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

Staffing

Hours and turnover

RN hours / resident day

1.00

Registered nurse staffing

LPN hours / resident day

0.51

Licensed practical nurse staffing

Aide hours / resident day

2.35

Nurse aide staffing

Weekend hours

3.35

Weekend nurse staffing

RN turnover

14%

Annual RN turnover

Total nurse turnover

22%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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