Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carmel Richmond Healthcare And Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, diabetes, and protein-calorie malnutrition was admitted with intact skin and later developed moisture-associated skin damage (MASD) to the sacrum and buttocks. Nursing staff requested a wound consult but did not document a wound assessment or physician notification, and treatment for MASD was delayed and inconsistently documented, with no clear evaluation of effectiveness. After transfer to the hospital, the resident was found to have multiple wounds, including a stage III sacral ulcer, hip pressure injuries, heel deep tissue injuries, gangrenous toes, and left bunion skin loss. On readmission, an RN documented sacral, hip, heel, and toe wounds but did not notify the MD or initiate care plans, and a subsequent MD order for collagenase did not specify the body site. The care plan and wound care RN’s assessment failed to reflect all hospital-documented wounds, and there was no documented treatment for several wounds, while interviews showed that staff deferred to the wound care RN, did not fully review hospital records, and did not consistently assess, report, or document wound progression.
A resident with ESRD on hemodialysis, diabetes, and severe malnutrition developed moisture-associated skin damage to the sacrum and buttocks, for which topical treatment was ordered but not clinically reassessed or documented for effectiveness over an extended period, despite later evidence of wound deterioration. After a hospital stay, the resident was readmitted with eight documented wounds, including a Stage III sacral ulcer, bilateral hip wounds, heel injuries, gangrenous toes, and a left bunion wound. On readmission, nursing documented multiple wounds, but the physician history and physical noted only sacral moisture-associated skin damage, and a debriding agent was ordered without specifying the body site. A wound nurse assessment documented findings that did not match the hospital discharge summary or nursing admission note, and subsequent orders addressed only sacral dermatitis and a left hip abrasion, with no documented physician orders, assessments, or treatments for the right hip wound, left bunion wound, or gangrenous toes, and no podiatry consult. The wound PA later assessed only selected areas directed by the wound nurse, while the readmitting MD, attending MD, and medical director each acknowledged limited or no direct examination of the resident and incomplete follow-through on the documented wounds, resulting in a failure of effective physician supervision of medical care.
A resident with multiple chronic conditions and moderately impaired cognition developed moisture associated dermatitis to the sacrum and bilateral buttocks, for which topical treatment was ordered and administered. A wound consult was requested by an RN, but there was no timely wound assessment or documentation of physician notification at that time, and later documentation by the wound care RN showed the skin condition and treatment orders. Despite facility policy requiring notification and documentation of contact with the responsible party when a change in condition occurs, there was no evidence in the EMR that the resident’s designated representative was informed of the new skin condition. The resident’s representative confirmed they were unaware of the issue, while the unit manager RN, wound care RN, and DON each described differing understandings of who was responsible for notifying families about skin changes.
A resident with multiple complex medical conditions, including cellulitis, bacteremia, and numerous documented wounds (e.g., Stage III sacral ulcer, deep tissue injuries to hips and heels, unstageable hip wound, gangrenous toes, and a left bunion wound), was admitted and readmitted with detailed hospital records and facility admission notes describing these skin issues. Despite this, MDS assessments in two separate assessment periods documented no skin problems or only moisture-associated skin damage, omitting the full-thickness wounds, pressure injuries, and gangrene. The MDS coordinator and MDS director reported relying on the wound nurse’s documentation and the medical record without physically assessing the resident or reconciling discrepancies between hospital discharge information and internal wound assessments, resulting in inaccurate MDS coding of the resident’s skin condition.
A resident with severe cognitive impairment and a care plan requiring two-person assistance for transfers was repeatedly moved by single CNAs, contrary to documented instructions. The resident was later found with a left hip fracture, with no reported fall or trauma, indicating that staff did not follow established transfer protocols.
A resident with cognitive impairment was involved in an incident where a CNA threw melted ice cream at them after the resident initially threw it at the CNA. The facility's investigation confirmed abuse, leading to the CNA's suspension and termination.
A resident with a history of stroke, hypertension, and diabetes mellitus was identified with an unstageable pressure injury and a deep tissue pressure injury. The facility failed to complete a Significant Change in Status Assessment within the required 14 days after this change in condition. The Minimum Data Set Coordinator did not complete the assessment due to not receiving the wound tracker report from the Wound Care Nurse.
A resident with cognitive impairment was found on the floor with head injuries, including a nasal bone fracture, after an unwitnessed fall. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the New York State Department of Health. The facility's investigation concluded no abuse or neglect occurred, but the Director of Nursing acknowledged the reporting failure.
The facility failed to store and prepare food according to safety standards, with expired bratwurst found in storage and sandwiches not maintained at safe temperatures. Staff interviews revealed a lack of awareness and monitoring of food expiration and temperature compliance.
A resident with cognitive impairment was found on the floor with head injuries, including a nasal bone fracture, after an unwitnessed fall. The facility did not report the incident to the New York State Department of Health as required, despite the policy stating that such incidents must be reported within 2 hours if they involve serious bodily injury.
A resident with a history of stroke, hypertension, and diabetes mellitus was identified with new pressure injuries, but the facility failed to complete a Significant Change in Status Assessment within the required 14 days. The Minimum Data Set Coordinator did not receive the necessary wound tracker report, leading to the oversight.
The facility failed to store and prepare food according to safety standards, with expired bratwurst found in storage and sandwiches not maintained at safe temperatures. Staff interviews revealed a lack of awareness and monitoring of food expiration and temperature compliance.
Failure to Assess, Treat, and Document Multiple Wounds and MASD
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders to maintain a resident’s highest practicable physical well-being. The resident was admitted with diagnoses including end-stage renal disease on hemodialysis, diabetes mellitus, and protein-calorie malnutrition, and was assessed on admission with intact skin and no pressure ulcers. A Braden Scale assessment identified the resident as at moderate risk for pressure injury. Despite a wound care consultation request being entered by a nurse, there was no documented wound assessment, no description of the wound, and no evidence that the attending physician was notified at that time. Moisture-associated dermatitis of the sacrum and bilateral buttocks was not formally assessed until days later by the wound care RN, who documented moisture-associated dermatitis and obtained a physician order for topical treatment. Between the initiation of treatment and the resident’s subsequent transfer to the hospital, there was a lack of consistent documentation of treatment application and wound progression. The treatment record showed the last documented treatment on one date with no further documentation of treatment or evaluation of effectiveness for several days. A nurse practitioner later documented moisture-associated skin damage to the sacrum and issued a new order for hydrophilic cream, followed by another change in treatment to Medi-honey and calcium alginate, but there was no documented evidence that the effectiveness of these treatments was evaluated. The resident was then transferred from dialysis to the emergency room with increased leukocytosis. Hospital records documented multiple wounds, including moisture-associated skin damage to the sacrum/coccyx, stage I and II pressure injuries to the trochanters, deep tissue injuries to both heels, and other wounds to the left bunion and toes. On hospital discharge back to the facility, the resident was documented with a stage III sacral ulcer, unstageable and deep tissue injuries to the hips, deep tissue injuries to both heels, dry gangrene of toes, and partial thickness skin loss at the left bunion. Upon readmission to the facility, the admitting nurse documented a pressure wound to the sacrum, wounds to bilateral hips, gangrene to all toes, and bilateral heel wounds, but did not notify the physician or nursing supervisor and did not initiate care plans, instead expecting the wound care nurse to reassess. The physician’s readmission note mentioned only moisture-associated skin damage to the sacrum and did not identify the stage III sacral ulcer or other wounds listed in the hospital discharge summary. A subsequent physician order for collagenase ointment did not specify the body site, and the treatment administration record showed it was given on only two days before being discontinued. The impaired skin integrity care plan addressed only moisture-associated skin damage to the sacrum and did not include the multiple additional wounds documented by the hospital. The wound care RN’s post-readmission assessment documented only a right hip superficial abrasion and sacral moisture-associated dermatitis, with bilateral lower extremities and feet described as unremarkable, which did not correlate with the hospital’s documentation of bilateral heel deep tissue injuries, gangrenous toes, and left bunion skin loss. There was no documented evidence of treatment for four wounds: the right hip, left bunion full thickness skin loss, and bilateral gangrenous toes. Interviews with facility staff and the wound care consultant confirmed that hospital skin assessments were not fully reviewed, that unit nurses deferred to the wound care nurse for skin issues, that some wounds were not assessed or reported, and that treatment effectiveness and wound progression were not consistently documented. This deficient practice resulted in actual harm to the resident, though it was not cited as Immediate Jeopardy. Additional interviews further detailed the actions and inactions contributing to the deficiency. The nurse practitioner acknowledged not following up on the sacral moisture-associated skin damage, relying on unit nurses to notify them if the wound healed or required additional treatment, and did not recall gangrenous feet and toes. The RN who first requested the wound consult admitted there was no documentation of their assessment or physician notification and stated that unit nurses were responsible for providing treatment and notifying the wound care RN of deterioration, while the wound care RN was responsible for monitoring and documenting effectiveness. The readmitting RN acknowledged unwrapping the resident’s leg dressings, observing necrotic heels and toes, but failing to notify the physician or supervisor or initiate care plans. The wound care RN stated they did not review the hospital skin assessment because they preferred to assess with their own eyes, and asserted that the resident did not develop pressure ulcers in the facility. The unit manager stated they saw documentation of wounds in the hospital record but did not notify the wound care nurse and did not get involved with skin assessments. The wound care specialist PA reported assessing only the areas directed by the wound care RN and was unaware of some documented wounds. The DON and Administrator acknowledged that the nurse who first noted skin changes should have notified the physician and that the wound care nurse should have reviewed hospital discharge documentation and compared it to the resident’s condition on readmission.
Failure of Physician Supervision and Wound Management for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical care was effectively supervised by a physician, in accordance with facility policy and regulatory requirements. The resident had multiple serious comorbidities, including end stage renal disease on hemodialysis, diabetes mellitus, and protein calorie malnutrition, and was assessed as having moderately impaired cognition and a moderate risk for pressure injury. Initially, the resident had no documented skin problems, but on 08/12/2025 an RN requested a wound care consultation without documenting an identified wound or notifying the attending physician. No wound assessment was documented until 08/14/2025, when the wound care nurse identified moisture associated dermatitis to the sacrum and bilateral buttocks and a physician ordered topical treatments for 30 days. Although a subsequent nursing note on 08/15/2025 documented skin openings to the bilateral buttocks and indicated that the wound nurse and physician were to evaluate, there was no documented evidence of wound progression, effectiveness of treatment, or clinical reassessment between 08/14/2025 and 11/29/2025, despite a later surgical note on 12/17/2025 describing a sacral wound with serosanguinous exudate and specific measurements. After the resident was transferred to the hospital and later discharged back to the facility, the hospital discharge record documented eight wounds, including a Stage III sacral ulcer, unstageable and deep tissue injuries to both hips, deep tissue injuries to both heels, dry gangrene of the left toe, a necrotic right great toe, gangrene of all toes, and a left bunion with partial thickness skin loss. On readmission, the facility nurse documented pressure wounds to the sacrum, bilateral hips, gangrene to all toes, and bilateral heels, but the physician’s history and physical documented only moisture associated skin damage to the sacrum and did not identify the Stage III sacral ulcer or the other seven wounds listed in the hospital discharge summary. A physician order for collagenase was written without specifying the body site, and the treatment administration record showed the treatment as given on two days without identifying where it was applied. The wound care nurse’s assessment on 01/05/2026 documented only a right hip superficial abrasion, moisture associated dermatitis to the sacrum, and unremarkable lower extremities and heels, which did not correlate with the hospital discharge assessment or the nurse’s admission/readmission note. Subsequent physician orders on 01/05/2026 addressed Medi-honey treatment for irritant contact dermatitis and Triad cream for a left hip abrasion, but there was no documented evidence of physician orders or treatment for four of the wounds: the right hip wound, left bunion partial thickness skin loss, and bilateral gangrenous toes. There was also no documented evidence of a podiatry consultation. The wound care physician assistant later documented assessments of the sacrum and left hip (identified as a Kennedy terminal ulcer) but did not assess the gangrenous toes or left bunion wound, stating they only examined areas directed by the wound care nurse. The readmitting physician stated they reviewed the hospital discharge record and saw moisture associated skin dermatitis but did not observe the hip wounds, attempted but did not document a refused lower extremity exam, and did not order podiatry because they did not assess the bandaged extremities. The attending physician for the unit reported never seeing the resident after readmission and was unaware of the multiple wounds and gangrenous toes, relying on the wound care team and unit nurses for communication. The medical director acknowledged reviewing the hospital discharge notes and seeing the list of wounds, stated that the readmitting physician should have ordered treatments for all wounds, and confirmed they did not physically examine the resident. Collectively, these documented omissions and incomplete assessments demonstrate that the resident’s medical care, particularly wound management, was not effectively supervised by a physician as required by facility policy and regulation.
Failure to Notify Resident Representative of New Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a designated resident representative of a change in a resident’s condition, as required by facility policy and state regulation. The facility’s policy on Notification of Resident’s Change in Condition (dated 04/2020) states that when a change in condition is detected, the nurse must notify the physician, resident, or responsible party and document the date, time, name, method of notification, actions taken, and resident’s response in the medical record. Resident #1, admitted with multiple diagnoses including dementia with moderately impaired cognition, anemia, end stage renal disease on hemodialysis, diabetes mellitus, atrial fibrillation, coronary artery disease, heart failure, COPD, malnutrition, and respiratory failure, experienced a change in skin condition. On 08/12/2025, RN #3 requested a wound care consultation, but there was no documentation of an identified wound, no documentation that the attending physician was notified, and no wound assessment documented at that time. On 08/14/2025, RN #2 (wound care nurse) completed a wound assessment and documented moisture associated dermatitis to the sacrum and bilateral buttocks, described as moist, pink/red, with no odor, no drainage, and no pain, and treatment with Triad cream mixed with A&D ointment was ordered and administered every shift through the end of the month. The electronic medical record and treatment administration record contained no documentation that Resident #1’s designated representative was notified of this new moisture associated skin damage. In an interview, the resident’s representative stated they were not aware of the skin condition. RN #3 stated they did not notify the representative because they believed the wound care nurse was responsible for notifying families of skin problems and reported being not very involved with wounds due to the presence of a full-time wound nurse. RN #2 acknowledged usually notifying families of skin issues but stated they missed notifying this resident’s representative, and also stated that unit nurses could have notified the family. The DON stated the full-time wound nurse is responsible for notifying families of skin changes and that on weekends or holidays the unit nurse is responsible for such notifications.
Inaccurate MDS Coding of Resident Skin Conditions and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident’s skin condition and wounds. During an abbreviated survey, it was identified that one sampled resident had cellulitis and multiple wounds documented in hospital discharge records and facility admission notes, but these conditions were not captured on the resident’s MDS assessments. An MDS dated in July 2025 documented no skin problems or pressure ulcers, despite hospital records and a Patient Review Instrument from mid-July 2025 indicating bacteremia with cellulitis, a full-thickness wound on the lower right extremity, and the need for wound care for stasis ulcers. Further record review showed that when the resident was discharged again from the hospital in late December 2025, the hospital discharge summary listed multiple significant wounds, including a Stage III sacral ulcer, deep tissue injuries to the left hip and both heels, an unstageable right hip wound, dry gangrene of toes, black necrosis of the right great toe, and a partial-thickness wound at the left bunion. A nursing admission/readmission note from early January 2026 documented pressure wounds to the sacrum, wounds to both hips, and gangrene to all toes and both heels. However, a wound/skin assessment by the facility’s wound care nurse on January 5, 2026, described only a right hip superficial abrasion, moisture-associated dermatitis to the sacrum, and unremarkable bilateral lower extremities, heels, and feet, which did not correlate with the hospital discharge assessment. An MDS dated January 9, 2025, recorded the resident as having moderately impaired cognition and documented only moisture-associated skin damage in the skin condition section, with no evidence that the unstageable right hip ulcer, gangrenous toes, or left bunion wound were assessed or coded. Interviews with the MDS coordinator revealed that they reviewed the hospital discharge records and were aware of multiple wounds but relied on the wound nurse’s assessment without physically assessing the resident’s skin or reconciling discrepancies between hospital and facility documentation. The MDS director stated that MDS completion is based on assessments documented in the medical record and acknowledged that ulcers in the hospital records may have been overlooked. These actions and inactions resulted in MDS assessments that did not accurately reflect the resident’s actual skin status, contrary to the facility’s MDS Completion Policy and regulatory requirements.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment for a resident, resulting in an accident. A resident with severe cognitive impairment, dementia, and anxiety disorder, who was assessed as requiring total dependence on two-person assistance for transfers using a stand pivot technique, was repeatedly transferred by a single Certified Nursing Assistant (CNA) on multiple occasions. The resident's care plan and CNA instructions clearly documented the need for two-person assistance for all transfers between bed and chair. Despite these documented requirements, three different CNAs transferred the resident by themselves over several days, without the required assistance. One CNA admitted to transferring the resident alone both before and after breakfast, and only noticed a discoloration on the resident’s left inner thigh after returning the resident to bed. Another CNA, who was not regularly assigned to the resident, also transferred the resident alone, stating they believed the care plan required only one-person assistance. A third CNA, new to the job, was unaware of how to access the resident’s care instructions and also transferred the resident alone. None of the CNAs reported any immediate difficulty during the transfers, and none observed any falls or trauma at the time. The resident was later observed to have a purplish discoloration on the left inner thigh, and an x-ray revealed an acute intertrochanteric fracture of the left hip. The incident was classified as an injury of unknown origin, as there was no observed fall or trauma. The facility’s policies required staff to review and follow the resident’s plan of care and to provide care in a safe manner, but these were not followed by the involved CNAs, leading to the resident sustaining a significant injury.
Resident Abuse Incident Involving CNA and Ice Cream
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. On the specified date, a Licensed Practical Nurse (LPN) reported to a Registered Nurse Supervisor that a CNA threw a cup of melted ice cream at a resident. The incident was captured on surveillance video, which showed the resident taking a cup of melted ice cream from a medication cart and subsequently throwing it at the CNA. In response, the CNA threw the ice cream back at the resident, resulting in a wet stain on the resident's clothing. The resident involved in the incident was admitted to the facility with diagnoses including Dementia with behavior, Anxiety, and Major Depression. The resident's cognitive impairment was documented, with a score indicating moderate cognitive impairment. A care plan for victimization was in place, which included interventions such as involving the resident in social activities and using a calm approach. Despite these measures, the incident occurred, highlighting a failure in the facility's abuse prevention policy. Interviews with staff members, including the CNA involved, revealed that the CNA admitted to throwing the ice cream back at the resident as a reflex reaction. The facility's investigation confirmed the occurrence of abuse, as the CNA's actions were contrary to the facility's policy prohibiting abuse. The incident was reported to the police, and the facility concluded that abuse had occurred, leading to the suspension and termination of the CNA involved.
Failure to Complete Significant Change Assessment for Resident with Pressure Injuries
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment within 14 days after a significant change in condition was identified for a resident. Specifically, on June 30, 2024, a resident was found to have an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the left heel. Despite this significant change in the resident's condition, the facility did not complete the required assessment within the mandated timeframe. The facility's policy requires that the Minimum Data Set Coordinator determine if a resident has experienced a significant change in condition and, if so, notify the team and proceed with a Significant Change assessment. However, in this case, the Minimum Data Set Coordinator did not complete the assessment, citing a lack of receipt of the wound tracker report from the Wound Care Nurse as a reason for the oversight. The resident, who had diagnoses including stroke, hypertension, and diabetes mellitus, was noted to have severely impaired cognition and no pressure ulcers in a previous assessment, highlighting the significance of the change in condition.
Failure to Report Unwitnessed Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed incident involving a resident who was found on the floor with lacerations to the forehead and nose bridge, which later resulted in a nasal bone fracture. The incident occurred on 07/21/2024, and the resident was sent to the emergency department for evaluation. Despite the injuries sustained, the facility did not report the incident to the New York State Department of Health as required by their policy and state regulations. The policy mandates that all alleged violations involving abuse, neglect, or injuries of unknown source be reported immediately, but not later than 2 hours after the allegation is made. The resident involved had diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia, and was assessed to have moderately cognitive impairment. The facility's investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred, which led to the decision not to report the incident. However, the Director of Nursing acknowledged that any injury of unknown origin should have been reported within the required timeframe, highlighting a failure to adhere to reporting protocols.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen task observation, it was found that two boxes containing 20 packages of bratwurst were stored beyond their best by date in both the kitchen refrigerator and the freezer in the emergency food area. Interviews with the Patient Food Services Utility Worker and the Chef Manager revealed a lack of awareness regarding expired food items, despite daily rounds being conducted to check for such items. Additionally, potentially hazardous foods were not maintained at an acceptable temperature to limit the growth of pathogens. Observations on the 2nd and 6th floors showed that egg salad and tuna sandwiches were stored at temperatures significantly above the required 41 degrees Fahrenheit. The sandwiches were prepared earlier in the day and were not adequately chilled before being served. Interviews with the Chef Manager and Food Service Director indicated that sandwiches are made daily and placed in the freezer to lower their temperature, but there was no evidence of temperature checks being conducted to ensure compliance with food safety standards.
Failure to Report Unwitnessed Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed incident involving a resident who was found on the floor with lacerations to the forehead and nose bridge, which later resulted in a nasal bone fracture. The incident occurred on 07/21/2024, and the facility did not report it to the New York State Department of Health as required by their policy and state regulations. The policy mandates that all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. Resident #132, who has diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia, was found on the floor beside their bed with injuries. The resident, who has moderately cognitive impairment, could not recall how they ended up on the floor. Despite the injuries and the unwitnessed nature of the fall, the facility concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred and did not report the incident. The Director of Nursing acknowledged that the incident was not reported because it was determined to be a fall, even though it was unwitnessed.
Failure to Complete Significant Change Assessment for Resident with Pressure Injuries
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment within 14 days after a significant change in condition was identified for a resident. Specifically, on June 30, 2024, a resident was found to have an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the left heel. Despite this significant change in the resident's condition, the facility did not complete the required assessment within the mandated timeframe. The facility's policy requires that the Minimum Data Set Coordinator determine if a resident has experienced a significant change in condition and, if so, notify the team and proceed with a Significant Change assessment. However, in this case, the Minimum Data Set Coordinator did not complete the assessment, citing a lack of receipt of the wound tracker report from the Wound Care Nurse as a reason for the oversight. The resident, who had diagnoses including stroke, hypertension, and diabetes mellitus, was noted to have severely impaired cognition and no pressure ulcers in a previous assessment, highlighting the significance of the change in condition.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen task observation, it was found that two boxes containing 20 packages of bratwurst were stored beyond their best by date in both the kitchen refrigerator and the freezer in the emergency food area. Interviews with the Patient Food Services Utility Worker and the Chef Manager revealed a lack of awareness regarding expired food items, despite daily rounds being conducted to check for such items. Additionally, potentially hazardous foods were not maintained at an acceptable temperature to limit the growth of pathogens. Observations on the 2nd and 6th floors showed that egg salad and tuna sandwiches were stored at temperatures significantly above the required 41 degrees Fahrenheit. The sandwiches were prepared earlier in the day and were not adequately chilled before being served. Interviews with the Chef Manager and Food Service Director indicated that sandwiches are made daily and placed in the freezer to lower their temperature, but there was no evidence of temperature checks being conducted to ensure compliance with food safety standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 1,374 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Staten Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Vanderbilt Rehabilitation And Care Center, Inc | 1.8 mi | ★★★★★ | 0 | 0 |
| Clove Lakes Health Care And Rehabilitation Center, | 1.9 mi | ★★★★★ | 10 | 2 |
| Richmond Ctr For Rehab And Specialty Healthcare | 1.9 mi | ★★★★★ | 11 | 0 |
| Golden Gate Rehabilitation & Health Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Sea View Hospital Rehabilitation Center And Home | 2.3 mi | ★★★★★ | 0 | 0 |
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