Throgs Neck Rehabilitation & Nursing Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents are free of any significant medication errors. This was evident in one (1) (Resident #193) of five (5) residents reviewed for medication administration out of 39 total sampled residents. Specifically, Resident #193 was not administered 26 doses of methocarbamol (a muscle relaxant) as ordered by a physician.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) (Resident #160) of three (3) residents reviewed for accidents out of 39 total sampled residents. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident receiving respiratory care received such care consistent with professional standards of practice. This was evident for one (1) (Residents #96) of one (1) resident reviewed for respiratory care out of 39 total sampled residents. Specifically, Resident #96 received oxygen continuously at a flow rate of two (2) liters per minute without a physician's order.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that clinical records were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for one (1) (Resident #201) of one (1) resident reviewed for death out of 39 total sampled residents. Specifically, Resident #201's medical record did not contain assessment of the resident's change in condition on 02/19/2026.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for two (2) (Residents #208 and #209) of three (3) residents reviewed for beneficiary notification. Specifically, the facility failed to ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made.

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey 1DED64-H1, the facility failed to submit the direct care staffing information on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for Quarter four (4), 07/01/2025 -09/30/2025 in a timely manner.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/1/2023, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Unit 6) of 5 resident units. Specifically, blood pressure (BP) cuffs were not disinfected between resident use.

Inspectors wroteBased on record review and staff interview conducted during the Recertification and Complaint Survey (NY00277748), the facility did not ensure that residents' representatives were immediately notified about residents' conditions. Specifically, (1) the facility did not notify the resident's representative prior scheduled and taken resident for consult surgical procedure, (Resident #172). This was evident for 1 of the 3-residents reviewed for Notification of Change (Resident #172).

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident's goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no CCP developed for resident's use of Oxygen therapy. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #167)

Inspectors wroteBased on observation , record review and staff interviews , the facility did not ensure that services provided or arranged by the facility as outlined by the Comprehensive Care Plan meet professional standards of quality including current evidence based practice. Specifically, Licensed Nurses did not inform the physician / Nurse practitioner when a resident with diagnosis of Diabetes Mellitus had elevated Blood glucose readings and refusing treatment as ordered by the Physician. This was evident for 1 of 38 residents reviewed for care. (Resident #9) The finding is: The Licensed Practical Nurse job description states on the purpose as The primary purpose of your position is to provide direct nursing care to the residents ,and to supervise the day to day nursing activities performed by CNAs and other nursing personnel. [...]

Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification survey, the facility did not ensure an ongoing activities program 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. Specifically, a resident with severe cognitive impairment was observed for extended periods of time without meaningful activities. This was evident for 1 of 2 residents reviewed for Activities out of 38 sampled residents (Resident # 61). The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan to address a resident's elevated glucose levels and non-compliance with diabetes management. Specifically, a resident's frequent refusals of medication, finger sticks, and elevated blood glucose levels were not addressed by the care team to prevent possible complications associated with Diabetes Mellitus. This was evident in 1 of 38 sampled residents. (Resident #9) The finding is: The facility Policy and Procedure titled Diabetic Management dated 06/2021 documented the attending Physician orders treatment modalities in conjunction with a resident's individual needs. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure that a resident received necessary services to prevent new ulcers from developing. Specifically, a resident was not turned and positioned as indicated on the care plan This was evident for 1 of 2 residents reviewed for Position, Mobility and 1 of 1 residents reviewed for Physical Restraints out of total sample of 38 residents. (Resident # 105 and Resident #61)

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that services and treatments were provided to prevent further decrease in range of motion (ROM) or mobility. Specifically, a hand roll and a hand splint were not provided to resident as per physician order. This was evident for 1 of 2 residents reviewed for Position, Mobility out of total sample of 38 residents. (Resident # 105)

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that the Physician reviewed the resident's total program of care at each visit. Specifically, there was no documented evidence the Physician addressed a resident's consistently high blood sugars and non-compliance with diabetic management. This was evident for 1 of 38 sampled residents. (Resident #9) The finding is: The facility Policy and Procedure titled Diabetic Management dated 06/2021 documented the attending Physician orders treatment modalities in conjunction with a resident's individual needs. Disease management may include insulin management, fingerstick checks for blood glucose monitoring, and labs as indicated. Resident # 9 was admitted to the facility with diagnoses of Diabetes Mellitus, Cerebrovascular Accident (CVA), and Atrial Fibrillation. [...]

Inspectors wroteBased on observations, record review and staff interview conducted during the Recertification/Complaint survey, the facility did not ensure that the medication error rate was not less than 5%. Specifically, a resident was not administered with six (6) of the prescribed medications due during the Medication Administration Observations. This was evident for 6 of 29 opportunities observed, resulting in a medication error rate of 20.69%. (Resident #86).

Inspectors wroteBased on observations, record reviews, and staff interviews conducted during the recertification survey, the facility did not ensure that proper infection control practices and procedures were maintained. Specifically, an oxygen tubing was observed with no label, and there was no documented evidence that the oxygen tubing was changed. This was evident for 1 of 3 residents reviewed for Respiratory Care out of a sample of 38 residents. (Resident #111) The finding is: The facility's policy and procedure titled Oxygen Therapy, last updated on 06/2021, documented that oxygen tubing should be dated and initialed when started each week. Resident #111 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease, Hypertension, and Heart Failure. The Minimum Data Set (MDS) dated [DATE] documented Resident # 111 with intact cognition. [...]