of food. The lack of regular oversight and adherence to established sanitary practices contributed to the deficiencies observed during the survey.
Deficiencies in Cleanliness and Maintenance in Resident Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations of unclean and poorly maintained wheelchairs across multiple units. On Unit 8, several residents were observed in wheelchairs with encrusted dirt, debris, and dried food particles. Similar conditions were noted on Unit 5, where multiple wheelchairs had white and brown stains, debris, and grimy stains on the frames and locks. Interviews with staff revealed inconsistencies in the cleaning schedule and a lack of clarity on when the wheelchairs were last cleaned, with some staff unable to recall the last cleaning date. Additionally, the facility's Unit 4 was found to have environmental deficiencies, including chipped and unpainted window sills, mismatched paint on cement walls, and a dusty heating system with dried food and paper remnants. The floor tiles in the center hallway were also observed to be ripped and broken. Interviews with the Director of Housekeeping and the Director of Maintenance indicated that these issues were known but had not been addressed in a timely manner. The facility's policy, dated January 2023, states the commitment to providing a safe and clean environment, yet the observations and staff interviews during the survey period highlighted a failure to adhere to this policy. The lack of a structured cleaning schedule and oversight contributed to the deficiencies observed, impacting the residents' right to a homelike environment.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple observations during the recertification survey. A housekeeper was observed cleaning a room under contact and droplet precautions without wearing the required personal protective equipment (PPE), such as a gown. The housekeeper admitted to being unsure about the necessary PPE and had only received limited training. The Director of Housekeeping confirmed that PPE should be used in such situations, and the Infection Preventionist stated that staff should wear gowns, gloves, and masks in rooms with contact or droplet precautions. Additionally, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with hand hygiene in the dining room without cleaning their hands between residents. The CNA acknowledged the risk of cross-contamination but did not perform hand hygiene between assisting different residents. The Registered Nurse Supervisor emphasized the importance of hand hygiene to prevent cross-contamination, and the Infection Preventionist noted that staff should ensure residents' hands are clean before meals. Furthermore, several nurses failed to perform hand hygiene appropriately during medication administration and did not clean blood pressure cuffs between residents. Observations included a Licensed Practical Nurse (LPN) using a blood pressure machine on multiple residents without cleaning it and a Registered Nurse (RN) handling medication and equipment without proper hand hygiene. The Assistant Director of Nursing stated that staff are trained to follow infection control protocols, including hand hygiene and equipment cleaning, but these practices were not consistently followed.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's designated representative regarding a change in the resident's condition. Specifically, a nurse's progress note documented that a resident was observed with a bruise on their nose, and while the charge nurse and supervisor were informed immediately, the family was not notified until three days later. This delay in communication was contrary to the facility's policy, which mandates prompt notification of the resident's representative and physician to facilitate appropriate treatment and monitoring. The resident involved had diagnoses including hypertension, anxiety disorder, and diabetes mellitus, and was noted to have moderately impaired cognition. Despite the resident being seen by a medical doctor on the same day the bruise was observed, and an x-ray being ordered, there was no documented evidence that the family was informed at that time. Interviews with staff revealed inconsistencies in the reporting process, with some staff claiming the family was notified, but without documentation to support this claim.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide appropriate notification to a resident or their designated representative regarding the termination of Medicare Part A benefits. Specifically, the facility did not issue the Notice of Medicare Non-Coverage at least two calendar days before the end of Medicare-covered services, as required by their policy. This deficiency was identified during a recertification survey, where it was found that the notice was given only one day before the termination of services for a resident who had 71 days of coverage remaining. Interviews with facility staff revealed that the Minimum Data Set Assessor and Director were aware of the requirement to provide the notice 48 hours in advance to allow residents the opportunity to appeal. However, the notice was signed by the resident just one day before discharge, and there was no documentation in the medical record indicating that the resident had requested an early discharge. A utilization review meeting was held with the resident, during which the resident requested discharge, but this discussion was not documented in the resident's chart.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a person-centered Comprehensive Care Plan for a resident who was taking anticoagulant medication. This deficiency was identified during a recertification survey, where it was found that the resident, who had diagnoses including Unspecified Atrial Fibrillation, Cerebrovascular Accident, and Heart Failure, was taking Eliquis, an anticoagulant, without a corresponding care plan. The facility's policy required the interdisciplinary team to create a care plan addressing the resident's needs, preferences, and goals, but this was not done for the resident's anticoagulant use. Observations and interviews revealed that the resident had bluish skin discoloration on their lower legs, which was noted by staff but not addressed in a care plan. A Certified Nursing Assistant mentioned that the discoloration was not accompanied by pain or discomfort, and a Registered Nurse admitted that the lack of a care plan for the anticoagulant use was an oversight. The Director of Nursing was unaware of the missing care plan, indicating a lapse in the facility's care planning process.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. Resident #109, who was admitted with diagnoses including Anxiety Disorder, Depression, and Non-Alzheimer's Dementia, had care plans for psychotropic medications that were not updated following quarterly assessments. Despite receiving antianxiety and antidepressant medications, there was no documented evidence that the care plans were reviewed and revised after the assessments completed on 07/05/2024 and 09/30/2024. The oversight occurred because the Registered Nurse Supervisor responsible for initiating and updating the care plans was on vacation, and the team failed to catch the omission during the quarterly assessment review. Similarly, Resident #145, admitted with conditions such as Renal Osteodystrophy and Low Back Pain, did not have their pain management care plan reviewed or revised after the Minimum Data Set assessments on 6/25/2024 and 9/25/2024. The resident was prescribed various pain medications, including Oxycodone and Lidocaine patches, but the care plan was not activated after a readmission in August 2024. The Registered Nurse Supervisor admitted to forgetting to activate the care plan, and the oversight was not corrected during care planning meetings. Interviews with facility staff, including the Director of Nursing and the Minimum Data Set Director, revealed gaps in the process of reviewing and updating care plans. The Director of Nursing acknowledged the responsibility of Registered Nurse Supervisors in maintaining current care plans and noted that interdisciplinary team meetings are held to ensure care plans are up to date. However, the failure to update the care plans for Residents #109 and #145 highlights a lapse in the facility's adherence to its policies and procedures regarding care plan management.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional standards of practice, as observed during a recertification survey. On the 5th Floor medication cart, an opened and undated vial of insulin and eye drops were found, with dates only on the bags containing the medications. A registered nurse admitted to focusing on the outside plastic bag for labeling rather than the medication itself. The nurse supervisor confirmed that insulin vials should be labeled and checked regularly, but the pharmacy did not inform them about labeling the outside of the medications. On the 3rd Floor, a vial of Levemir insulin was found with an open date exceeding 28 days, and other insulin vials and eye drops lacked open dates on their labels. The medications were stored in individual bags with dates, except for one insulin vial and eye drops, which had no dates. A licensed practical nurse acknowledged the responsibility of dating medications but relied on the bag's date. Another registered nurse stated that the pharmacy labels the box, and staff are educated to place medications back in the box after use. The Assistant Director of Nursing emphasized that expired medications should not be present and that labeling should occur immediately upon opening.
Menu Substitution and Communication Deficiency
Penalty
Summary
The facility failed to ensure that menus were followed as per the dietary requirements and preferences of the residents, as observed during the Recertification Survey. This deficiency was evident for four residents who were served meals that did not match the items listed on their tray tickets. For instance, Resident #70, who was cognitively intact, received a lunch tray missing sweet potato fries and a cookie, which were listed on the tray ticket. The resident expressed a dislike for sweet potato fries and a preference for certain desserts, indicating a lack of communication regarding menu changes. Similarly, Resident #77, who had moderate cognitive impairment, was served a meal missing broccoli, which was listed on their tray ticket. The resident expressed a mild preference for broccoli, but no changes were noted on the tray ticket to reflect the substitution. Resident #156, also with moderate cognitive impairment, received meals on two separate occasions that did not match the tray ticket, with missing items such as sweet potato fries and broccoli, and unlisted items like carrots and mashed potatoes being served instead. Resident #201, with memory impairment and moderately impaired decision-making skills, was served a meal with regular fries and mixed vegetables instead of the sweet potato fries and carrots listed on the tray ticket. Interviews with staff, including the Registered Nurse Supervisor, Dietitian, Director of Nutrition, and Food Service Supervisor, revealed a lack of communication and documentation regarding menu substitutions. The Director of Food Services acknowledged minor menu changes due to shortages but failed to provide documentation of communication with the dietitian about these changes.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. Specifically, the recycling trash bin was found open with items both bagged and unbagged above the rim, contrary to the facility's policy. During a kitchen observation, it was noted that the recycling bins were overflowing with various items, including a wooden handle and a blue air supply fan, and the covers were not closed. Dietary Aide #1 added more items to the already overflowing bin without closing it, indicating a lack of adherence to the facility's waste disposal policy. Interviews with staff revealed a lack of coordination and responsibility regarding waste management. Dietary Aide #1 mentioned that this was the first time they saw the trash in such a state and indicated that their supervisor does not call for garbage pickup. The Director of Housekeeping stated that trash is picked up on a schedule, but emergency pickups can be arranged if necessary. The Infection Preventionist admitted to not regularly checking the trash area, despite acknowledging the importance of proper trash storage for infection control. This lack of oversight and communication among staff contributed to the improper disposal of garbage and refuse.
Failure to Post Nurse Staffing Information Appropriately
Penalty
Summary
The facility failed to ensure that the Nurse Staffing Information was posted appropriately during the Recertification Survey conducted from 11/13/2024 to 11/20/2024. The facility's policy, dated 10/10/2021 and reviewed on 01/15/2024, required that the Nursing Staffing Information be posted daily at the beginning of each shift in a prominent place accessible to residents and visitors. However, observations on 11/13/2024 revealed that the State Surveyor could not locate the posting of the daily nurse staffing levels or any signage indicating its location. On 11/14/2024, a posting was found near the elevator, but it lacked the current daily census and the actual hours worked by each category of staff. Additionally, the facility could not provide copies of previous staffing postings. Interviews with the Staffing Coordinator and the Director of Nursing revealed a lack of awareness and compliance with the posting requirements. The Staffing Coordinator stated that they began posting the daily staffing on 11/14/2024 and were unaware that the notice needed to be visible to visitors, families, and residents. The Director of Nursing confirmed that prior to 11/14/2024, the staffing schedule was posted near the Nursing office, which was not readily accessible to residents or visitors. This failure to post the required information in a prominent and accessible location led to the deficiency cited under 10 NYCRR 415.13.
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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 Flushing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sapphire Center For Rehabilitation & Nursing Of Ce | 0.1 mi | ★★★★★ | 0 | 0 |
| Long Island Care Center Inc | 0.1 mi | ★★★★★ | 2 | 0 |
| Elmhurst Care Center, Inc, | 0.3 mi | ★★★★★ | 0 | 0 |
| Cliffside Rehab & Residential Health Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Cypress Garden Center For Nursing And Rehabilitati | 0.4 mi | ★★★★★ | 0 | 0 |
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