Rego Park Nursing Home

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 10, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on December 12, 2024.

• Citation F0582. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on December 12, 2024.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on December 12, 2024.

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CMS lists this as a standard inspection.

• Citation K0347. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly provide smoke detection systems in areas open to corridors.

  CMS lists it as corrected on November 28, 2024.

• Citation K0311. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on December 3, 2024.

  CMS has cited this home for K0311 2 times since 2023.

• Citation K0911. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on December 3, 2024.

• Citation K0161. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on October 17, 2024.

  CMS has cited this home for K0161 2 times since 2023.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Staffing

  Total nurse staffing reported to CMS went from 3.8 to 3.3 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on May 16, 2023.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on May 16, 2023.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on May 16, 2023.

  CMS has cited this home for F0657 2 times since 2021.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on May 16, 2023.

• Citation F0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

  CMS lists it as corrected on May 16, 2023.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on May 16, 2023.

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CMS lists this as a standard inspection.

• Citation K0161. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on July 3, 2023.

• Citation K0311. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have an enclosure around a vertical opening shaft.

  CMS lists it as corrected on June 16, 2023.

• Citation E0015. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on June 16, 2023.

• Citation E0023. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on June 16, 2023.

• Citation E0024. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on June 16, 2023.

• Citation E0026. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on June 16, 2023.

• Citation E0036. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on June 16, 2023.

• Citation K0901. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

  CMS lists it as corrected on June 16, 2023.

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CMS lists this as a standard inspection.

• Citation F0657. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on June 8, 2021.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 6, 2021.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on June 8, 2021.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on June 8, 2021.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on April 12, 2021.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 8, 2021.

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CMS lists this as a standard inspection.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on April 22, 2021.

• Citation K0922. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use and maintenance of medical gas equipment.

  CMS lists it as corrected on April 22, 2021.

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