Inspection Reports for
Peninsula Nursing and Rehabilitation Center
50-15 Beach Channel Drive, Far Rockaway, NY, 11691
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Inspection Report — Oct 31, 2025
Complaint Investigation State
Date: Oct 31, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from June 2022 to May 2026 with citation and complaint history, enforcement actions, and deficiency details.
Complaint Details
The state logged 81 complaints about this facility with 9 on-site inspections resulting from complaints. Eight citations were issued related to complaints during the reporting period.
Findings
Across 8 inspections, 6 resulted in citations totaling 26 deficiencies primarily related to standard health and life safety code issues. The facility had 81 complaints with 9 on-site inspections and one enforcement action involving fines.
Citations (21)
Free Of Accident Hazards/supervision/devices: Failed to maintain a safe environment free of accident hazards.
Investigate/prevent/correct Alleged Violation: Did not adequately investigate or prevent alleged violations.
Quality Of Care: Deficiencies in quality of care resulting in actual harm.
Infection Prevention & Control: Failed to ensure proper infection prevention and control measures.
Medicaid/medicare Coverage/liability Notice: Did not comply with Medicaid/Medicare coverage or liability notice requirements.
Physician Visits - Review Care/notes/order: Inadequate review of physician visits, care notes, or orders.
Routine/emergency Dental Srvcs In Nfs: Failed to provide routine or emergency dental services as required.
Gas Equipment - Cylinder And Container Storag: Improper storage of gas equipment cylinders and containers.
Reporting - National Health Safety Network: Failed to properly report to the National Health Safety Network.
Activities Meet Interest/needs Each Resident: Activities did not meet the interests or needs of each resident.
Safe/clean/comfortable/homelike Environment: Environment was not maintained as safe, clean, comfortable, or homelike.
Building Construction Type And Height: Building construction type and height did not meet Life Safety Code requirements.
Cooking Facilities: Cooking facilities did not comply with Life Safety Code requirements.
Fire Alarm System - Out Of Service: Fire alarm system was out of service, violating Life Safety Code.
Fire Alarm System - Testing And Maintenance: Fire alarm system testing and maintenance were inadequate.
Illumination Of Means Of Egress: Illumination of means of egress did not meet Life Safety Code standards.
Means Of Egress - General: Means of egress were not compliant with Life Safety Code requirements.
Multiple Occupancies - Contiguous Non-health: Multiple occupancies in contiguous non-health areas violated Life Safety Code.
Roles Under A Waiver Declared By Secretary: Roles under a waiver declared by the Secretary were not properly followed.
Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were insufficient.
Vertical Openings - Enclosure: Vertical openings enclosure did not meet Life Safety Code standards.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 26
Inspections with violations: 6
Inspections without violations: 2
Complaints total: 81
On-site complaint inspections: 9
Citations from complaints: 8
Enforcement actions: 1
Total fines: 12000
Inspection Report — Oct 31, 2025
Abbreviated Survey CMS
Date: Oct 31, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, and failure to provide appropriate care to residents, specifically focusing on Resident #1 who was found unresponsive and later pronounced deceased.
Complaint Details
The survey was complaint-related, triggered by allegations of abuse, neglect, and failure to provide appropriate care. The complaint was substantiated as the facility failed to properly investigate and respond to the incident involving Resident #1.
Findings
The facility failed to thoroughly investigate alleged violations related to Resident #1's death due to choking on food, failed to provide timely cardiopulmonary resuscitation, and did not ensure adequate supervision to prevent accidents. Resident #1 was at risk for aspiration and wandering, was found unresponsive with food lodged in their airway, and the facility's response was delayed and inadequate.
Citations (3)
F 0610: The facility failed to ensure all alleged violations were thoroughly investigated and reported, evident in the inadequate investigation of Resident #1's death due to choking on food.
F 0684: The facility failed to provide treatment and care according to professional standards and the resident's care plan, resulting in delayed assessment and resuscitation of Resident #1 who was found unresponsive and later pronounced deceased.
F 0689: The facility failed to provide a safe environment free from accident hazards and adequate supervision, leading to Resident #1's death from choking on food despite known aspiration risk and wandering behavior.
Report Facts
Residents sampled: 14
Residents affected: 1
Staff in-service completion: 41
Staff in-service completion: 75
Staff in-service completion: 1
Staff in-service completion: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Responded to Resident #1 being found unresponsive, initiated CPR, and provided statements during investigation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Found Resident #1 unresponsive and alerted nursing staff |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Involved in transporting Resident #1 and provided statements about the incident |
| Physician #1 | Physician | Signed death certificate and provided medical information about Resident #1 |
| Speech Therapist #1 | Speech Therapist | Evaluated Resident #1 for swallowing function and aspiration precautions |
| Administrator | Facility Administrator | Informed of the incident and immediate jeopardy, involved in corrective action planning |
Inspection Report — Jul 3, 2024
Annual Inspection CMS
Date: Jul 3, 2024
Visit Reason
The survey was conducted as a Recertification survey from 06/26/2024 to 07/03/2024 to assess compliance with regulatory requirements for Peninsula Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare Non-Coverage notices, lack of physician orders for intravenous catheter care, failure to ensure annual dental evaluations, and inadequate infection prevention and control practices including improper use of Enhanced Barrier Precautions and hand hygiene.
Citations (4)
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage to residents' representatives on the same day as telephone notification for 2 of 3 residents reviewed.
F 0711: The facility failed to ensure physician orders specified care and frequency of dressing changes for intravenous catheter lines for 2 residents.
F 0791: The facility did not ensure a resident was promptly referred for annual dental evaluation and care; one resident lacked evidence of dental evaluation after 5/25/2023.
F 0880: The facility failed to implement infection prevention and control practices, including failure to use gowns for Enhanced Barrier Precautions during catheter care and inadequate hand hygiene by staff.
Report Facts
Residents reviewed for Beneficiary Notification: 3
Residents sampled: 37
Residents affected by Medicare Non-Coverage deficiency: 2
Residents affected by physician order deficiency: 2
Residents affected by dental services deficiency: 1
Residents affected by infection control deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Observed performing dressing change without gown and involved in intravenous catheter care deficiency | |
| Registered Nurse #4 | Observed performing dressing change without gown and involved in intravenous catheter care deficiency | |
| Registered Nurse #5 | Observed performing wound care and interviewed regarding Enhanced Barrier Precautions | |
| Registered Nurse #7 | Interviewed regarding hand hygiene monitoring | |
| Minimum Data Set Assessor #1 | Interviewed regarding Medicare Non-Coverage notification process | |
| Minimum Data Set Assessor #2 | Interviewed regarding Medicare Non-Coverage notification process | |
| Minimum Data Set Coordinator | Interviewed regarding Medicare Non-Coverage notification policy | |
| Director of Nursing | Interviewed regarding physician orders and Enhanced Barrier Precautions | |
| Medical Director | Interviewed regarding physician order documentation | |
| Attending Physician | Interviewed regarding physician order process | |
| Nursing Supervisor #1 | Interviewed regarding dental consult scheduling and Enhanced Barrier Precautions | |
| Infection Control Preventionist/Assistant Director of Nursing | Interviewed regarding Enhanced Barrier Precautions | |
| Certified Nursing Assistant #3 | Interviewed regarding Enhanced Barrier Precautions for Resident #23 | |
| Certified Nursing Assistant #4 | Observed and interviewed regarding hand hygiene and meal service |
Inspection Report — Jun 22, 2023
Abbreviated Survey CMS
Date: Jun 22, 2023
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with elopement prevention policies following an incident where a resident left the facility unsupervised.
Complaint Details
This was a complaint-related abbreviated survey triggered by an elopement incident involving Resident #1. The resident was found safe after leaving the facility unsupervised. The complaint was substantiated as the facility failed to prevent the elopement.
Findings
The facility failed to adequately supervise a resident to prevent elopement. Security staff allowed the resident to exit the building without proper verification, and staff monitoring was insufficient despite documented elopement risk and monitoring instructions.
Citations (1)
F 0689: The facility failed to ensure adequate supervision to prevent resident elopement. Security staff buzzed a resident out without verifying identity, and staff did not detect the resident's absence during rounds.
Report Facts
Residents sampled: 14
Time resident left facility: 20.53
Time resident was discovered missing: 21.4
Date resident returned: Jun 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SG #1 | Security Guard | Named in elopement incident for buzzing resident out without verification |
| CNA #1 | Certified Nursing Assistant | Documented monitoring rounds and last saw resident in bed |
| CNA #2 | Certified Nursing Assistant | Conducted 9:30 pm rounds and reported resident missing |
| RNCN #1 | Registered Nurse Charge Nurse | Notified security and nursing supervisor about missing resident |
| DON | Director of Nursing | Reviewed incident and stated responsibility for supervision |
| ADM | Administrator | Supervised security guard and stated elopement was caused by human error |
Inspection Report — Jul 28, 2022
Annual Inspection CMS
Date: Jul 28, 2022
Visit Reason
The inspection was conducted as a recertification survey from 07/21/2022 to 07/28/2022 to assess compliance with regulatory requirements including housekeeping, maintenance, and provision of resident activities.
Findings
The facility failed to maintain a safe, clean, and homelike environment in Unit 4-Bay, with multiple areas observed dirty and in disrepair. Additionally, the facility did not provide an ongoing program of activities to meet the interests and well-being of residents, as evidenced by Resident #320 not participating in meaningful activities and lack of recreational staff visits.
Citations (2)
F 0584: The facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for 1 of 5 units. Resident room, staff bathroom, oxygen room, and resident care equipment were dirty and in disrepair with no documented repair requests.
F 0679: The facility did not provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents. Resident #320 was observed not participating in meaningful activities, with no documented recreational visits or group activities during the survey period.
Report Facts
Residents affected: 1
Residents affected: 1
Units inspected: 5
Residents reviewed for activities: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit 4-Bay Housekeeper | Interviewed about cleaning duties and maintenance communication | |
| Director of Environmental Services (DES) | Interviewed about facility cleanliness and staffing | |
| Director of Maintenance (DOM) | Interviewed about facility inspections and maintenance procedures | |
| Certified Nursing Assistant (CNA #1) | Interviewed about care provided to Resident #320 and activities | |
| Registered Nurse Charge Nurse (RN #1) | Interviewed about assistance with TV and activities for Resident #320 | |
| Director of Therapeutic Recreation (DTR) | Interviewed about activities program and Resident #320's preferences | |
| Director of Nursing (DON) | Interviewed about activities program and follow-up plans | |
| Administrator | Interviewed about recreation department and follow-up plans |
Inspection Report — Aug 14, 2019
Annual Inspection CMS
Date: Aug 14, 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 resident dignity and privacy, thoroughness of accident investigations, implementation and revision of comprehensive care plans, adherence to physician orders for treatments, and proper storage of controlled medications.
Citations (7)
F 0550: The facility failed to ensure resident dignity and privacy by not covering a Foley bag with a privacy pouch for Resident #78, exposing it to public view.
F 0610: The facility did not thoroughly investigate a fall incident for Resident #79, lacking documentation of who was present during the fall.
F 0656: The facility failed to implement comprehensive care plans properly, including failure to ensure Resident #42 wore a prescribed Z-Flex boot and Resident #123 had a prescribed left half siderail on the bed.
F 0657: The facility did not revise the comprehensive care plan for Resident #129 to reflect a fall with injury on 6/20/19.
F 0658: Resident #142 did not receive dressing changes as ordered on 8/4/19 and 8/6/19, and the Treatment Administration Record was inaccurately signed as if care was provided.
F 0684: Resident #142 did not receive treatment and care according to orders and professional standards, including failure to document refusals and notify appropriate parties.
F 0761: Controlled drugs were not stored securely due to a faulty lock on the narcotic box in the medication cart on the 3rd floor Oceanside unit.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Medication carts inspected: 5
Lock attempts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Named in dignity/privacy finding for Resident #78 | |
| Registered Nurse (RN) Unit Supervisor | Named in dignity/privacy and fall investigation findings | |
| Director of Nursing Services (DNS) | Named in multiple findings including dignity/privacy, fall investigation, care plan, and treatment deficiencies | |
| Falls Coordinator RN #8 | Named in fall investigation finding | |
| Occupational Therapist (OT) | Named in fall investigation finding | |
| Certified Nursing Assistant (CNA #2) | Named in fall investigation finding | |
| Rehab Director | Named in care plan implementation finding | |
| Registered Nurse (RN) MDS Coordinator | Named in care plan revision finding | |
| Licensed Practical Nurse (LPN) #1 | Named in treatment refusal and documentation finding | |
| Licensed Practical Nurse (LPN) #2 | Named in treatment refusal and documentation finding | |
| Registered Nurse (RN) #3 | Named in treatment refusal and documentation finding | |
| Registered Nurse (RN) #5 | Named in medication cart lock deficiency | |
| Assistant Director of Nursing Services (ADNS) | Named in medication cart lock deficiency | |
| Director of Maintenance | Named in medication cart lock deficiency | |
| Assistant Administrator | Named in medication cart lock deficiency |
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