Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rockaway Care Center during CMS and state inspections, most recent first.
A resident with dementia and a known history of elopement risk was able to leave the facility unsupervised after a security guard failed to follow protocol and staff did not perform required 30-minute visual checks. The resident was not noticed missing for over an hour and was later found by emergency services with hypothermia and acute kidney injury.
A resident with severe cognitive impairment and ventilator dependence was found with both hands restrained inside pillowcases taped at the wrists, applied by a respiratory therapist after repeated self-decannulation attempts. The restraint was used without physician order, assessment, or documentation, and did not follow facility policy requiring the least restrictive intervention and proper protocol.
A resident with a tracheostomy and respiratory failure did not have a comprehensive care plan addressing tracheostomy care, despite physician orders for oxygen, suctioning, and tracheal care. Facility staff confirmed that such a care plan should have been created and updated, but it was missing from the medical record, resulting in a deficiency for not meeting care planning requirements.
A resident with complex medical needs was placed in bilateral hand mittens as a restraint to prevent trach removal, with physician orders requiring release every two hours for range of motion and skin checks. Facility staff failed to document or provide evidence that these mittens were released as ordered, and interviews revealed confusion among CNAs, LPNs, and the DON regarding responsibility for monitoring and documentation.
A resident with Huntington's Disease and a history of suicidal ideation repeatedly attempted to harm themselves by trying to open windows and verbalizing intent to jump. Despite multiple hospitalizations for behavioral evaluation, the facility did not update the care plan or implement effective interventions, and the resident was returned to the same room with only 30-minute checks. The resident ultimately removed a window panel and fell from the fourth floor, resulting in death. The deficiency was cited as immediate jeopardy due to failure to provide necessary behavioral health care and services.
A resident with a history of hypertension and bipolar disorder reported being hit and pushed by a CNA. Although the facility investigated and found the abuse allegation inconclusive, the care plan was not reviewed or updated by the interdisciplinary team to reflect the incident or its outcome, contrary to facility policy.
A resident with Huntington's Disease and behavioral disturbances was repeatedly transferred to the hospital for suicidal ideation and agitation. Hospital discharge summaries recommended reducing the resident's Abilify dosage, but facility physicians did not review or act on these recommendations, and the psychiatrist was not informed. The resident's medication was increased instead, and there was no documentation of physician evaluation or monitoring of medication effectiveness, leading to continued dangerous behaviors and a fatal incident.
Failure to Prevent Elopement Due to Inadequate Supervision and Security Protocols
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for elopement received adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including dementia, psychotic disorder with delusions, and anxiety, was known to be ambulatory and had a documented history of elopement risk, including a prior incident where the resident left the building and was returned by security and police. The care plan and physician's orders specified 30-minute visual checks for safety, and the resident had refused to wear a wander guard. Despite these measures, documentation showed that staff were monitoring the resident every two hours instead of every 30 minutes as ordered, and the last visual check was recorded at 4:00 PM, after which the resident was not accounted for until much later. On the day of the incident, the resident was last seen by staff at 4:00 PM talking with a family member. Security Guard #1, stationed at the front desk, opened the main entrance door for the resident, allowing them to exit the building unsupervised. The security guard did not follow facility protocol, which required screening every person prior to leaving the building to ensure residents do not leave without authorization. The security guard later admitted to this failure and was terminated. Staff did not become aware that the resident was missing until 5:35 PM, at which point a search was initiated, and law enforcement was contacted. The resident was later found by emergency services and admitted to the hospital with diagnoses of encephalopathy secondary to hypothermia and acute kidney injury. Interviews with staff revealed inconsistencies in monitoring practices and a lack of clarity regarding responsibility for the resident's supervision. Certified Nursing Assistants and nursing staff described being occupied with other duties and not performing the required 30-minute checks. The security guard failed to recognize the resident as someone at risk for elopement, despite the resident's picture being posted at the security desk. The facility's policies for elopement prevention and front desk security monitoring were not followed, resulting in the resident's unsupervised exit and subsequent harm.
Improper Use of Physical Restraint Without Physician Order or Assessment
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure, a history of cardiovascular accident, seizure disorder, anxiety disorder, and who was ventilator and gastrostomy tube dependent, was found with both hands inside pillowcases that were taped around their wrists. The resident was observed to be restless and agitated while on a mechanical ventilator. Facility policy requires that physical restraints only be used when medically necessary, with proper assessment, physician orders, and documentation, and that the least restrictive interventions be used. However, there was no evidence in the medical record of a physician's order or assessment for the use of limb restraints for this resident. The incident was discovered when an LPN entered the resident's room and observed the restraint. The LPN immediately notified the supervising RN, who removed the restraints. Interviews with staff revealed that the resident had previously exhibited agitated behavior and had attempted to remove their tracheostomy, but there was no documentation or order for the use of hand mittens or other restraints. The respiratory therapist responsible for applying the restraints reported that the resident had decannulated themselves multiple times during the night and, unable to obtain hand mittens, used pillowcases and tape as a restraint. The facility's investigative summary confirmed that the respiratory therapist applied the restraints without following protocol, and there was no prior use or order for hand mittens or limb restraints for this resident. The facility's restraint policy was not followed, as there was no assessment, physician order, or documentation supporting the use of restraints, and the intervention used was not the least restrictive option as required by policy.
Failure to Develop Comprehensive Tracheostomy Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a tracheostomy. The facility's policy requires that each resident have a care plan addressing their individualized needs, including medical, nursing, mental, and psychosocial aspects, with measurable objectives and timeframes. Despite this, there was no documented evidence of a care plan specifically addressing tracheostomy care, treatments, or goals for the resident who had a non-traumatic brain injury and respiratory failure requiring a tracheostomy tube. The resident's medical record included physician orders for continuous oxygen via tracheal collar, tracheal suctioning, and tracheal care every shift and as needed, but these interventions were not reflected in a comprehensive care plan. Interviews with facility staff, including a nursing supervisor and the Director of Nursing, confirmed that a tracheostomy care plan should have been created at admission and updated as needed. The staff acknowledged that the absence of such a care plan meant there was no formal guidance for the care and treatments associated with the resident's tracheostomy. The deficiency was cited under 10 NYCRR 415.11(c)(1) for failing to ensure a comprehensive care plan was developed and implemented to meet the resident's needs.
Failure to Document and Monitor Physical Restraint Use as Ordered
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding the use and monitoring of physical restraints. For one resident with multiple complex medical diagnoses, including acute respiratory failure, seizure disorder, and ventilator dependence, bilateral hand mittens were ordered by a physician to prevent the resident from pulling out their tracheostomy tube. The physician's order required that the mittens be released every two hours for range of motion and skin checks. However, there was no documented evidence in the medical record that this was done as ordered. The facility's own policy required monitoring and documentation of restraint use, but this was not reflected in the resident's records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for monitoring and documenting the use of hand mittens. Certified Nursing Assistants believed nurses were responsible for applying and monitoring the mittens, while nurses indicated that documentation should occur on the Treatment Administration Record. Multiple staff members, including a Registered Nurse and the Director of Nursing, confirmed that there was no documentation of the required monitoring and release of the mittens for the resident. The deficiency was identified through observations, record reviews, and staff interviews.
Failure to Provide Appropriate Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with Huntington's Disease and exhibiting significant mental and psychosocial adjustment difficulties, including repeated suicidal ideation and attempts. Over a period of time, the resident was observed by staff attempting to open windows in their own and other residents' rooms, verbalizing intentions to jump out, and displaying increased agitation and behavioral disturbances. Despite multiple incidents where the resident was transferred to the hospital for behavioral evaluation after expressing or acting on suicidal ideation, upon return to the facility, the resident was placed back in the same room without updates to their care plan or implementation of new interventions to address the ongoing risk behaviors. Documentation revealed that the resident's care plan was not revised to reflect the repeated suicidal ideations and behaviors, nor were consistent or effective monitoring interventions implemented. The resident was at times placed on 1:1 monitoring, but after returning from the hospital following a suicide attempt, was only placed on 30-minute visual checks. Staff interviews indicated a lack of communication and awareness among facility leadership and clinical staff regarding the resident's repeated hospitalizations and behavioral health needs. Additionally, recommendations from hospital providers, such as medication adjustments, were not consistently reviewed or acted upon by the facility's medical staff. On the night of the fatal incident, the resident returned from the hospital and was placed on 30-minute checks. Within hours, the resident was found outside the window, having removed the window panel, and subsequently fell from the fourth floor, resulting in death. The facility's investigation concluded the event was unforeseeable and attributed it to the resident's neuropsychiatric condition, but there was no evidence that the care plan had been updated or that effective interventions were implemented following prior incidents. The deficiency was cited as immediate jeopardy due to the facility's failure to ensure the resident received necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being.
Failure to Update Care Plan After Abuse Allegation
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an allegation of abuse. Specifically, a resident with diagnoses including hypertension and bipolar disorder, and with intact cognition, reported to the Social Worker that they were hit on the head and pushed to the ground by a Certified Nursing Assistant. The incident was documented in the facility's Accident/Incident Report, and an investigation was conducted, concluding that the abuse allegation was inconclusive. Despite this significant event, the resident's care plan, which previously included interventions for risk of abuse, was not updated to reflect the new allegation or its outcome. Record review showed that no new interventions had been implemented since before the incident, and the care plan had not been revised since the previous update. Interviews with facility staff, including the DON and a Registered Nurse Supervisor, confirmed that the care plan was not updated due to oversight. The facility's own policy requires care plans to be revised to reflect current needs based on incidents such as accidents or behavioral changes, but this was not followed in this case.
Failure to Review and Act on Hospital Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including medications, at each required visit. A resident with Huntington's Disease and a history of behavioral disturbances, including suicidal ideation, was transferred multiple times to the hospital emergency department following episodes of agitation and self-injurious behavior. Hospital discharge summaries included recommendations to decrease the resident's Abilify dosage due to risks of akathisia, restlessness, and agitation. However, there was no documented evidence that these recommendations were reviewed or acted upon by the facility's physicians. Medical records showed that after each hospital transfer and return, the resident continued to receive the same medication regimen, and there was no documentation of physician evaluation or intervention regarding the hospital's recommendations. The psychiatrist was not notified of the hospital's recommendation to decrease Abilify, and the resident's medication was instead increased by the psychiatrist without knowledge of the hospital's advice. Nursing notes and interviews confirmed that staff did not consistently communicate or document the hospital's recommendations, and physicians could not recall being informed or reviewing the relevant discharge summaries. The lack of physician oversight and failure to review and incorporate hospital recommendations into the resident's care plan resulted in missed opportunities to adjust treatment and monitor the effectiveness of psychoactive medications. The resident continued to exhibit dangerous behaviors, including a fatal incident where the resident jumped from a window. Interviews with facility staff and physicians revealed gaps in communication, documentation, and follow-up regarding the resident's care after hospitalizations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Far Rockaway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lawrence Nursing Care Center, Inc | 0.3 mi | — | 0 | 0 |
| Ocean Gardens Care Center | 1 mi | — | 5 | 0 |
| Resort Nursing Home | 1 mi | — | 0 | 0 |
| Far Rockaway Center For Rehabilitation And Nursing | 1.1 mi | — | 0 | 0 |
| Peninsula Nursing And Rehabilitation Center | 1.1 mi | — | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.