Inspection Reports for
Ocean Gardens Care Center
64-11 Beach Channel Drive, Arverne, NY, 11692
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 12, 2026
Visit Reason
The inspection was conducted as part of a Recertification and Abbreviated Survey including complaint investigations related to notification of changes and reporting of abuse or injury incidents.
Complaint Details
The inspection included complaint investigations (#607115, #2630760, and #607117) related to failure to notify representatives of resident condition changes and failure to report injuries of unknown origin timely. The complaints were substantiated based on findings.
Findings
The facility failed to immediately notify residents' representatives of significant changes in condition for two residents and failed to timely report injuries of unknown origin to the State Survey Agency as required by policy and regulations.
Deficiencies (2)
F 0580: The facility failed to immediately inform the resident's representative of an accident resulting in injury or hospitalization for two residents, despite documented next of kin information.
F 0609: The facility failed to timely report suspected abuse, neglect, or injuries of unknown origin to the State Survey Agency within two hours for two residents, contrary to facility policy and state regulations.
Report Facts
Residents sampled: 38
Residents reviewed for abuse: 5
Residents cited for abuse findings: 2
Residents reviewed for notification of change: 38
Residents cited for notification failure: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Named in failure to notify next of kin for Resident #242 and failure to follow up on notification attempts |
| Director of Nursing | Director of Nursing | Provided statements regarding notification failures and facility policies |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Responsible for reporting accident/incidents and acknowledged failure to report Resident #242 injury timely |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding late reporting of Resident #126 injury |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
One Level 2 deficiency for reporting of alleged violations corrected as of June 16, 2025.
Findings
One Level 2 deficiency for reporting of alleged violations corrected as of June 16, 2025.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The visit was conducted as an abbreviated survey to evaluate the facility's compliance with timely reporting requirements for suspected abuse, neglect, exploitation, mistreatment, or misappropriation of resident property.
Complaint Details
The survey was complaint-related, triggered by allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property involving six residents. The facility's investigations found some incidents with reasonable cause to believe abuse or neglect occurred, but reporting to authorities was delayed or incomplete.
Findings
The facility failed to ensure that alleged violations involving abuse, neglect, or misappropriation of resident property were reported immediately or within required timeframes to the appropriate authorities. Multiple incidents involving six residents were not reported timely or to law enforcement as required.
Deficiencies (1)
F 0609: The facility did not timely report suspected abuse, neglect, or theft and failed to report investigation results to proper authorities as required by regulation.
Report Facts
Residents involved: 6
Date of survey completion: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Observed multiple incidents involving residents and reported delays | |
| Licensed Practical Nurse #1 | Received report of alleged misappropriation of property | |
| Housekeeper #1 | Alleged to have taken money from Resident #7 | |
| Director of Nursing | Interviewed regarding reporting requirements and facility policies | |
| Assistant Director of Nursing | Interviewed regarding responsibility for reporting incidents |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
One Level 2 deficiency for free from abuse and neglect with no correction noted.
Findings
One Level 2 deficiency for free from abuse and neglect with no correction noted.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of resident abuse involving Resident #1 and a nursing home staff member.
Complaint Details
The investigation was complaint-related, triggered by a report from the Occupational Therapist observing Resident #1 with a black eye. The facility concluded there was reasonable cause to believe abuse occurred. Resident #1 consistently reported the incident, and staff interviews corroborated the timeline and events.
Findings
The facility failed to protect Resident #1 from physical abuse by a nursing home staff member, Registered Charge Nurse #1, who was identified by the resident as having punched them in the eye. The facility concluded there was reasonable cause to believe abuse, mistreatment, or neglect had occurred.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident #1 was punched in the eye by Registered Charge Nurse #1, who did not immediately assess or report the injury as required.
Report Facts
Residents Affected: 1
Date of Incident: Sep 6, 2023
Date of Observation: Sep 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Charge Nurse #1 | Registered Charge Nurse | Identified by Resident #1 as the person who punched them in the eye and failed to assess or report the injury. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented observation of discoloration on Resident #1 and escorted Resident #1 during the incident. |
| Occupational Therapist #1 | Occupational Therapist | Reported observing Resident #1 with a black eye, initiating the investigation. |
| Director of Nursing | Director of Nursing | Notified of the incident, conducted interviews, removed the accused nurse from the unit, and coordinated investigation. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported that Registered Charge Nurse #1 saw the discoloration but did not assess Resident #1. |
| Assistant Director of Nursing | Assistant Director of Nursing | Assessed Resident #1 and confirmed the presence of a black eye. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 27, 2023
Visit Reason
The survey was conducted as a Recertification/Complaint survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including residents' access to mail on weekends, failure to provide prescribed floor ambulation program to a resident, medication administration errors, improper food storage and sanitation practices, and inadequate infection control practices related to cleaning of medical equipment.
Deficiencies (5)
F 0576: The facility did not ensure residents' right to send and receive mail on Saturdays, as mail received on weekends was held until Monday for distribution.
F 0676: Resident #129 was not provided with the prescribed floor ambulation program twice daily as ordered by the physician and recommended by physical therapy.
F 0759: Medication errors occurred when Resident #134 was administered half the prescribed doses of Metformin and Amlodipine, resulting in a medication error rate of 5.69%.
F 0812: Food safety standards were not met as open produce was stored without dates, boxes were stored on the freezer floor, and refrigerator temperature was observed at 70°F, exceeding the acceptable limit of 41°F.
F 0880: Infection control practices were inadequate as nurses failed to clean and disinfect blood pressure cuffs and glucometers between resident uses, risking cross-contamination.
Report Facts
Medication error rate: 5.69
Medications observed: 35
Medications with errors: 2
Residents sampled for ADLs: 38
Residents reviewed for infection control: 38
Residents affected by infection control deficiency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #7 | Registered Nurse | Administered incorrect medication doses and failed to clean BP cuff between residents |
| RN #3 | Registered Nurse | Failed to clean glucometer between resident uses |
| Director of Nursing | Director of Nursing | Interviewed regarding mail distribution, medication administration oversight, and infection control practices |
| Director of Social Work | Director of Social Work | Interviewed regarding mail delivery procedures |
| Administrative Assistant #11 | Administrative Assistant | Interviewed regarding mail sorting and distribution |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #129's ambulation status |
| Registered Nurse #2 | Registered Nurse | Interviewed about PT communication and infection control training |
| Rehab Director | Rehab Director | Interviewed about floor ambulation program procedures |
| Food Service Director | Food Service Director | Interviewed about food storage and refrigerator temperature issues |
| Food Service Supervisor | Food Service Supervisor | Interviewed about freezer upkeep and cleaning responsibilities |
| Dietary Aide #2 | Dietary Aide | Interviewed about freezer storage practices |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 14
Date: Sep 27, 2023
Visit Reason
Multiple Level 2 deficiencies related to quality of care and life safety code, all corrected by November or December 2023.
Findings
Multiple Level 2 deficiencies related to quality of care and life safety code, all corrected by November or December 2023.
Deficiencies (14)
Accuracy of assessments
Activities daily living (adls)/mntn abilities
Baseline care plan
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Free of medication error rts 5 prcnt or more
Infection control
Infection prevention & control
Pain management
Right to forms of communication w/ privacy
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Sprinkler system - maintenance and testing
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey to evaluate compliance with regulatory requirements and investigate specific complaints related to resident care and facility practices.
Complaint Details
The complaint investigation revealed issues with inaccurate resident assessments, failure to provide baseline care plans, incomplete care plans, inadequate supervision leading to a resident elopement, and insufficient pain management monitoring.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, failure to provide residents with written baseline care plans, incomplete comprehensive care plans, inadequate supervision leading to a resident elopement, and insufficient pain management monitoring for a resident.
Deficiencies (5)
F 0641: The facility did not ensure the Minimum Data Set 3.0 assessment accurately reflected a resident's status, specifically failing to document tracheostomy care for Resident #32.
F 0655: The facility did not provide residents or their representatives with a written summary of the baseline care plan within 48 hours of admission for Residents #85, #164, and #176.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan related to pain management for Resident #194.
F 0689: The facility did not ensure adequate supervision and an environment free from accident hazards, resulting in Resident #166 eloping from Unit 2 to a locked Unit 3.
F 0697: The facility did not provide safe and appropriate pain management for Resident #194, failing to monitor the efficacy of pain medication consistently.
Report Facts
Residents sampled: 38
Residents reviewed for pain management: 3
Residents reviewed for accidents: 5
Residents affected by deficiencies: 1
Residents affected by baseline care plan deficiency: 3
Residents affected by incomplete care plan: 1
Residents affected by inadequate supervision: 1
Pain monitoring failures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Assessed Resident #194's pain and reported to RN and MD |
| Registered Nurse #2 | Registered Nurse | Reviewed progress notes and acknowledged oversight in pain management for Resident #194 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including MDS documentation, baseline care plans, and pain management |
| MDS Coordinator | MDS Coordinator | Acknowledged missing documentation of tracheostomy care in MDS for Resident #32 |
| Social Worker Director | Social Worker Director | Stated that baseline care plans are discussed but not provided in writing to residents |
| Housekeeper #2 | Housekeeper | Interviewed regarding elevator use and resident elopement incident |
| CNA #5 | Certified Nurse Assistant | Reported Resident #166 missing from room and assisted in search |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Charge nurse during Resident #166 elopement incident |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Provided information about Resident #166's behavior and use of walker |
| Housekeeping Director | Housekeeping Director | Interviewed about elevator operation and supervision related to Resident #166 elopement |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 16, 2022
Visit Reason
One Level 2 deficiency for reporting to national health safety network with no correction noted.
Findings
One Level 2 deficiency for reporting to national health safety network with no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Renewal
Deficiencies: 9
Date: May 11, 2021
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey to assess compliance with regulatory requirements for nursing home licensure and certification.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly financial statements to residents, inadequate surety bond coverage for resident funds, incomplete and untimely care plans, failure to act on pharmacist medication regimen review recommendations, expired medications in storage, unsafe food handling practices, improper infection control related to oxygen therapy, and lack of a functional Legionella water management plan.
Deficiencies (9)
F 0568: The facility failed to provide quarterly statements of resident personal funds within 30 days after the end of the quarter for 3 of 4 residents reviewed.
F 0570: The facility did not maintain a surety bond covering the total amount of resident personal funds, with a bond amount of $300,000 insufficient for $664,363.87 in resident funds.
F 0656: The facility failed to develop a comprehensive care plan with measurable objectives and timeframes for a resident diagnosed with a urinary tract infection.
F 0657: The facility did not review and revise a resident's care plan after reinsertion of an IV PICC line, missing updated interventions for infection precautions.
F 0658: The facility failed to provide care and services to prevent infection for a resident with an IV PICC line, including failure to order flushing and dressing changes.
F 0756: The facility did not ensure pharmacist-identified medication irregularities were reviewed and acted upon, lacking documentation of physician response for one resident.
F 0761: The facility stored expired medications and biologicals, including Heparin flush solutions and IV fluids, in the medication room.
F 0812: The facility failed to discard expired food and did not ensure proper hand hygiene and glove use by dietary staff, risking food contamination.
F 0880: The facility did not follow infection prevention practices for oxygen therapy tubing labeling and replacement, and lacked a functional Legionella water management plan with required assessments and sampling.
Report Facts
Resident personal funds total: 664363.87
Surety bond amount: 300000
Residents with personal funds accounts: 218
Residents with uncovered funds: 183
Medication irregularities reviewed: 1
Expired Heparin flush solutions: 24
Expired IV fluid bags: 1
Residents observed with oxygen tubing issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse Supervisor/Nursing Care Coordinator | Interviewed regarding medication storage and oxygen tubing practices |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, medication irregularities, medication storage, and infection control |
| DA #1 | Dietary Aide | Observed and interviewed regarding food handling and hand hygiene |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen tubing change practices |
| Medical Director | Medical Director | Interviewed regarding medication regimen review and IV PICC line care |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding medication storage and inspections |
| Administrator | Administrator | Interviewed regarding surety bond, Legionella plan revision, and documentation practices |
| Infection Preventionist | Infection Preventionist | Interviewed regarding oxygen tubing and infection control |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Oct 8, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify residents timely about Medicare coverage termination, lack of baseline and revised care plans, inadequate treatment and monitoring for residents, failure to prevent accidents, and deficiencies in infection control policies.
Deficiencies (9)
F 0582: The facility failed to notify 2 residents timely about the termination of their Medicare Part A skilled services as required.
F 0655: The facility did not develop a baseline comprehensive care plan within 48 hours for a resident with schizophrenia.
F 0657: The facility failed to revise the mobility care plan within 7 days to include a prescribed active range of motion program for a resident.
F 0676: The facility did not ensure a standing program was carried out or communicated properly for a resident who was refusing it, leading to functional decline.
F 0684: The facility failed to provide appropriate insulin management and failed to notify the physician of elevated blood sugars for a diabetic resident.
F 0684: The facility failed to assess and notify the physician immediately about a resident's suicidal ideation, delaying psychiatric evaluation.
F 0688: The facility did not provide active range of motion treatment as ordered and failed to in-service nursing staff on the specific instructions for the program.
F 0689: The facility failed to ensure a resident environment was free from accident hazards when a resident sprayed aerosol deodorant at a peer and the item was not removed.
F 0880: The facility did not conduct an annual review or update of the written infection prevention and control policies and procedures.
Report Facts
Blood sugar readings above 400: 7
Standing program not performed: 28
CNA Accountability Record compliance: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | DNS | Interviewed regarding multiple deficiencies including care plans, insulin management, and infection control. |
| Registered Nurse Assistant Director of Nursing Services | RN ADNS | Interviewed about Medicare beneficiary notification process. |
| Licensed Practical Nurse #1 | LPN | Documented blood sugar readings and interviewed about failure to notify physician. |
| Licensed Practical Nurse #2 | LPN | Interviewed about blood sugar monitoring and notification. |
| Physician | Interviewed about lack of notification of elevated blood sugars and suicidal ideation. | |
| Physical Therapist | PT | Interviewed about active range of motion program and staff in-service. |
| Rehabilitation Director | Rehab Director | Interviewed about standing program and range of motion program implementation. |
| Social Worker | Bachelor's level Social Worker | Interviewed about suicide risk assessment and peer altercation. |
| Registered Nurse Supervisor | RN Supervisor | Interviewed about standing program and CNA accountability. |
| Certified Nursing Assistant #1 | CNA | Interviewed about range of motion program implementation. |
| Certified Nursing Assistant #2 | CNA | Interviewed about range of motion program implementation. |
| Certified Nursing Assistant #3 | CNA | Interviewed about range of motion program implementation. |
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