Inspection Reports for
Queens Nassau Rehabilitation and Nursing Center
520 Beach 19th Street, Far Rockaway, NY, 11691
Back to Facility Profile6 Reports
Inspection Report — Jul 9, 2025
Recertification CMS
Date: Jul 9, 2025
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to assess compliance with regulatory requirements and investigate specific complaints.
Complaint Details
The survey included complaint investigations related to failure to inform residents about advance directives and failure to timely report injuries of unknown source. The complaint regarding advance directives was substantiated for Resident #84. The complaint regarding injury reporting was substantiated for Resident #159.
Findings
The facility was found deficient in multiple areas including failure to inform residents about advance directives, failure to timely report injuries of unknown source, inaccurate Minimum Data Set assessments, incomplete and untimely care plans, improper medication storage, and inadequate infection control practices.
Citations (7)
F 0578: The facility failed to ensure residents were informed about their right to accept or refuse medical treatment and to formulate advance directives, as evidenced by lack of documented discussion with Resident #84.
F 0609: The facility did not timely report suspected abuse or injuries of unknown source to the State Survey Agency within 2 hours, as evidenced by failure to report Resident #159's injury.
F 0641: The facility did not ensure Minimum Data Set assessments accurately reflected residents' status, including failure to document use of hand mittens, wander guard device, and Stage 3 pressure ulcer for Residents #63, #79, and #93 respectively.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes for Resident #96 at risk for pressure ulcers.
F 0657: The facility did not review and revise comprehensive care plans timely, as evidenced by failure to update care plans for Resident #63 after a Stage 3 pressure ulcer re-opened.
F 0761: The facility did not ensure drugs and biologicals were stored and labeled properly, including undated and expired multi-dose insulin vials in the medication refrigerator.
F 0880: The facility failed to implement infection prevention and control practices, as Registered Nurse #5 did not don a gown during wound care for Resident #22 despite enhanced barrier precautions signage.
Report Facts
Residents reviewed for Advance Directives: 38
Residents reviewed for Pressure Sores: 8
Residents reviewed for Mood and Behavioral Symptoms: 5
Residents reviewed for Activities of Daily Living: 2
Number of undated multi-dose insulin vials: 1
Number of opened multi-dose insulin vials not discarded within 30 days: 3
Length of skin cut on Resident #159: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Night Shift Nurse Supervisor | Named in injury incident and reporting failure for Resident #159 |
| Social Worker #1 | Named in failure to document advance directives discussion for Resident #84 | |
| Director of Social Service | Interviewed regarding advance directives policy and documentation | |
| Registered Nurse #3 | Observed medication storage deficiencies with insulin vials | |
| Associate Director of Nursing Services | Interviewed regarding injury reporting and medication storage | |
| Director of Nursing | Interviewed regarding injury reporting, medication storage, and infection control | |
| Registered Nurse #5 | Failed to follow enhanced barrier precautions during wound care for Resident #22 | |
| Registered Nurse #1 | Nursing Supervisor | Interviewed regarding wound care observations and infection control |
| Infection Control Preventionist/Inservice Coordinator | Interviewed regarding infection control policies and staff education |
Inspection Report — Jul 9, 2025
State
Date: Jul 9, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2025 with citation and enforcement history including complaint investigations and COVID-19 surveys.
Complaint Details
The state logged 56 complaints about this facility; 6 led to on-site inspections. Complaint surveys resulted in citations including a Level 4 Immediate Jeopardy citation for accident hazards and Level 2 citations for abuse and neglect.
Findings
Across 8 inspections, 6 resulted in citations totaling 23, including standard health and life safety code violations. The facility had 56 complaints with 6 on-site inspections and 3 enforcement actions with fines totaling $26,000.
Citations (23)
Standard Health Citation — quality of care: Accuracy Of Assessments found deficient with pattern scope.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficient with isolated scope.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficient with isolated scope.
Standard Health Citation — quality of care: Infection Prevention & Control deficient with isolated scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficient with isolated scope.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficient with isolated scope.
Standard Health Citation — quality of care: Request/refuse/discontinue Treatment; formulate Advance Directive deficient with isolated scope.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notification deficient with scope unspecified.
Life Safety Code Citation — NFPA requirements: Physical Environment deficient with pattern scope.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficient with isolated scope.
Standard Health Citation — quality of care: Free From Abuse And Neglect deficient with isolated scope.
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficient with widespread scope, not yet corrected.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficient with isolated scope.
Standard Health Citation — quality of care: Accuracy Of Assessments deficient with isolated scope.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficient with isolated scope.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary deficient with pattern scope.
Standard Health Citation — quality of care: Increase/prevent Decrease In Range of Motion/mobility deficient with isolated scope.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals deficient with isolated scope.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficient with isolated scope.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Corridor - Doors deficient with isolated scope.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficient with isolated scope.
Standard Health Citation — quality of care: Reporting - National Health Safety Network deficient with widespread scope, not yet corrected.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 23
Inspections with violations: 6
Inspections without violations: 2
Total complaints: 56
On-site complaint inspections: 6
Citations issued from complaints: 2
Enforcement actions: 3
Total fines: 26000
Inspection Report — Sep 27, 2023
Abbreviated Survey CMS
Date: Sep 27, 2023
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of physical abuse of a resident by nursing home staff.
Findings
The facility failed to protect Resident #1 from physical abuse by a Certified Nursing Assistant (CNA #1), who was witnessed hitting the resident on the forehead during care. The resident sustained swelling and discoloration and was transferred to the emergency room for evaluation. The abuse was confirmed by staff statements and the facility's investigation.
Citations (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident #1 was physically abused by CNA #1, who hit the resident on the forehead during incontinent care. The abuse was witnessed and resulted in injury requiring emergency room evaluation.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named as the staff member who physically abused Resident #1. |
| CNA #2 | Certified Nursing Assistant | Witnessed the abuse and assisted during the incident. |
| RNS #3 | Registered Nurse Supervisor | Assessed Resident #1 after the incident and assisted with the investigation. |
| LPN #1 | Licensed Practical Nurse | Provided a statement about the incident and was present during care. |
| Director of Nursing | Director of Nursing | Notified of the incident, reviewed statements, and took disciplinary action. |
| Resident #1's primary physician | Primary Physician | Examined Resident #1 after the injury and confirmed bruising and swelling. |
Inspection Report — Sep 12, 2023
Abbreviated Survey CMS
Date: Sep 12, 2023
Visit Reason
The abbreviated and partial extended survey was conducted due to a failure to ensure adequate supervision to prevent elopement of a resident identified as an elopement risk.
Findings
The facility failed to ensure that Resident #1, who was cognitively impaired and at risk for elopement, was adequately supervised after returning from a clinic appointment on 08/29/2023. Resident #1 left the building undetected, resulting in immediate jeopardy to resident health and safety, though no actual harm occurred.
Citations (1)
F 0689: The facility failed to ensure a resident identified as an elopement risk received adequate supervision to prevent elopement. Resident #1 left the facility undetected on 08/29/2023 despite having a wander alert device and care plan for 15-minute monitoring.
Report Facts
Employees: 195
Employees educated: 188
Employees on leave: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to monitor Resident #1 and failure to notify staff of resident's return |
| RNS #1 | Registered Nurse Supervisor | Named in notification and search efforts for missing Resident #1 |
| CNA #4 | Certified Nursing Assistant | Escorted Resident #1 to clinic appointment and returned resident to unit |
| SG #1 | Security Guard | Named in failure to hear or reset wander alert alarm when Resident #1 exited |
| DON | Director of Nursing | Conducted investigation and notified immediate jeopardy |
| Administrator | Involved in investigation and security responsibilities | |
| AP #1 | Attending Physician | Observed Resident #1 on surveillance footage |
| DOM | Director of Maintenance | Responsible for wander alert system inspections |
Inspection Report — Mar 16, 2023
Annual Inspection CMS
Date: Mar 16, 2023
Visit Reason
The survey was conducted as a recertification and abbreviated annual inspection to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper care plans or assessments, failure to timely report injuries of unknown origin, inaccurate Minimum Data Set (MDS) assessments, incomplete comprehensive care plans, inadequate range of motion care, improper medication storage with expired drugs found, and food safety violations including unlabeled and expired food items and improper employee hair/beard coverings.
Citations (7)
F 0604: The facility did not ensure residents were free from physical restraints without medical justification, assessment, or care plans. Residents #54 and #141 had lap tray restraints used without proper documentation or evaluation.
F 0609: The facility failed to report Resident #59's injury of unknown origin (left distal tibia fracture) to the State Survey Agency within 2 hours as required.
F 0641: The Minimum Data Set (MDS) assessments did not accurately document trunk restraints for Residents #54 and #141, and discharge assessment for Resident #179 was inaccurate regarding discharge status.
F 0656: The facility failed to develop and implement comprehensive care plans addressing residents' needs for Residents #54 (lap tray restraint), #93 (activities), and #128 (midline catheter and IV antibiotics).
F 0688: Residents #45 and #66 with limited range of motion were not provided ordered devices (left palm guard and left resting hand roll) consistently, risking further decline in range of motion.
F 0761: Medications were not stored according to professional standards; two bottles of expired Bisacodyl tablets were found in the 3 North Unit medication room.
F 0812: Food was not stored, prepared, and distributed in accordance with professional standards. Multiple unlabeled and undated food items were found in refrigerators and emergency storage. An employee was observed without proper hair and beard restraints.
Report Facts
Residents reviewed: 35
Residents with lap trays: 16
Expired medication count: 2
Expired food items: 2
Inspection Report — Feb 19, 2020
CMS
Date: Feb 19, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Queens Nassau Rehabilitation and Nursing Center.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
