Queens Village, NY

Windsor Park Rehab & Nursing Center

2-star overall rating with 1-star inspections with $306,240 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

212 40 Hillside Avenue, Queens Village, NY

(718) 468-0800

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

70

Certified beds

Average residents

63

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-07-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.00

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.51

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.86

All reported nurse hours · state 3.65 · national 3.89

Licensed hours

1.51

RN + LPN hours · state 1.47 · national 1.54

Weekend hours

3.35

Weekend nurse staffing · state 3.16 · national 3.43

Weekend RN hours

0.66

Weekend registered nurse coverage · state 0.47 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

1.07

CMS adjusted RN staffing hours

Adjusted total hours

4.13

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

22%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,717

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.46% · Performance 24.21% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 11.49% · Performance 11.62% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

3.27

Baseline 3.38 hours · Performance 4.01 hours · Measure score 3.27 · Achievement 3.27 · Improvement 2.11

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.1%	10.72% 2.4 pts worse	No Different than the National Rate · Eligible stays 48 · Observed rate 22.92% · Lower 95% interval 8.91%
Discharge to community	38.3%	50.57% 12.3 pts worse	No Different than the National Rate · Eligible stays 37 · Observed rate 24.32% · Lower 95% interval 24.87%
Medicare spending per beneficiary	1.41	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 42 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	23.81%	53.69% 29.9 pts worse	Numerator 5 · Denominator 21
Discharge mobility score	14.29%	50.94% 36.6 pts worse	Numerator 3 · Denominator 21
Pressure ulcers or injuries, new or worsened	2.38%	2.29% 0.1 pts worse	Numerator 1 · Denominator 42 · Adjusted rate 1.56%
Healthcare-associated infections requiring hospitalization	11.62%	7.12% 4.5 pts worse	No Different than the National Rate · Eligible stays 43 · Observed rate 25.58% · Lower 95% interval 6.97%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 93
Staff flu vaccination coverage	45.16%	42% 3.2 pts better	Numerator 42 · Denominator 93
Discharge function score	23.81%	56.45% 32.6 pts worse	Numerator 5 · Denominator 21
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	7.69%	25.2% 17.5 pts worse	Numerator 2 · Denominator 26

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.3 0.2 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	91.2% 8.8 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.3% 4.7 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.0% 3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.0%	18.5% 11.5 pts better	11.4% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 1.8% · Q3 7.5% · Q4 5.5% · 4Q avg 7.0%
Percentage of long-stay residents who lose too much weight	3.2%	6.1% 2.9 pts better	5.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 1.9% · Q4 5.1% · 4Q avg 3.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	3.9%	13.5% 9.6 pts better	19.6% 15.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.3% · Q3 3.6% · Q4 3.3% · 4Q avg 3.9%
Percentage of long-stay residents who received an antipsychotic medication	11.5%	14.8% 3.3 pts better	16.7% 5.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 11.6% · Q3 10.3% · Q4 11.4% · 4Q avg 11.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	13.9%	15.1% 1.2 pts better	16.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 10.3% · Q3 14.0% · Q4 13.6% · 4Q avg 13.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.6%	15.5% 0.1 pts worse	14.9% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 13.0% · Q3 12.8% · Q4 11.1% · 4Q avg 15.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.6% 0.3 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	1.4% 0.5 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.7%	20.8% 10.1 pts better	19.8% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 13.5% · Q3 9.6% · Q4 6.5% · 4Q avg 10.7%
Percentage of long-stay residents with pressure ulcers	5.9%	6.9% 1 pts better	5.1% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.0% · Q3 4.6% · Q4 7.1% · 4Q avg 5.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	76.7% 23.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	8.1%	9.7% 1.6 pts better	12.0% 3.9 pts better	Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.1% · Expected 9.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.6%	1.2% 1.4 pts worse	1.6% 1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 8.7% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	78.8% 21.2 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.1%	20.6% 13.5 pts worse	23.9% 10.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 33.3% · Expected 23.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-03 · Fire 2024-10-03

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2022-09-01 · Fire 2022-09-01

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-10-29 · Fire 2019-10-29

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-10-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-25

F · Potential for more than minimal harm 2022-09-01

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-01

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-10-07

D · Potential for more than minimal harm 2022-09-01

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2022-10-07

D · Potential for more than minimal harm 2019-10-29

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2019-11-11

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-10-03

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-11-27

D · Potential for more than minimal harm 2024-10-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-27

C · Minimal harm 2024-10-03

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-11-27

K · Immediate jeopardy 2024-06-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-05

K · Immediate jeopardy 2024-06-30

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-07-05

K · Immediate jeopardy 2024-06-30

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-07-05

K · Immediate jeopardy 2024-06-30

F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected 2024-07-05

K · Immediate jeopardy 2024-06-30

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-07-05

F · Potential for more than minimal harm 2024-06-30

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-07-05

E · Potential for more than minimal harm 2024-06-30

F841 · Nursing and Physician Services Deficiencies

Health

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected 2024-07-05

D · Potential for more than minimal harm 2023-10-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-12-11

D · Potential for more than minimal harm 2023-10-24

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-12-11

D · Potential for more than minimal harm 2023-10-24

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-12-11

Penalties and ownership

What sits behind the stars

$306,240 2024-06-30

Fine

Fine · fine $306,240

Fine