Peninsula Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (2643598), the facility failed to provide an environment that is free from accident hazards and to ensure that a resident received adequate supervision to prevent accidents. This was evident for one (1) of 14 residents sampled (Resident #1). 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 00:00:12 (12 seconds after midnight) and they arrived at the facility at 00:04 AM (12:04 AM) on 08/17/2025. Resident #1 was pronounced deceased at 12:27 AM by the Emergency Medical Service team. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (2643598), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This was evident for one (1) of 14 residents (Residents #1) sampled. Specifically, Resident #1 was found unresponsive in the hallway on 08/16/2025 at 11:45 PM by Certified Nursing Assistant #1 and was not immediately assessed and cardiopulmonary resuscitation was not initiated at that time. Additionally, Emergency Medical Services was called 15 minutes after the resident was found and responded to the scene at 12:04 AM on 08/17/2025. Resident #1 was pronounced deceased at 12:27 AM by the Emergency Medical Service team. This resulted in actual harm that is not Immediate Jeopardy.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]