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 Windsor Park Rehab & Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe and homelike environment, as observed during a survey. Deficiencies included a resident's wheelchair with a torn cushion, a rusty Hoyer lift, chipped paint on a door frame, and mismatched paint on an elevator door. The issues were not documented in the maintenance records, and interviews revealed lapses in oversight by the Director of Rehabilitation and the Director of Maintenance.
An LPN in an LTC facility failed to clean and disinfect a blood pressure cuff and machine between uses on multiple residents, contrary to the facility's infection control policy. The LPN admitted to forgetting the procedure, despite being trained on the importance of cleaning shared equipment after each use.
The facility did not post daily nurse staffing information in a prominent place accessible to residents and visitors, as required. Observations during a survey revealed the absence of such postings, and interviews indicated a lack of awareness and responsibility among staff. The facility's policy did not address the requirement for daily postings, contributing to the deficiency.
The facility failed to respect the rights of 13 Justice Involved Residents, who were not allowed to choose their physician, make phone calls, or receive visitors freely. They were restrained, secluded, and denied participation in communal activities, with their interactions controlled by the Bureau of Prisons. This compromised their dignity and quality of life.
The facility failed to uphold the self-determination rights of thirteen Justice Involved Residents, who were restricted by shackles and constant supervision by prison guards. These residents were unable to participate in group activities, choose their own activities, or receive visitors and make phone calls at their preferred times. Facility policies on resident rights were not followed, and residents were unaware of how to contact an Ombudsman or file complaints, resulting in an Immediate Jeopardy situation.
The facility failed to ensure that residents were informed of their right to formulate advance directives, as 13 Justice Involved Residents were designated as Full Code without being provided written information about their rights. Interviews revealed that residents were not given the opportunity to choose their code status, and the Director of Social Service admitted that while residents were informed of their Full Code status, they were not asked if they wanted to change it. The Administrator claimed that residents were admitted with the same rights as others, with law enforcement in charge.
The facility failed to uphold the rights and dignity of 13 Justice Involved Residents, who were not allowed to exercise basic rights such as choosing their physician, making phone calls, or receiving visitors. These residents were confined to their rooms, placed in restraints, and not allowed to participate in facility activities, resulting in Immediate Jeopardy. The restrictions were imposed by the Federal Bureau of Prisons, not the facility itself.
The facility failed to ensure that Justice Involved Residents were free from physical restraints, as 13 residents were found shackled without medical justification or physician orders. Despite the facility's restraint-free policy, the restraints were enforced by the Bureau of Prison for security reasons. Staff interviews revealed awareness of the issue but a belief that they had no control over the situation.
The facility failed to accurately document the use of restraints for 13 Justice Involved Residents, as observed during a survey. Despite the presence of restraints, the Minimum Data Set (MDS) assessments did not reflect this, leaving Section P blank. Facility policy requires restraints to be used only for medical symptoms and with a physician's order, but no restraint care plans or pre-restraining assessments were documented. Staff interviews revealed that the restraints were enforced by the Federal Bureau of Prisons for security reasons, not by the facility.
The facility failed to accurately document the use of restraints for Justice Involved Residents, as observed during a survey. Restraints were used on 13 residents, but the Minimum Data Set (MDS) assessments did not reflect this, violating facility policies and residents' rights. Interviews revealed a misunderstanding among staff regarding the responsibility for documenting restraints, as they were imposed by the Department of Correction.
The Medical Director failed to ensure the implementation of resident care policies for Justice Involved Residents, who were observed wearing shackles and confined to their rooms, violating their rights to a dignified existence and self-determination. These residents were not allowed to participate in group activities or communicate freely, with their mail being opened by the Federal Bureau of Prison Services. The Medical Director was aware of these restrictions but stated they had no control over the actions of the Bureau of Prison.
A resident with mild intellectual disabilities and schizoaffective disorder hit a CNA while being escorted to their room. In response, the CNA pulled the resident's hair. The incident was captured on surveillance footage and confirmed the following day, leading to the CNA's removal from the schedule.
A facility failed to report a suspected abuse incident to local law enforcement within the required timeframe. Surveillance footage showed a resident hitting a CNA, who then pulled the resident's hair. The incident was reported several days later during a Department of Health investigation.
A resident was administered Haloperidol for anxiety without documented evidence of non-pharmacological interventions being attempted first. Staff interviews revealed that the resident was not aggressive but had specific care preferences. The LPN, RN, and MD involved did not document any non-pharmacological attempts or the rationale for the medication order. The DON acknowledged the lack of proper documentation and inappropriate use of Haloperidol.
Deficiencies in Maintenance and Environment Observed
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during the Recertification Survey. On the West Side unit, several deficiencies were noted, including a resident's wheelchair with a torn cushion on the left armrest, a Hoyer lift with rust and dark yellow and blackish stains on the metal frame, a wooden door frame in the whirlpool room with chipped paint, and an elevator door with layers of mismatched paint. These issues were not documented in the unit's Maintenance Workbook from January 2024 through September 2024, indicating a lack of proper maintenance and oversight. Interviews conducted during the survey revealed that the Director of Rehabilitation was responsible for inspecting and repairing wheelchairs but missed the torn armrest on the resident's wheelchair. The resident mentioned that the cushion had been torn since their admission, and it was only replaced after the surveyor's observation. Additionally, the Director of Maintenance acknowledged responsibility for maintaining the walls and equipment, including the Hoyer lift, but admitted to missing areas that required repainting. These lapses in maintenance and oversight contributed to the facility's failure to uphold the residents' right to a safe and homelike environment.
Infection Control Breach with Blood Pressure Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices as observed during a recertification survey. Specifically, a Licensed Practical Nurse (LPN) was seen using the same blood pressure cuff on multiple residents without cleaning and disinfecting it between uses. This was observed with three residents, where the LPN did not sanitize the blood pressure cuff or machine after taking each resident's blood pressure. The facility's policy requires that shared equipment be cleaned and disinfected after each use, but this was not adhered to by the LPN. The LPN acknowledged awareness of the requirement to clean the equipment between uses but admitted to forgetting to do so. The Director of Nursing confirmed that the nursing staff had been trained on the proper cleaning procedures for the blood pressure equipment. Despite this training, the LPN failed to follow the established protocol, leading to a breach in infection control practices.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily in a prominent place accessible to residents and visitors, as required by regulations. During the Recertification Survey conducted from 09/26/2024 to 10/03/2024, the State Surveyor observed that there was no posting of daily nurse staffing information for each shift, nor any signage indicating where such information could be found. The facility's policy, reviewed in 01/2024, did not include instructions for posting daily nurse staffing information, only mentioning the submission of staffing data to the Centers for Medicaid and Medicare Services payroll-based journal system quarterly. Interviews revealed a lack of awareness and responsibility regarding this requirement. The Staffing Coordinator stated that only the names of staff and their assigned units were posted, without the actual hours worked or the resident census. The Director of Nursing was unaware of the regulation mandating daily posting of nurse staffing information. The Administrator indicated that it was the Staffing Coordinator's responsibility to ensure the information was posted.
Violation of Resident Rights for Justice Involved Residents
Penalty
Summary
The facility failed to uphold the rights of 13 Justice Involved Residents, as identified during an Abbreviated Survey. These residents were not allowed to exercise their rights, such as choosing their own physician, making phone calls, formulating advance directives, receiving visitors at their discretion, receiving unopened mail, or communicating freely with other residents. The facility's policies on resident rights and visitation were not adhered to, as the residents remained under the authority of the Federal Bureau of Prisons, which imposed restrictions on their freedoms. Observations revealed that the Justice Involved Residents were subjected to physical restraints, such as shackles, and were secluded in their rooms for most of the day. They were not allowed to participate in communal dining or facility activities, and their privacy was compromised by the constant presence of security guards. Interviews with the residents confirmed these restrictions, and staff interviews indicated that the Bureau of Prisons controlled the residents' interactions and activities, rather than the facility itself. Specific cases highlighted include residents with various medical conditions requiring specialized care, such as intravenous antibiotic therapy and restorative therapy. Despite their medical needs, these residents were denied the autonomy to engage in activities or communicate freely, as all interactions and activities required approval from the Bureau of Prisons. The facility's failure to evaluate or order the use of restraints further compounded the issue, creating an environment that did not promote the residents' quality of life or respect their dignity.
Violation of Self-Determination Rights for Justice Involved Residents
Penalty
Summary
The facility failed to ensure that thirteen Justice Involved Residents had the right to self-determination and that their choices were supported. Observations made on multiple dates revealed that these residents were wearing shackles that limited their movement and were under constant supervision by Federal Bureau of Prison guards. This supervision restricted their ability to participate in group activities, choose their own activities, and receive visitors or make phone calls at their preferred times, thereby infringing on their rights to privacy and self-determination. The facility's policies on Resident Self Determination and Resident Rights were not upheld for these Justice Involved Residents. The policies stated that residents should be able to choose activities and schedules consistent with their interests and values, and have access to communication and services. However, the Justice Involved Residents were not allowed to participate in community dining or group activities, and their music choices were subject to approval by an officer. Additionally, they were unaware of how to contact an Ombudsman or file a complaint, further limiting their autonomy. Interviews with the residents and facility staff confirmed these restrictions. The Director of Recreation noted that residents were provided with MP3 players, but music choices required officer approval. The Director of Social Work stated that visitation and phone calls were not restricted by the facility but required court approval. These conditions resulted in an Immediate Jeopardy situation, indicating a likelihood of harm to the residents due to the facility's failure to promote and facilitate their self-determination.
Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents were afforded the right to formulate advance directives while residing in the skilled nursing facility. This deficiency was identified during an Abbreviated Survey, where it was found that 13 Justice Involved Residents were designated as Full Code without being provided written information about their right to formulate advance directives. The Director of Social Work confirmed that these residents were assigned Full Code status by the Federal Bureau of Prisons and were not advised of their rights to formulate advance directives according to their wishes. Interviews with several Justice Involved Residents revealed that they were not given the opportunity to choose their code status. For instance, one resident stated that they were told by the Bureau of Prisons that they could not die in prison because they were a convicted felon, and thus, they were aware they could not change their Full Code status. Another resident mentioned that they did not recall the facility discussing advance directives with them, and a third resident stated they did not know what an advance directive was, indicating a lack of communication and education from the facility regarding their rights. The Director of Social Service stated that Naphcare, the payor source, completed the advance directives prior to the residents' admission to the facility. However, the Director also admitted that while they informed the residents of their Full Code status, they did not ask if the residents wanted to change their code status or formulate other advance directives. The facility's Administrator claimed that the Justice Involved Residents were admitted with the same rights as the regular resident population and that law enforcement was in charge, asserting that the residents' rights were not violated.
Violation of Resident Rights for Justice Involved Residents
Penalty
Summary
The facility failed to treat 13 Justice Involved Residents with respect and dignity, and did not provide care in an environment that promotes the maintenance or enhancement of their quality of life. These residents were not allowed to exercise their rights, such as choosing their own physician, making phone calls, formulating advance directives, receiving visitors at their chosen times, receiving unopened mail, or communicating with other residents. They were also placed in restraints and secluded in their rooms for most of the day, which resulted in an Immediate Jeopardy situation with the likelihood of harm. Observations revealed that Justice Involved Residents were wearing shackles and were confined to their rooms, eating only there and not participating in facility activities. Interviews with the residents confirmed that they were not allowed to have visitors, make or receive phone calls without approval, or participate in group activities. Their mail was opened, and they were not allowed to dine in the community dining area. The facility's policies on resident rights and visitation were not upheld for these residents, as their rights were restricted by the Federal Bureau of Prisons. Interviews with facility staff, including the Director of Recreation and the facility Psychologist, indicated that the Justice Involved Residents' activities and interactions were heavily monitored and restricted by Senior Officer Specialists. The Administrator stated that the facility itself was not imposing these restrictions, but rather the Senior Officer Specialist team was responsible for limiting the residents' freedoms. This situation highlights a significant deficiency in the facility's ability to provide a dignified and respectful environment for all residents, particularly those who are justice-involved.
Improper Use of Restraints on Justice Involved Residents
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless medically necessary, as observed during an Abbreviated Survey. The survey revealed that 13 Justice Involved Residents were subjected to physical restraints without proper medical justification or physician orders. Specifically, 11 residents were found wearing shackles around their ankles, and one resident with a right leg amputation had their left wrist handcuffed to the bedside rail. These restraints were not documented in the residents' care plans, and there was no evidence of a pre-restraining assessment or attempts to use less restrictive alternatives. The facility's policy on the use of restraints, dated January 2024, clearly states that restraints should only be used for the safety and well-being of residents and only after other alternatives have been tried unsuccessfully. However, the policy was not followed, as there were no physician's orders or documented evidence justifying the use of restraints for the Justice Involved Residents. The Minimum Data Set assessments for these residents did not identify the use of shackles, and there was no documentation of ongoing re-evaluation of the need for restraints. Interviews with facility staff, including the Medical Director, Director of Nursing, and Administrator, revealed that the restraints were enforced by the Bureau of Prison for security reasons, despite the facility's restraint-free policy. The staff acknowledged the conflict between the facility's policy and the Bureau of Prison's enforcement but did not take action to address the issue. The Medical Director and Director of Nursing admitted that they were aware of the restraints but believed they had no control over the situation, as it was mandated by an outside agency.
Failure to Accurately Document Restraint Use for Justice Involved Residents
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, specifically for 13 Justice Involved Residents. Observations during an Abbreviated Survey revealed that 12 residents were wearing two-foot-long restraints around their ankles, and one resident had a wrist cuffed to their bed rail. However, the Minimum Data Set (MDS) assessments for these residents did not indicate the use of restraints, as Section P, which documents physical restraints, was left blank. This indicates that the facility did not properly assess or document the use of restraints on these residents. The facility's policy on the use of restraints states that they should only be used for the safety and well-being of residents and only after other alternatives have been tried unsuccessfully. Restraints should be used to treat medical symptoms and not for discipline or staff convenience. Despite this policy, the facility did not develop restraint care plans for the Justice Involved Residents, and there was no documented evidence of pre-restraining assessments or physician orders for the use of restraints. Interviews with facility staff revealed that the Director of Nursing had informed the Federal Bureau of Prisons that the facility is a restraint-free environment, but the Bureau insisted on enforcing restraints for security reasons. The Director of Nursing and the MDS Coordinator stated that the restraints were not coded in the MDS because they were imposed by the Federal Bureau of Prisons, not the facility. The Administrator also stated that Justice Involved Residents were admitted with the same rights as other residents, and law enforcement was in charge of their restraints.
Failure to Accurately Document Restraints for Justice Involved Residents
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, specifically for 13 Justice Involved Residents. Observations during an Abbreviated Survey revealed that 12 residents were wearing two-foot-long restraints around their ankles, and one resident had a wrist cuffed to their bed rail. However, the Minimum Data Set (MDS) assessments for these residents did not document the use of restraints, indicating a failure to properly assess and record the residents' conditions. This oversight was a violation of the residents' rights and the facility's policies regarding the use of restraints. The facility's policy on the Minimum Data Set requires adherence to guidelines for accurate resident assessments, including the documentation of physical restraints. Despite this, the MDS for Justice Involved Residents did not reflect the use of restraints, as Section P under Physical Restraints was left blank. The facility's policy on the use of restraints states that they should only be used for the safety and well-being of residents, with a physician's written order, and after other alternatives have been tried unsuccessfully. However, the facility did not conduct pre-restraining assessments or develop restraint care plans for these residents. Interviews with facility staff revealed a misunderstanding regarding the responsibility for documenting restraints. The Director of Nursing stated that the facility informed the Federal Bureau of Prison that it is a restraint-free facility, but the Bureau enforced restraints for security reasons. The Minimum Data Set Coordinator also stated that the restraints were not considered as such because they were imposed by the Department of Correction, not the facility. This misinterpretation led to the omission of restraint documentation in the MDS, contributing to the deficiency.
Medical Director Fails to Implement Resident Care Policies for Justice Involved Residents
Penalty
Summary
The Medical Director of the facility failed to ensure the implementation of resident care policies and respect for resident rights, as observed during an Abbreviated Survey. Specifically, 13 Justice Involved Residents were subjected to restrictive measures, including being shackled and confined to their rooms, which violated their rights to a dignified existence and self-determination as outlined in the facility's policies. These residents were observed wearing shackles and were not allowed to participate in group activities, community dining, or communicate freely with visitors, as their mail was opened by representatives of the Federal Bureau of Prison Services. The report highlights specific cases, such as a resident with Nontraumatic Compartment Syndrome and another with Advanced Atrophic Macular Degeneration, who were restricted to their rooms and denied participation in facility activities. Interviews with these residents revealed that they were not allowed to have visitors or make phone calls without approval from the Bureau of Prison. The Medical Director acknowledged awareness of these restrictions but stated they had no control over the Federal Bureau of Prison's actions, believing it was normal due to the residents' incarcerated status.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse. Specifically, the facility's surveillance camera showed that a resident with mild intellectual disabilities and schizoaffective disorder hit a CNA while being escorted from the dining room to their room. In response, the CNA pulled the resident's hair. The resident had a history of moderately impaired cognition and potential for both victimization and abusive behavior, as documented in their psychosocial well-being care plan. On the night of the incident, the resident was observed to be agitated and non-compliant, walking around with their rolling walker and becoming aggressive towards staff. Multiple staff members, including CNAs and an LPN, attempted to redirect the resident. The surveillance footage revealed that while the resident was being escorted by the CNA, the resident began hitting the CNA, who then pulled the resident's hair in response. The incident was not immediately reported to the Director of Nursing (DON) until the following day during an Interdisciplinary Team (IDT) meeting, which led to a review of the surveillance footage. Interviews with the involved staff members provided varying accounts of the incident. The CNA involved claimed that they did not intentionally pull the resident's hair but were trying to block the resident from hitting them. The LPN and Registered Nurse Supervisor (RNS) on duty did not witness the hair-pulling but confirmed the resident's aggressive behavior. The DON confirmed that the CNA was removed from the schedule immediately after the surveillance footage was reviewed and the incident was confirmed.
Failure to Timely Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime against a resident to local law enforcement within the required timeframe. Specifically, the facility's surveillance camera footage showed a resident hitting a CNA, who then pulled the resident's hair. This incident occurred while the CNA was escorting the resident from the dining room to their room. The incident was not reported to local law enforcement within the mandated 2-hour window but was instead reported several days later when Department of Health surveyors were onsite investigating the allegation of abuse. The facility's policy mandates that all alleged or suspected violations and substantiated incidents of abuse or crimes be promptly reported to appropriate state agencies and other entities as required by law. Despite this, the Director of Nursing (DON) did not report the incident to local law enforcement immediately, citing the resident's family's request not to do so. The incident was eventually reported to local law enforcement only after the Department of Health surveyors began their investigation.
Failure to Attempt Non-Pharmacological Interventions Before Administering Antipsychotic Medication
Penalty
Summary
The facility did not ensure that a resident's drug regimen was free from unnecessary medication. This was evident for one resident who was administered Haloperidol, an antipsychotic medication, as a one-time dose for anxiety without documented evidence of non-pharmacological interventions being attempted first. The resident, who had been newly admitted with diagnoses including pneumonia, arthritis, and anxiety disorder, was observed to be anxious and yelling, which led to the administration of the medication. However, there was no documentation of any non-pharmacological attempts to address the resident's anxiety before resorting to medication. Interviews with staff revealed that the resident was not physically abusive or aggressive but was specific about their care preferences and had difficulty focusing on topics. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved in the case admitted that they did not recall attempting any non-pharmacological interventions before administering the Haloperidol. The Medical Doctor (MD) who ordered the medication also did not document any non-pharmacological interventions or the rationale for the STAT order in the resident's medical record. The Director of Nursing (DON) acknowledged that there should have been more documentation regarding the reason for the STAT order of Haloperidol. The DON stated that yelling alone is not an acceptable indicator for the use of Haloperidol. The lack of documentation and failure to attempt non-pharmacological interventions before administering an antipsychotic medication led to the deficiency cited in the report.
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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 Queens Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollis Park Manor Nursing Home | 1.3 mi | ★★★★★ | 0 | 0 |
| Holliswood Center For Rehabilitation And Healthcar | 1.3 mi | ★★★★★ | 0 | 0 |
| Queen Of Peace Residence | 1.7 mi | ★★★★★ | 11 | 0 |
| New Glen Oaks Nursing Home, Inc | 2.4 mi | ★★★★★ | 0 | 0 |
| Little Neck Care Center | 2.5 mi | ★★★★★ | 1 | 1 |
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