Peninsula Nursing And Rehabilitation Center

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center

50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Peninsula Nursing and Rehabilitation Center

50 15 Beach Channel Drive Far Rockaway, NY 11691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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)

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Facility ID:

If continuation sheet