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Complaint Investigation

Peninsula Nursing And Rehabilitation Center

October 31, 2025 · Far Rockaway, NY · 50 15 Beach Channel Drive
Citations 3
CMS Rating 2/5
Beds 200
Provider ID 335387
Healthcare Facility
Peninsula Nursing And Rehabilitation Center
Far Rockaway, NY  ·  View full profile →
Inspection Summary

PENINSULA NURSING AND REHABILITATION CENTER in FAR ROCKAWAY, NY — inspection on October 31, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

oral assessment and removed solid bread from Resident #1's mouth, but did not suction the resident.

Registered Nurse Supervisor #1 stated the emergency medical team arrived on the unit (unsure of time), took over, and pronounced Resident #1 at 12:27 AM on 08/17/2025.

Registered Nurse Supervisor #1 stated they were not in Resident #1's room when the emergency medical service team was working on Resident #1.

Registered Nurse Supervisor #1 called surveyor on 10/23/2025 at 2:59 PM stating that they reviewed Resident #1's chart and came to realize that they did not document seeing food in Resident #1's mouth and would like to recant their interview statement of seeing/removing solid bread out of Resident #1's mouth.

During an interview on 10/28/2025 at 10:32 AM, the Director of Nursing stated they were informed by Registered Nurse Supervisor #1 on 08/16/2025, sometime during the night (unsure of time), reporting that Resident #1 was found unresponsive.

The Director of Nursing stated that they collected statements from the staff who worked on the night shift but did not investigate because the staff responded immediately and appropriately.

The Director of Nursing stated when a resident is found unresponsive a Code Blue is typically called; 911 called, and cardiopulmonary resuscitation initiated, and the Automated External Defibrillator applied.

The Director of Nursing stated they were not aware Resident #1 was found with food in their mouth.

The Director of Nursing further stated, if Resident #1 was found unresponsive during mealtime, staff would have been more likely to check their mouth.

The Director of Nursing also stated they were aware Resident #1 had the behavior of taking other residents' food, and that staff would redirect the resident. 10 NYCRR 415.4 (b)(1)(ii)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center

50 15 Beach Channel Drive Far Rockaway, NY 11691

SUMMARY STATEMENT OF DEFICIENCIES

transferring the resident into their bed.

Certified Nursing Assistant #2 stated they did not see food on the resident, and they did not serve the resident any food.

Certified Nursing Assistant #2 stated Resident #1 had behavior of always moving around, wandering into other resident's rooms and taking their food.

Certified Nursing Assistant #2 stated if they observed the resident with food they would take it away.

During an interview on 10/27/2025 at 10:09 AM, Physician #1 stated they received a call (unsure of time/person who called) informing them that Resident #1 passed away.

Physician #1 stated that they signed and completed the death certificate which documented cardiac arrest due to hyperlipidemia.

Physician #1 stated they were not notified of Resident #1's condition prior to the resident's death because another Physician was on-call during the night.

Physician #1 stated Resident #1 was at risk for aspiration and was receiving a puree textured and nectar thicken liquid diet and soft sandwiches.

Physician #1 stated Resident #1 had to be monitored and/or assisted during meals to ensure consistency with their diet.During an interview on 10/28/2025 at 10:32 AM, the Director of Nursing stated they were informed by Registered Nurse Supervisor #1 on 08/16/2025, sometime during the night (unsure of time), that Resident #1 was found unresponsive.

The Director of Nursing stated that they collected statements from the staff who worked on the night shift but did not investigate because the staff responded immediately and appropriately.

The Director of Nursing stated when a resident is found unresponsive a Code Blue is typically called; 911 called, and cardiopulmonary resuscitation initiated, and the Automated External Defibrillator applied.

The Director of Nursing stated they were not aware Resident #1 was found with food in their mouth.

The Director of Nursing further stated, if Resident #1 was found unresponsive during mealtime, staff would have been more likely to check their mouth.

The Director of Nursing also stated they were aware Resident #1 had the behavior of taking other residents' food, and that staff would redirect the resident. 10 NYCRR 415.12

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/31/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center

50 15 Beach Channel Drive Far Rockaway, NY 11691

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

were updated.4) Facility reviewed their Policies and Procedures on Cardiopulmonary Resuscitation and Heimlich Maneuver.a) The Cardiopulmonary Resuscitation policy and procedure was revised (10/29/2025) to include not to move the resident to the bed or another area, begin cardiopulmonary resuscitation where the resident is found.b) The Heimlich Maneuver policy and procedure was revised (10/29/2025) to include to lower resident to a firm surface and activate Emergency Medical Service (911), begin cardiopulmonary resuscitation starting with compressions, before delivering breaths during cardiopulmonary resuscitation cycles, open mouth and look for visible object, remove only if seen, do not perform blind finger sweeps.5) Facility reevaluated all location of nourishment and snacks on the units to ascertain if current measures to secure said nourishment is adequate. a) A statement dated 10/30/2025 by the Administrator documented that the facility feels the current locations where the nourishments and snacks are held behind the nursing station in the cupboard and refrigerator is safe and secure and does not pose a risk to the residents.6) Facility initiated in-service education on 10/29/2025 to Certified Nursing Assistants, Licensed Nurses, Speech Therapist and Dieticians regarding residents at risk for aspiration, facility safety practices, policy update, rounding and documentation, and environmental safety measures.a) As of 10/31/2025 the facility provided the following staff who received in service on resident safety and supervision, aspiration precautions and emergency response.

Listed as follows: Licensed Nurse - 41/41=100 %, Certified Nursing Assistants-75/77 = 97.4 %, Speech Therapist -1/1 =100 %, Dietician - 2/2 =100 %. 10 NYCRR 415.12(h)(2)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FAR ROCKAWAY, NY, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PENINSULA NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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