The Pavilion at Queens for Rehabilitation & Nursin

Inspectors wroteBased on record review and interview conducted during survey, the facility failed to immediately consult with the resident's physician, when there was a need to alter treatment significantly. This was evident in one out of five residents sampled (Resident #1). Specifically, Resident #1 had a Physician's Orders dated 07/15/2026 for BiPAP (bi-level positive airway pressure), IPAP (Inspiratory positive airway pressure):28, EPAP (Expiratory Positive Airway Pressure):5 settings. On 07/16/2026, the Director of Respiratory Therapy changed the BiPAP settings from 28/5 to 25/5 without notifying a physician and Resident #1's representative.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan. This was evident in one out of five residents (Resident #1). Specifically, Resident #1 who was admitted from the hospital to the facility on [DATE] did not receive their BiPAP (bi-level positive airway pressure) at bedtime on 07/15/2026 as per physician's order. The BiPAP machine was ordered on 07/16/2026 and arrived at 8:00 PM on 7/16/2026. Additionally, Director of Respiratory Therapy changed the settings on the BiPAP machine on 07/16/2026 without notifying a physician and without a physician's order.

Inspectors wroteBased on record review, and interviews during survey conducted the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. Director of Respiratory Therapy failed to document changes in Resident #1's medical record. This was evident in one out of five residents sampled (Resident #1). Specifically, Resident #1 had a Physician's Orders dated 07/15/2026 for BiPAP (bi-level positive airway pressure), IPAP (Inspiratory positive airway pressure):28, EPAP (Expiratory Positive Airway Pressure):5 settings. On 07/16/2026, the Director of Respiratory Therapy changed the BiPAP settings on the machine from 28/5 to 25/5 on 07/16/2026 without a physician's order. The changes were not documented in Resident #1's medical record.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024 , the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure food was served and dishware was handled in accordance with professional standards for food service safety. Specifically, 1). numerous kitchen staff were observed not wearing beard restraints while preparing and assembling food, and 2). the Food Service Director did not wash their hands after contact with a garbage can while checking food temperatures on the tray line. This was evident during the Kitchen Observation task.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from on 11/13/24 to 11/20/24, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 3 (Unit 8, Unit 5, and Unit 4) of 9 resident units. Specifically, Unit 8 and Unit 5 were observed with multiple wheelchairs embedded and heavily layered with dirt and debris and Unit 4 was observed with dirty, dusty heating system. The facility policy and procedure titled Resident Environment dated 01/02/2023 documented that it is the policy of the facility to provide a safe clean comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/13/2024 to 11/20/2024, 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. [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification survey from 11/13/2024 to 11/20/2024, 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 1 (Resident #76) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification conducted from 11/13/2024 to 11/20/2024, the facility did not ensure a person-centered Comprehensive Care Plan was developed and implemented to address the resident's needs. This was evident for 1 (Resident #150) of 5 residents reviewed for Unnecessary Medication out of 38 total sampled residents. Specifically, a Comprehensive Care Plan related to Resident #150's use of anticoagulant medication was not developed and implemented.

Inspectors wroteBased on record review and interview conducted during the Recertification survey between 11/13/2024 and 11/20/2024, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for 1 (Resident #109) of 5 resident reviewed for Unnecessary Medications and 1 (Resident #145) of 3 Residents reviewed for Pain Management out of 38 sampled residents. Specifically, 1) the Comprehensive Care Plan for Psychotropic Medications were not updated and revised for Resident #109, and 2). the Comprehensive Care Plan for Pain Management was not reviewed and revised for Resident #145.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure drugs and biologicals were labeled in accordance with professional standards of practice. This was evident on 2 (Unit 5 and Unit 3) of 8 resident units. Specifically, 1). an opened and undated individual vial of insulin and eye drops was observed on the medication cart in the 5th Floor medication cart, and 2). A vial of insulin was not discarded 28 days after opening and open vials of insulin and a vial of eye drops did not contain dates of when the medication was opened on the label was observed on one of the 3rd Floor medication cart. This was evident for the Medication Storage and Labeling task.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure menus were followed. This was evident for 4 residents (Resident # 70, Resident # 77, Resident #156, and Resident #201) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure that the Nurse Staffing Information was posted appropriately. Specifically, there has been no posting in the appropriate required form of the daily nurse staffing information and was not posted in a prominent area which was readily accessible to residents and visitors. The finding is: The facility policy and procedure titled Posted Nurse Staffing Information dated 10/10/2021 with a review date of 01/15/2024 documented that the facility will ensure that the Nursing Staffing Information is posted daily at the beginning of each shift in a prominent place where it is accessible to residents and visitors. [...]

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure that garbage or refuse was disposed of properly. Specifically, the recycling trash bin was observed open with recycling trash items in bags or unbagged above the recycling bin rim. This was observed during the Kitchen Observation task.

Inspectors wroteBased on record review and interviews conducted during a Recertification and Complaint survey (NY00347992) from 11/13/2024 to 11/20/2024 the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident for 1 (Resident #177) of 1 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, a Nurse's Progress Note dated 07/05/2024 documented that Resident #177 was noted with a bruise on their nose and the charge nurse and supervisor were informed, however family was not informed about the bruise until 3 days later on 07/08/2024.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey 11/7/22 to 11/15/22, the facility did not ensure that food was stored, prepared, distribute and served in accordance with professional standards for food service safety. Specifically, an unopened container of expired cottage cheese was noted in the refrigerator. This was evident during the initial tour and follow up tour conducted during the Kitchen facility task.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey from 11/7/22 to 11/15/22, the facility did not ensure residents' rooms were maintained in a clean, comfortable, and homelike environment. Specifically, two rooms on the second floor were noted with enteral feeding poles with dried cream brown colored stain and oxygen ventilator unit tank base stand and oxygen tank straps were noted to have gray colored dust buildup. This was evident for 1 out of 7 floors observed for the Environment.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 11/07/22 to 11/15/22, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 of 2 residents reviewed for Mobility out of 38 sampled residents. (Resident #151) Specifically, Resident #151 was observed on multiple occasions without a right handroll in accordance with a physician's order.

Inspectors wroteBased on observations, record review, and staff interviews during the re-certification survey, the facility did not store food properly to prevent foodborne illness. Specifically, (1) raw tilapia fish was observed stored above pre-cooked corned beef on a multi-tiered metal rack in the walk in refrigerator, (2) raw frozen tilapia fish was observed stored above pre-cooked frozen onion rings and potato pancakes, and frozen vegetables in the walk in freezer, and (3) raw sole fish rolled with scallops and crab meat was observed stored over pre-cooked frozen vegetable lasagna in the walk in freezer. This was evident for the Kitchen reviewed during the Kitchen facility task. The finding is: The Food Storage Policy and Procedure, revised on 4/10/19, documented the following: Procedure #13 Refrigerated Food Storage, line E. [...]