Rockaway Care Center

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (459982), the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was evident in one (1) of 12 residents (Resident #1) sampled for elopement. Specifically, Resident #1 left the building on 02/17/2025 at 4:03 PM after being buzzed out the exit door in the lobby by Security Guard #1. Facility staff did not become aware that Resident #1 was not in the building until 5:35 PM. On 02/18/2025 at 1:20 AM, the hospital notified Nursing Supervisor #2 that Resident #1 was in the hospital. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 5 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. This was evident for five (5) of (5) residents (Resident #4, #10, #7, #6, and #221) reviewed for Unnecessary Medications out of 41 sampled residents. Specifically, there was no documented evidence in the clinical records of Residents #4, #10, #7, #6, and #221 that monthly Medication Regimen Reviews were completed.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification conducted from 09/24/2025 to 10/01/2025, the facility did not ensure sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Residents reported the facility was short staffed with Certified Nursing Assistants, especially on weekends both days and nights, which resulted in a lack of timely staff response to call bells and delays in performing Activities of Daily Living and personal care. 2). The facility Payroll Based Journal for Quarter 3 (April 1 - June 30) also revealed an excessively low weekend staffing, and 3). [...]

Inspectors wroteBased on interview, and record reviews conducted during the Recertification survey, the facility did not ensure a performance review of every nurse aide was completed at least once every 12 months, and regular in-service education was based on the outcome of these reviews. This was evident during a review of Sufficient and Competent Nursing Staffing task. Specifically, six (6) of six (6) Certified Nursing Assistant personnel files contained no evidence of yearly performance evaluations and in-services based on the results of performance evaluations.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure the medication error rate was less than 5 percent. This was evident for 2 of 32 medications observed during the Medication Administration task. Specifically, Resident #180 was given the wrong dose of Lopressor 25 mg tablets and, Zyprexa 35 mg was also administered at the wrong time. This resulted in a medication error rate of 6.5%.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests.

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification survey, the facility did not ensure the facility-wide assessment was updated to include and address the total resident population and resources that were necessary to care for those residents. This was evident during a review of Sufficient and Competent Nursing Staffing. Specifically, 1). the Facility Assessment did not identify or address care for ventilator dependent residents in the total population of services offered including respiratory therapist personnel required to meet that populations daily staffing needs, and 2). on-site hemodialysis treatment was listed as a service provided and the facility did not have a certified dialysis unit.

Inspectors wroteNumber of residents sampled: 7Number of residents cited: 1 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection control practices and procedures were maintained. This was observed during medication administration for one (1) of seven (7) residents (Resident #187) observed. Specifically, Enhanced Barrier Precautions were not used when Registered Nurse #5 administered medications to Resident #187 via the gastrostomy tube.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure a building elevator was maintained in a safe working condition. This was observed in one (1) of three (3) elevators (Elevator #2) observed. Specifically, Elevator #2 was broken and out of service for over 10 months, causing delays and restricting resident movement around the facility, including attending medical appointments.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1 Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced dignity. This was evident for one (1) of two (2) residents (Resident #12) reviewed for Catheter out of a sample of 41 residents. Specifically, Resident #12's foley catheter drainage bag and tubing were not covered with a privacy bag.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1 Based on observations, record reviews, and interviews conducted during the Recertification and abbreviated survey (460002), the facility did not ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraints out of 41 sampled residents. Specifically, Resident #9 was observed by facility staff in their bed restless and agitated while on a mechanical ventilator, with each hand inside a pillowcase wrapped with tape around their wrists.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated (459971) and Recertification survey, the facility did not ensure a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. This was evident for one (1) of two (2) residents (Resident #223) reviewed for Hospitalization out of 41 sampled residents. Specifically, there was no comprehensive care plan developed for tracheostomy care for Resident #223.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #9) reviewed for Physical Restraint out of 41 sampled residents. Specifically, there was no documented evidence bilateral hand mittens for Resident #9 were released every two-hours as per Physician's order.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated (459994) and Recertification survey, the facility did not ensure the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for one (1) of two (2) residents (Resident #229) reviewed for Hydration out of a total of 41 sampled Residents. Specifically, a Comprehensive Metabolic Panel laboratory test was ordered for Resident #229 on 04/09/2025, there was no documented evidence that blood test was performed.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1 Based on observation, record review, and interviews during the Recertification survey, the facility did not ensure the resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident for one (1) of two (2) residents (Resident #225) reviewed for Hydration out of 41 total sampled residents. Specifically, Resident #225, who had a physician's order for thickened liquid, was observed drinking coffee and water without a thickener.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents who needed respiratory care were provided care that was consistent with professional standards of practice. This was evident for one (1) of two (2) residents (Resident #78) reviewed for Respiratory Care out of a total sample of 41 residents. Specifically, Resident #78 was observed with an undated oxygen nasal cannula and an undated nebulizer mask and tubing.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a Quality Assurance and Performance Improvement program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents. Specifically, 1.) the facility had pattern deficiencies in the areas of Resident Rights, Sufficient Nursing Staff, Pharmacy Services, Administration, Infection Control and Physical Environment, and 2). There were repeated deficiencies from the last survey conducted from 07/20/2023 through 07/27/2023. (Refer to F604 and F880)

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (NY00376954), the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. This was evident in 1 out of 10 residents (Resident #1) sampled for behavioral health. Specifically, from [DATE] through [DATE], Resident #1 who had a diagnosis of Huntington's Chorea Disease (a neurological disorder that causes nerve cells in the brain to break down and die, leading to uncontrolled movements, cognitive decline, and personality changes) exhibited and verbalized suicidal ideation with increased agitation and behavioral disturbances. [...]

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (NY00360059), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident in one (1) out of ten (10) residents (Resident #2) sampled. Specifically, on 11/11/2024 Resident #2 alleged Certified Nursing Assistant #5 hit them on their head and pushed them to the ground on the evening of 11/10/2024. The facility investigated the allegation and concluded that the abuse allegation was inconclusive. Resident #2's care plan was not reviewed and revised to reflect the allegation of abuse and it's outcome.

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey, (NY00376954), the facility failed to ensure that the physician reviewed the resident's total program of care, including medications, at each visit. This was evident in one (1) out of ten (10) residents (Resident #1) sampled for quality of care. Specifically, Resident #1 who exhibited increased agitation with behavioral disturbances secondary to Huntington's Disease, verbalized suicidal ideation from [DATE] to [DATE]. Resident #1 was transferred to the hospital emergency department on [DATE], [DATE], and [DATE]. A Patient Visit Information (Hospital Discharge Summary) from the hospital emergency department dated [DATE], documented as recommended on [DATE], Abilify 20 milligram to be decreased to 10 milligram daily due to the risk of akathisia restlessness, and agitation. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 7/19/2023 to 7/27/2023, the facility did not ensure a resident remained free of physical restraints. This was evidenced for Resident #88 reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #88 was observed with bilateral 1/2 SR in place and unable to independently use or release the SRs.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint Survey (NY00303837) from 07/19/2023 to 07/27/2023, the facility did not ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health (NYSDOH), but not later than 2 hours after the alleged occurrence. This was evident for 2 (Resident # 153 and # 100) of 4 residents reviewed for Abuse out of 38 total sampled residents. Specifically, an altercation involving Resident #153 and # 100 was not reported to the NYSDOH within 2 hours of occurrence.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Abbreviated (NY0029797) survey, the facility did not ensure correct installation and maintenance of bed rails. This was evident for 1 (Resident #33) of 5 residents reviewed for Accidents out of 38 total sampled residents. Specifically, Resident #33 had bilateral half upper side rails (SR) in place without an assessment for risk of entrapment and proper installation and Resident #33 fell from the bed while attempting to use the SRs.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 07/19/2023 to 7/27/2023, the facility did not ensure each resident received food that accommodated resident's allergies and preferences. This was evident for 1 (Resident #2) of 38 total sampled residents. Specifically, Resident #2 preferred not to consume milk and was observed with milk served on their meal tray.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 7/19/2023 to 7/27/2023, the facility did not ensure safe food storage was practiced. This was evident during observation of the Kitchen. Specifically, 48 cans of expired beans were observed in the emergency food storage area.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/27/2023, the facility did not ensure a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day, and a provision that the facility immediately notifies hospice about a need to transfer the resident from the facility for any condition. This was evident for Resident #55 reviewed for Hospice out of 38 total sampled residents. Specifically, there was no documented evidence the facility communicated with Hospice when Resident #55 was transferred to the hospital. The finding is: [...]

Inspectors wroteBased on observation and interview conducted during the Recertification survey from 07/19/2023 to 07/27/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 1 (Resident #111) of 6 residents investigated for Pressure Ulcer/Injury out of 38 total sampled residents. Specifically, the Registered Nurse (RN) failed to practice hand hygiene and glove changes during wound care observation.

Inspectors wroteBased on observations, record review and interview during the Recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call bell buttons were not kept within the reach of the residents. This was evident for 6 of 9 residents reviewed for Accommodation of Needs in the Environment facility Task (Residents #8, 84, 120, 157, 185 and 186).

Inspectors wroteBased on record review and interview during the Recertification survey, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, a resident who was placed on a wander guard device since [DATE] was not coded for having a wander guard device. This was evident for 1 of 37 sampled residents reviewed for MDS assessment (Resident #68). The finding is: Resident #68 was admitted to the facility with diagnoses which include Hypertension and Schizophrenia. The most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. Resident #68 required the limited assistance of one person for Activities of Daily Living (ADLs). On [DATE] at 11:09 AM, Resident #68 was observed in the hallway with a Wander guard device on the left wrist. On [DATE] at 12: [...]

Inspectors wroteBased on staff interview and record review conducted during a the Recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address a resident's concerns. Specifically, care plans were not developed to address the care needs of oxygen therapy, nebulizer treatment, CPAP use, inslin use, and anticoagulant therapy. This was evident for 2 of 37 sampled residents (Resident #46 and Resident #66).

Inspectors wroteBased on observations, record reviews and interviews during the recertification survey, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers. Specifically, a resident with orders to apply bilateral heel pads when in bed and in the wheelchair was observed not wearing the heel pads during multiple observations. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #9). The finding is: The facility's Policy and Procedure dated 4/12/2012, titled Adaptive Equipment Policy documented It is the policy of this facility that assistive/adaptive equipment is issued after resident's evaluation by the licensed rehabilitation therapist. The nursing department and the rehabilitation department will monitor care and proper use of adaptive device. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility failed to ensure infection control 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, Oxygen tubing, nebulizer tubing, and nebulizer masks were observed on multiple occasions touching the floor, uncovered, and improperly stored. This was evident for 3 of 6 residents reviewed for Respiratory Care (Resident #46, #118, #438) out of an investigative sample of 37 residents.