Peninsula Nursing And Rehabilitation Center

Based on observation, record review, and interviews conducted during an abbreviated survey (2643598), the facility failed to ensure that all alleged violations are thoroughly investigated in response to allegations of abuse, neglect, exploitation, or mistreatment, and that the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency. This was evident for 1 of 14 residents (Residents #1) sampled. Specifically, Resident #1, who was severely cognitively impaired, at risk for aspiration/choking, required supervision with eating and had a history of wandering and taking other resident's food, was found unresponsive in the hallway on 08/16/2025 at 11:45 PM by Certified Nursing Assistant #1. Emergency Medical Service was called at midnight and responded at 12:04 AM on 08/17/2025. Resident #1 was pronounced deceased at 12:27 AM by the Emergency Medical Service team. The facility did not conduct a thorough investigation to ascertain how Resident #1, who was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 06/24/2024 to 07/03/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1). Enhanced Barrier Precautions were not implemented for 2 residents (Resident #377 and Resident #50) with indwelling medical devices and 1 resident (Resident #23) during a wound care observation, and 2). A Certified Nursing Assistant did not perform hand hygiene while assisting multiple residents in the dining room. The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review conducted during the Recertification survey from 06/26/2024 to 07/03/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 2 (Residents #166 and 428) of 3 residents reviewed for Beneficiary Notification out of 37 total sampled residents. Specifically, the Notice of Medicare Non-Coverage were not mailed out to Resident #166 and #428 designated representatives on the same day as telephone notification. The findings are: The facility policy titled Medicare Determination for SNF (Skilled Nursing Facility) with an effective date of 1/2021 states that the facility is required to provide notification of termination of services/Medicare coverage at least 2 business days before the last covered day. Notices mailed are certified and the receipt of certified mail is stapled to a copy of the letter and maintained in the MDS office for file. 1. Resident #166 was discharged from skilled services on 5/28/2024 with 59 days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review conducted during the Recertification Survey from 06/24/2024 to 07/03/2024, the facility failed to ensure that the physician reviewed the resident's total program of care. This was evident for 2 residents (Resident #50 and Resident #377) observed for Medication Administration. Specifically, there were no physician orders specifying care and treatment for the maintenance of intravenous catheter lines. The findings are: The facility policy titled Care and Treatment of the Resident -Physician Orders Monthly Review, effective 06/2017, documented that to ensure appropriate ordering of medications, treatments, and services, it is the policy of the facility that the medical provider shall review and renew the monthly medication and treatments for the resident. The facility's policy titled Care and Treatment of the Peripherally Inserted Central Catheter, Maintenance and Care, documented that it is the policy of the facility to provide intermediate to long-term venous access in a safe, aseptic manner: General Guidelines Include - Lines should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey completed from 6/26/2024 to 7/3/2024, the facility did not ensure that a resident was promptly referred for annual dental evaluation and care. This was evident for 1 (Resident #92) of 4 residents reviewed for Dental out of a sample of 37 residents. Specifically, an annual dental evaluation was not performed for Resident #92. The facility policy titled Dental and Oral Health Services dated 11/2017 states that it is the policy of the facility to make routine and 24-hour emergency dental care available to its resident and that the dentist shall perform an annual re-evaluation for reach resident. A record of dental services and evaluations will be maintained in the resident's medical chart. Resident #92 was admitted with diagnoses that included Alzheimer's Disease, Non-Alzheimer's Dementia, and Seizure Disorder. The Annual Minimum Data Set, dated [DATE] documented that Resident #92 was moderately cognitively impaired, did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 7/21/22 to 7/28/22, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided for 1 (Unit 4-Bay) of 5 units. Specifically, a resident's room, staff bathroom, oxygen room, and resident care equipment were observed dirty and in disrepair. The findings are: On 07/26/22 at 11:53 AM, the following was observed during a tour of Unit 4-Bay: 1. Resident room [ROOM NUMBER] contained walls with brownish stains and streaks throughout the entire room. The wall paint behind the head of the resident's bed was cracked and chipped, and the floors had black dirt that was ground into the tiles and not easily removed. One metal bed frame had brown stains and dust, and an oxygen concentrator in use was covered with dust and debris. The garbage bin was heavily soiled and stained. A blue vinyl chair had a missing right arm rest, loose swiveling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview conducted during the Recertification / Complaint (NY274057, NY294505, NY286257, NY294811, NY264504, NY295942, NY294690, NY286257, NY290627) survey from 07/21/2022 to 07/28/2022, the facility did not ensure an ongoing program of activities was provided to meet the interests of, and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. This was evident for 1 (Resident #320) of 2 residents reviewed for Activities out of 37 sampled residents. Specifically, a resident was observed for extended periods of time not participating in any meaningful activities. The finding is: The facility Policy and Procedure tilted Activity Recreation Program and Assessment with effective date 03/2022 documented The facility shall provide for an ongoing program of activities designed to meet the interests and the physical, mental, psychosocial wellbeing of each resident. Resident #320 was admitted to the facility with diagnosis that included Anemia, Atrial fibrillation, and End…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity and received care in a manner that promotes maintenance or enhancement of their quality of life. This was identified for 1 (Resident #78) of 1 resident reviewed for dignity. Specifically, Resident #78 had a Foley bag attached to a Suprapubic catheter. The Foley bag was observed hanging at the bedside in his room without a privacy pouch to maintain the resident's dignity and privacy. The uncovered Foley bag was visible to anyone passing by his room. The finding is: The facility's policy and procedure dated 11/2017 titled Dignity documented . Using dignity-enhancing tools, such as catheter bag covers . Resident #78 has diagnoses including End Stage Renal Disease (ESRD), Obstructive and Reflux Uropathy, and Hemiplegia. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview during the recertification survey, the facility did not ensure that accident report investigations were thoroughly investigated to establish the cause of a fall. This was identified for one (Resident #79) of five residents reviewed for falls. Specifically, Resident #79 had a fall on 4/15/19 in the unit dining room during the dinner meal, sustained a laceration to the back of the head and was sent to the hospital for Head Trauma. The Accident/Incident (A/I) Report lacked documented evidence of who was in the dining room with the resident at the time of the fall. The finding is: Resident #79 was readmitted to the facility on [DATE] with diagnoses including Dementia without Behavioral Disturbance, Hemiplegia, and Dysphagia. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 3 which indicated severe cognitive impairment. The resident had no behavior problems, required extensive assist of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that comprehensive person-centered care plans were implemented for each resident to meet the resident's medical and nursing needs. This was identified for one (Resident #42) of six residents reviewed for Position/Mobility and one (Resident #123) of six residents reviewed for Communication. Specifically, 1) Resident #42 had a Physician's order to wear a Z-Flex boot to the right foot at all times; however, the resident was observed on two occasions not wearing the boot; and; 2) Resident #123 had a Physician's order for a left half siderail to be up while the resident was in bed; however, the resident's bed did not have a left siderail. The findings are: 1) Resident #42 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Seizure Disorder, and Acquired Absence of Left Leg Below Knee. The 5/26/19 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the recertification survey, the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team after each assessment. This was identified for 1 (Resident #129) of 1 resident reviewed for accidents. Specifically, Resident #129 has a fall incident with an injury. Review of the resident's CCP developed for Falls revealed that the CCP was not updated to reflect the 6/20/19 fall incident. The finding is: The facility's policy and procedure dated 7/2018 titled Care Planning Process documented . The care plan is reviewed and revised by the interdisciplinary team after each assessment . The care plan is revised by the members of the Interdisciplinary Team based on changing goals, preferences and needs of the resident, and in response to current intervention. The facility's policy and procedure dated 11/2016 titled Resident Accident Reporting And Investigation- New York documented . 14. Will review the plan of care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that services provided or arranged by the facility, as outlined by the the comprehensive care plan meet the current professional standards of quality. This was identified for one (Resident #142) of one resident reviewed for Skin Condition. Specifically, Resident #142 had a Physician's order for dressing change to his Left Plantar open callus one time daily on even days. The resident was observed on 8/7/19 with a dressing on his Left Plantar open callus dated 8/2/19. The Treatment Administration Record (TAR) dated August 2019 was signed on 8/4/19 and 8/6/19 as care was rendered; however, the care was not provided. The finding is: Resident #142 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus with Foot Ulcer and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #142) of one resident reviewed for Skin Condition. Specifically, Resident #142 had a Physician's order for dressing change to his Left Plantar open callus one time daily on even days and treatment was not administered as ordered by the Physician on 8/4/19 and 8/6/19. Additionally, the Treatment Administration Record (TAR) dated August 2019 was signed on 8/4/19 and 8/6/19 as care being rendered when care was not provided. The finding is: Resident #142 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with Foot Ulcer and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 11 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interviews during the Recertification Survey the facility did not ensure that controlled drugs were stored in accordance with State and Federal laws, including storing controlled drugs in separately locked, permanently affixed compartments in the medication carts. This was identified on 1 of 5 medication carts. Specifically, the medication cart on 3rd floor Oceanside unit had a faulty lock mechanism on the narcotic box and the box contained narcotic medication. The finding is: The facility Policy and Procedure dated 6/2018 titled storage of drugs, documented it is the policy of the facility that all medications be stored in accordance with federal and state laws and guidelines. The purpose is to assure proper storage and administration of medications. Controlled substances may be transferred during the medication pass to the locked cabinet section within the medication cart. Once the medication pass is completed, the controlled substance will be transferred back to the double-locked cabinet in the medication room. During review of the 3rd floor Oceanside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.