Below 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 Clove Lakes Health Care And Rehabilitation Center, during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment and adequate supervision for several residents, including one cognitively intact smoker on continuous O2 who repeatedly smoked in their room and entered the smoking area while still on oxygen, without effective intervention by the assigned smoking monitor or documented increases in safety checks or reassessment. Room searches of identified smokers revealed multiple residents with smoking materials and lighters, including residents on continuous O2, yet there was no documented evidence of follow-up smoking safety reassessments. Additionally, a severely cognitively impaired, high fall-risk resident experienced multiple falls with injuries over several months, while incident reports repeatedly recommended increased supervision and frequent checks that were not incorporated into the care plan or consistently documented in CNA task records, and nursing leadership acknowledged that supervision interventions and root cause analysis were lacking.
A resident with COPD requiring continuous O2, diabetes, heart failure, and a high fall risk was not given ordered evening medications, continuous oxygen, hourly safety checks, or a dinner meal over several hours. The assigned RN did not verify the resident’s whereabouts after being told the resident had a visitor, did not administer scheduled meds or ensure O2 use, and only began searching late in the shift, eventually finding the resident unresponsive on the floor beside the bed without oxygen in place. The assigned CNA did not perform ordered hourly checks, did not serve or confirm a dinner tray, and only checked the resident once more around mid-evening, despite care plans and task lists requiring close monitoring. Documentation of the incident omitted that the resident had been unaccounted for for hours, had missed medications, treatments, and a meal, and was not on oxygen when found, while leadership and the MD were not initially informed of these care gaps.
A resident with COPD on continuous O2, diabetes, heart failure, and multiple psychotropic and other meds had no documented administration of ordered medications or oxygen between late afternoon and late evening. The assigned RN assumed the resident was with a visitor, did not verify the resident’s location, did not administer 4 PM, 8 PM, or 9 PM meds, and did not notify the MD or RN supervisor of missed doses. For several hours, nursing and direct care staff were unaware of the resident’s whereabouts, and CNA safety checks and meal documentation stopped mid-afternoon. The resident was later found face down on the floor in the room, unresponsive, without O2 in place; CPR was initiated and EMS pronounced the resident deceased. Incident and nursing documentation did not reflect that the resident had been missing for hours, that medications and O2 were not provided, or that the resident was off oxygen when found, and leadership and the MD reported they were not informed of these facts at the time.
A resident with COPD, diabetes, heart failure, and depression had multiple scheduled medications and continuous O2 at 3 L/min ordered for the evening shift, but an RN did not administer the 4 PM, 8 PM, or 9 PM doses and did not ensure the resident received ordered oxygen, nor did the RN notify a supervisor or MD of the missed doses. The RN assumed the resident was with a visitor, did not verify the resident’s return, and only began looking for the resident later in the shift. The resident was ultimately found on the floor unresponsive without O2 in place, CPR was initiated, EMS assumed care, and the resident was pronounced deceased. Supervisory staff and the MD reported they were not informed during the shift that the resident was missing or that medications and oxygen had not been provided, and records showed no hourly safety checks or medication administration during the relevant period.
The facility failed to prevent neglect of a resident on continuous oxygen and at high fall risk when staff did not perform required hourly safety checks, administer medications, provide the dinner meal, or ensure oxygen therapy for several hours after the resident was noted missing, and leadership (including the DON and Administrator) were unaware for weeks that the resident had been unaccounted for prior to being found unresponsive and later pronounced deceased. The facility also failed to enforce smoking safety policies for residents with unsafe smoking behaviors and oxygen use by limiting smoking assessments to admission only, not reassessing after repeated incidents, not increasing monitoring, allowing residents to retain smoking materials, and not ensuring oxygen was removed before entry into the smoking room, while the Medical Director was not informed of ongoing noncompliant smoking behavior.
The facility failed to ensure accurate MDS coding of current tobacco use for multiple cognitively intact residents who were active smokers. Several residents with conditions such as COPD, pulmonary fibrosis, heart failure, schizophrenia, paraplegia, hypertensive heart disease, epilepsy, and depression were repeatedly observed smoking in the designated smoking room. Each had a signed smoking agreement, a smoking assessment identifying them as smokers, and a care plan addressing smoking in a designated area, yet their admission, annual, or significant-change MDS assessments did not reflect current tobacco use in Section J1300. The MDS Manager reported that Section J1300 is completed by the MDS department using resident assessments, staff interviews, medical record review, and a periodically updated smoking list from recreation, but was not aware of these specific discrepancies.
A resident with COPD, diabetes, and heart failure on continuous O2 was reported to have a visitor in the late afternoon, but an RN did not check on the resident for several hours and later could not locate the resident for medication administration. The resident was subsequently found on the floor unresponsive, with no pulse or respirations, and was pronounced deceased by EMS. Documentation showed no record that the resident was missing for several hours, no notification of the nursing supervisor or MD, and no documentation of dinner, hourly safety checks, or medication administration during that time. An internal investigation concluded the event was a medical incident and found no cause to believe abuse, mistreatment, or neglect had occurred, and the allegation was not reported to the State agency, despite facility policy requiring timely reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment.
A resident with COPD, respiratory failure, diabetes, intact cognition, and on continuous O2 was not checked by an RN for several hours after the RN was told the resident had a visitor. The resident was later found on the floor, face down and unresponsive, and was pronounced deceased by EMS. Facility documentation did not show that the resident was considered missing during the gap in monitoring, nor that a supervisor or MD were notified. The incident report concluded it was a medical event and noted environmental factors and a later-discovered facial skin tear, but omitted key details such as the resident’s reported missing status, the RN’s call to the resident’s family to look for the resident, and the exact position in which the resident was found. The ADON, DON, and Administrator all reported they were not informed of these critical facts until much later and stated that, had they known, the investigation’s conclusion would have been different, demonstrating that the facility failed to conduct a thorough abuse/neglect investigation.
The facility’s assessment failed to include required competencies for Activities staff assigned as smoking monitors. Activities personnel, including a Recreation Transporter, were responsible for assessing residents’ smoking practices and monitoring residents during smoking, including those on oxygen, but the facility-wide assessment did not specify the knowledge, training, or skills needed for safe smoking monitoring and oxygen safety. Although the Administrator reported that new smoking monitors receive training and are evaluated by demonstration, and that smoking was listed as a special care need in the assessment, the document did not detail the actual training requirements for this role, leading to a deficiency related to incomplete evaluation of staff competencies.
A resident with a documented mushroom allergy was served a meal containing mushrooms due to a failure to update dietary records and meal tickets. The resident experienced an allergic reaction, requiring immediate medical intervention. Staff interviews revealed gaps in communication and documentation regarding the allergy, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a resident with macerated skin around the stoma, despite a Nurse Practitioner ordering treatment. The resident, with cognitive impairments and multiple diagnoses, did not have an updated care plan addressing skin issues. Interviews revealed that the responsibility for care plan development and updates was not fulfilled, leading to the deficiency.
A resident with intact cognition and multiple diagnoses was involved in an incident where a CNA roughly pulled incontinent briefs away from them, holding the resident's arm in the process. The resident reported feeling upset, and the facility's investigation was inconclusive. The CNA resigned after viewing the surveillance footage, and the incident was reported to the police. No injuries were reported, but the facility failed to protect the resident from abuse as per their policy.
A facility failed to report a sexual abuse allegation to law enforcement as required by section 1150B of the Act. A visitor observed a resident putting their hand in another resident's pajama pants, but the facility's policy did not include reporting such suspicions to local law enforcement. The facility concluded there was no reasonable suspicion of a crime, as the involved resident denied the allegation and claimed they were helping the other resident with their clothing. The incident involved two residents, one with intact cognition and the other with moderately impaired cognition.
A resident with psychiatric behaviors, including refusing medication and verbal aggression, was not accurately assessed in the MDS 3.0 assessments, despite staff awareness and documentation of these behaviors. The facility's Social Services department, responsible for inputting MDS information, failed to code these behaviors, leading to a deficiency in assessment accuracy.
A facility failed to coordinate PASARR assessments for a resident with a new serious mental disorder diagnosis. Despite exhibiting behaviors such as medication refusal and verbal abuse, the resident was not referred for a PASARR Level II evaluation. The facility's policy lacked procedures for such referrals, and staff interviews revealed awareness of the resident's psychological issues without action taken.
A resident with a history of encephalitis and moderate cognitive impairment did not receive their prescribed anti-seizure medication, Brivaracetam, on multiple occasions due to it not being available. The facility failed to notify the physician and did not reorder the medication in a timely manner, despite having a system in place to signal when a refill is needed. Interviews with nursing staff revealed a lack of communication and follow-up, contributing to the lapse in medication administration.
A resident with a thyroid disorder did not receive Levothyroxine Sodium at the prescribed time due to medication storage issues, leading to late administration on multiple occasions. The resident, who is cognitively intact, reported the issue, and staff interviews revealed that the medication was often missed by the night nurse due to its unusual packaging.
A resident did not receive Brivaracetam, a seizure medication, due to unavailability, and the physician was not notified. The resident, with a history of encephalitis and other conditions, missed doses on multiple occasions. Nursing staff failed to reorder the medication timely and did not communicate effectively, leading to a significant medication error.
A resident with End Stage Renal Disease and Hyperlipidemia, who primarily speaks Cantonese, was not provided with appropriate communication tools or interpreter services, leaving them unable to fully understand their health status. Despite the facility's policy to provide interpretive services, staff relied on simple English words and gestures, which the resident did not fully understand. Interviews revealed a lack of awareness and implementation of available communication resources.
Two residents in an LTC facility did not have comprehensive care plans developed and implemented to address their specific medical needs. One resident, with multiple diagnoses and on hemodialysis, antipsychotic, and anticoagulant medications, lacked care plans for these treatments. Another resident, identified as a smoker, did not have a smoking care plan despite being observed smoking. The facility's failure to create these care plans was acknowledged by staff as an oversight.
A facility failed to update comprehensive care plans for two residents, one with outdated Advance Directives and another with unreviewed plans for physical restraints and tracheostomy. The facility's policy requires quarterly reviews, but these were not conducted, leading to care plans that did not reflect the residents' current medical needs.
A resident with respiratory failure was administered an expired Serevent Diskus inhalation device due to the facility's lack of policy on checking medication expiration dates. The medication, delivered by a vendor pharmacy, was expired upon receipt and administration. An LPN acknowledged the oversight, and the DON confirmed the absence of a procedure for verifying expiration dates.
Failure to Ensure Smoking Safety and Fall Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents, particularly related to smoking safety and fall prevention. One cognitively intact resident with COPD and pulmonary fibrosis was identified as a smoker, had a physician’s order for continuous oxygen via nasal cannula, and a care plan indicating they would smoke safely in a designated area with supervision. Despite this, nursing notes documented three separate incidents in which this resident smoked in their room, including while oxygen was in use, and staff confiscated cigarettes and a lighter. On another occasion, the resident was observed entering the designated smoking room while still on oxygen, and the assigned smoking monitor did not stop the resident or remove the oxygen. The facility’s own smoking policy required staff to intervene when residents smoked in non-designated areas, remove smoking materials, and conduct searches, but there was no evidence of increased safety checks or reassessment for safe smoking after these repeated unsafe behaviors. The facility also failed to reassess and document safe smoking practices for multiple other residents after contraband smoking materials were discovered. During room searches of all identified smokers, 19 residents were found with smoking materials, and four residents were found with lighters. Two of these residents also had continuous oxygen orders. There was no documented evidence that these four residents received a smoking reassessment for safe smoking after the lighters were found. The report states that these circumstances subjected all 565 residents in the facility to the likelihood of serious adverse outcomes that constituted Immediate Jeopardy. In addition, the facility did not provide adequate supervision and interventions for a resident at high risk for falls who had severe cognitive impairment and a history of multiple falls. This resident had a documented high fall risk and required supervision or touching assistance for bed mobility and transfers, and could ambulate short distances. Between late August and late February, the resident experienced seven fall incidents, three of which resulted in injuries including lacerations and a hospital visit for suturing of a facial laceration. Incident reports repeatedly recommended increased supervision and frequent checks, and one incident recommended observation near the nurse’s station and another recommended frequent observation every 30 minutes. However, the comprehensive care plans for actual falls and the fall-risk care plan did not include specific interventions for increased or defined supervision, and task lists and CNA documentation often lacked evidence of the recommended monitoring. Nursing supervisors and the DON acknowledged that supervision frequency was not reflected in the care plan, that new interventions were not added after falls, and that no formal root cause analysis was conducted for the repeated incidents.
Resident Neglect Due to Missed Medications, Oxygen, Supervision, and Meal Leading to Unresponsive Event
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications, continuous oxygen, supervision, and meals during an evening shift. The resident had chronic obstructive pulmonary disease requiring continuous oxygen at 3 L/min via nasal cannula, diabetes mellitus, heart failure, and major depressive disorder, and was cognitively intact but required supervision/touching assistance with activities of daily living. The resident was assessed as high risk for falls, had a history of falls, and had a care plan that included hourly visual safety checks, anticipation of needs, ensuring the call light was within reach, and providing physical and emotional support for safety. Physician orders included multiple scheduled medications and inhalers for COPD, diabetes, depression, and other conditions, with doses due at 4:00 PM, 8:00 PM, and 9:00 PM on the evening shift. On the date of the incident, the Medication Administration Record showed no documented evidence that any of the resident’s scheduled medications or treatments were administered between 4:00 PM and 9:00 PM. The Task List for CNAs showed the resident was to receive hourly visual checks for safety, but there was no documentation of hourly monitoring from 2:45 PM to 9:40 PM. The nutritional intake form also showed no evidence that the resident was served a meal or snack between 2:45 PM and 9:40 PM, and the visitor log contained no record of any visitor for the resident during that time. Despite the resident’s order for continuous oxygen, when the resident was later found, staff observed that the resident was not connected to oxygen. Registered Nurse (RN) #1 reported arriving on the unit at 4:15 PM and not seeing the resident during rounds, stating they had been told the resident had a visitor, but they did not verify the resident’s whereabouts and continued working without locating the resident. RN #1 did not administer the resident’s scheduled medications and did not ensure the resident received continuous oxygen. RN #1 stated they began looking for the resident around 9:40 PM, briefly checked the room, did not see the resident, and at approximately 9:43 PM called the resident’s adult child to ask if the resident had left with them. RN #1 then contacted the nursing supervisor to report the resident could not be located and subsequently found the resident at 9:49 PM lying face down on the floor beside the bed, unresponsive, with no pulse and no breathing. Certified Nursing Assistant (CNA) #1, assigned to the resident from 3:00 PM to 11:00 PM, stated they saw the resident in the room sitting on the bed at about 3:30 PM and did not see any visitor present. CNA #1 acknowledged they did not perform the ordered hourly safety checks and that the second time they checked on the resident was around 8:30 PM, when the resident was in the room and stated they were okay. CNA #1 also stated they did not serve a dinner tray to the resident because they were serving residents on the other side of the unit, did not know if the resident ate, and did not ask another CNA whether the resident had received a meal, despite being responsible for checking and documenting meal intake. Supervisory and leadership staff, including the RN supervisors, Infection Control Director, Director of Nursing, Administrator, and Medical Director, later confirmed they were not initially informed that the resident had been considered missing for several hours, had not received scheduled medications, treatments, or a meal, and that these facts were not documented in the incident report, which instead concluded the event appeared related to a medical event and that there was no cause to believe neglect had occurred. At 9:49 PM, the resident was found unresponsive on the floor beside the bed with no measurable vital signs, and CPR was initiated until EMS arrived at 10:07 PM and assumed care. The nursing progress note documented that the resident was found unresponsive with no pulse and no breathing, a STAT call was made, oxygen via nonrebreather mask at 15 L/min was applied, 911 was called, and IV fluids were started. EMS pronounced the resident expired at 10:24 PM. The Accident/Incident Investigation form documented that the call bell was within reach but had not been activated, the bed was in the lowest and locked position, and the floor was clean and dry. It also documented that the interdisciplinary team determined there was no cause to believe abuse, mistreatment, or neglect had occurred, and omitted that the resident had been unaccounted for from 4:15 PM to 9:48 PM, had not received evening medications, was not on oxygen when found, and that the nursing supervisor and physician were not notified of these circumstances at the time of the incident. During postmortem care, staff observed a large skin tear on the resident’s right cheek, described by the adult child as skin peeled off that looked like a burned skin injury. The adult child reported being called by RN #1 at about 9:43 PM and told the resident was missing, and then receiving another call that the resident had been found unresponsive beside the bed. The adult child stated that when they arrived, they were told the resident had expired at 10:24 PM and that a nurse supervisor attributed the facial injury to EMS. RN Supervisor #1 and RN Supervisor #2 both confirmed they responded to a report that the resident could not be found, but by the time they reached the unit, the resident had already been located on the floor unresponsive, and one supervisor noted that the resident was not connected to oxygen. The facility’s own policies defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required accident investigations and care plan revisions as needed, but the investigation documentation did not reflect the prolonged lack of monitoring, missed medications, missed meal, and absence of continuous oxygen that occurred prior to the resident being found unresponsive.
Failure to Administer Ordered Medications, Maintain Continuous Oxygen, and Monitor Resident Whereabouts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality for one resident with multiple chronic conditions, including COPD requiring continuous oxygen, diabetes mellitus, heart failure, major depressive disorder, and use of antipsychotic, antidepressant, and hypoglycemic medications. Physician orders directed that the resident receive multiple scheduled medications between 4:00 PM and 9:00 PM, including inhaled medications for COPD, Metformin for diabetes, Sertraline, Varenicline, Atorvastatin, Quetiapine, Trazodone, and continuous oxygen at 3 L/min via nasal cannula. The facility’s own policies required medications to be administered as ordered within one hour before or after the scheduled time, with documentation of administration or refusal, and prompt reporting and documentation of medication errors and physician notification. On the evening in question, the Medication Administration Record for the 3:00 PM–11:00 PM shift showed no evidence that any of the resident’s scheduled medications or continuous oxygen treatment were administered between 4:00 PM and 9:00 PM. RN #1, who was responsible for the resident’s care during that shift, stated they arrived on the unit at 4:15 PM, did not see the resident during rounds, and were told by unknown staff that the resident had a visitor. RN #1 reported they did not look for the resident, assuming the resident was with the visitor, and acknowledged that the 4:00 PM medications were not given for that reason. RN #1 further stated they were aware that the 4:00 PM, 8:00 PM, and 9:00 PM medications were not administered and did not recall notifying the RN supervisor or the physician, despite knowing they were required to do so when medications were not given. From approximately 4:15 PM until 9:49 PM, nursing and direct care staff were unaware of the resident’s whereabouts. The CNA accountability record for the 3:00 PM–11:00 PM shift contained no hourly safety checks or meal documentation for the resident after 2:45 PM. At about 9:49 PM, the resident was found on the floor beside the bed, face down, unresponsive, with no pulse and no respirations, and not connected to any oxygen source. A stat was called, CPR was initiated, and EMS arrived at 10:07 PM and later pronounced the resident deceased at 10:24 PM. The incident report and nursing progress note did not document that the resident had been missing for several hours, that staff were unaware of the resident’s whereabouts from 4:15 PM to 9:49 PM, that no 4:00 PM, 8:00 PM, and 9:00 PM medications were administered, or that the resident was not on oxygen when found. The Medical Director, DON, Administrator, and attending physician all reported they were not informed at the time that the resident had been missing for hours or that the evening medications and continuous oxygen had not been provided, and the Medical Director stated they did not review the chart and were not made aware of the missed medications until days later. The facility’s investigation documentation concluded the incident appeared related to a medical event and initially indicated there was no cause to believe abuse, mistreatment, or neglect had occurred. However, the investigation form did not include the fact that the resident’s whereabouts were unknown for several hours, that the resident did not receive ordered medications and treatments during the evening shift, or that the resident was not connected to oxygen when found. Supervisory nursing staff who responded to the emergency confirmed that when they arrived, the resident was already on the floor unresponsive and that no oxygen was connected. The Medical Director and other leadership staff stated they were not made aware that the resident had been missing or that medications and treatments were not administered as ordered during the relevant time period. These omissions in monitoring, medication administration, treatment provision, and timely, accurate reporting and documentation formed the basis of the cited deficiency under 10 NYCRR 415.11(c)(3)(i).
Failure to Administer Ordered Medications and Oxygen or Monitor Resident Whereabouts
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and received ordered oxygen therapy as prescribed. The resident had diagnoses including COPD, diabetes mellitus, heart failure, and major depressive disorder, and was ordered multiple medications, including inhaled bronchodilators and steroids, metformin, sertraline, varenicline, atorvastatin, quetiapine, trazodone, and continuous oxygen at 3 L/min via nasal cannula. The facility’s own policies required medications to be administered as ordered within one hour before or after the scheduled time, with documentation of administration or reasons for omission and physician notification, and required that significant medication errors be reported as soon as recognized. On the date in question, the resident was scheduled to receive medications at 4:00 PM, 8:00 PM, and 9:00 PM on the 3:00 PM–11:00 PM shift, but the Medication Administration Record showed no evidence that any of these medications or the ordered continuous oxygen were provided. RN #1 reported arriving on the unit at 4:15 PM, not seeing the resident during rounds, and being told by unknown staff that the resident had a visitor. RN #1 did not look for the resident at that time and continued working on the unit, did not verify the resident’s return, and did not administer the 4:00 PM medications within the allowed time frame. RN #1 acknowledged being aware that the 4:00 PM, 8:00 PM, and 9:00 PM medications were not given and did not recall notifying the nursing supervisor or the physician, despite knowing this was required. RN #1 stated they began looking for the resident at about 9:40 PM and briefly checked the resident’s room without finding them. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse and no breathing; CPR was initiated and EMS was called, and the resident was pronounced expired at 10:24 PM. Supervisory staff reported they were not aware during the shift that the resident had missed scheduled medications or that the resident had been missing for several hours. The Medical Director and the resident’s attending physician both stated they were not informed at the time that the resident had been missing or that medications from 4:00 PM through 9:00 PM had not been administered, and the Medical Director stated they could not opine whether missing one cycle of medications caused the resident’s collapse and death. The DON confirmed there was no documentation of hourly safety checks or meal consumption for the resident after 2:45 PM and no medications administered from 4:00 PM to 9:49 PM.
Failure to Prevent Resident Neglect and Enforce Smoking Safety Policies
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured residents were free from neglect and that required systems for monitoring and care were functioning. For one resident with continuous oxygen use and a high fall risk, staff became aware around 4:15 PM that the resident could not be located on the unit, yet the facility did not ensure required hourly safety checks, medication administration, oxygen therapy, or provision of the dinner meal from approximately 4:00 PM to 9:00 PM. There was no timely staff communication, physician notification, or escalation of concern despite the resident not being seen for several hours. The resident was later found unresponsive on the floor at 9:49 PM, a STAT call was made, CPR was initiated, EMS took over, and the resident was pronounced deceased at 10:24 PM. The report notes that the DON recalled learning of the event through a hospitalization group chat message sent between 2:00 AM and 3:00 AM, which stated that the resident had been found unresponsive on the floor the prior evening. The DON stated they were not informed that the resident had been reported missing prior to being found and only became aware weeks later that the resident had reportedly been missing for several hours before discovery. The DON also stated that the Infection Control Director knew the resident had initially been reported missing, but this was not discussed in the morning meeting. The Administrator similarly reported first learning of the incident via a hospitalization group chat message after midnight and was unaware that the resident had been reported missing, had not been monitored hourly, had no documented dinner intake, and had not received medications between 4:00 PM and 9:00 PM. A second deficiency concerns the facility’s failure to enforce smoking safety policies for residents with known unsafe smoking behaviors and oxygen use. The Director of Recreation stated that smoking assessments were conducted only upon admission, not reassessed after repeated smoking incidents, and that they continued to provide education without clearly identifying further interventions. The Director of Recreation indicated that a smoking monitor should have removed oxygen before a resident on oxygen entered the smoking room and that residents should not have smoking materials, yet residents were found with such materials, which were then confiscated. The DON stated that one resident on hourly safety checks was not reassessed for safe smoking after each incident and that monitoring frequency was not increased despite repeated noncompliance. The DON also stated they were unaware that other residents had smoking materials or that there were smoking issues until surveyors arrived. The Medical Director reported not knowing about the resident’s noncompliant smoking behavior, acknowledged that smoking in a room with continuous oxygen is dangerous, and could not determine whether the resident was a safe smoker.
Failure to Accurately Code Current Tobacco Use on MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ current tobacco use status, as required by facility policy and regulation. The facility’s policy on Accuracy of Assessment, last reviewed in October 2025, required that assessments be accurate and based on direct observation and communication with residents and staff on all shifts. Despite this, surveyors found that for five cognitively intact residents, the MDS Section J1300 (Current Tobacco Use) did not document that these residents were active smokers. For one resident with COPD, benign prostatic hyperplasia, and diabetes, surveyors observed the resident smoking in the designated smoking room on multiple occasions. The resident had a signed Smoking Regulation Agreement identifying him as a smoker, a smoking assessment documenting smoking status, and a care plan titled “Known Smoker” directing that he smoke safely in the designated area. However, his annual MDS dated 12/29/2025 did not indicate current tobacco use in Section J1300. Another resident with COPD, pulmonary fibrosis, and testicular cancer was repeatedly observed smoking in the smoking room, had a signed Smoking Regulation Agreement, a smoking assessment, and a “Known smoker” care plan, and a nursing note documented that he was found smoking in his room while on oxygen. His annual MDS also failed to document current tobacco use in Section J1300. Similarly, three additional residents with diagnoses including hypertension, schizophrenia, paraplegia, heart failure, chronic pancreatitis, hypertensive heart disease, epilepsy, and depression were each observed smoking in the smoking room on multiple occasions. Each had a signed Smoking Regulation Agreement identifying them as smokers, a smoking assessment documenting smoking status, and a care plan titled “Known Smoker” indicating they would smoke safely in the designated smoking area. For these residents, their admission, annual, or significant change MDS assessments, all of which documented them as cognitively intact, did not record current tobacco use in Section J1300. In an interview, the MDS Manager stated that Section J1300 was completed by the MDS department using resident assessments, staff interviews, and medical record review, and that a smoking list was obtained from the recreation department about every two weeks, but acknowledged unawareness of the discrepancies for these residents.
Failure to Report Alleged Abuse/Neglect After Resident Found Unresponsive and Deceased
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving potential abuse, neglect, or mistreatment, as required by policy and 10 NYCRR 415.4(b)(1)(i). The facility’s policy required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to be reported immediately, but not later than two hours if abuse or serious bodily injury was involved, or within 24 hours otherwise, to the New York State Department of Health. Despite this policy, the facility did not report an allegation related to a resident who was missing for several hours and later found unresponsive and pronounced deceased. The resident involved had diagnoses including COPD, diabetes mellitus, and heart failure, and was receiving continuous oxygen. The resident’s MDS documented intact cognition and a need for supervision/touching assistance with ADLs, and the care plan for risk of abuse/neglect included interventions to allow the resident to express fear or anxiety and to provide physical and emotional support for safety. On the day of the incident, an RN arrived on the unit at 4:15 PM and was informed by staff that the resident had a visitor. The RN did not check on the resident until 9:40 PM, at which time the resident could not be located for medication administration. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse or breathing, and was later pronounced expired by EMS at 10:24 PM. Record review showed no documentation that the resident was missing from 4:15 PM until 9:48 PM, and no documentation that the nursing supervisor or physician were notified. The Accident/Incident Investigation form documented that the incident appeared related to a medical event, with the resident found on the floor beside the bed, no measurable vital signs, and no visible injuries on initial assessment, though a large skin tear on the right cheek was noted during postmortem care. The call bell was within reach but not activated, the bed was in the lowest locked position, and the room floor was clean and free of clutter. The interdisciplinary team concluded there was no cause to believe abuse, mistreatment, or neglect had occurred, and therefore the allegation was not investigated or reported to the Department of Health. Subsequent interviews with the DON and Administrator revealed they were not made aware that the resident had been initially missing, not monitored hourly, and had no documented dinner or medications during the 4:00 PM–9:00 PM period, and that this information had been left out of the initial investigation, contributing to the failure to report the allegation.
Failure to Thoroughly Investigate Resident Death and Missing Status
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged incident of possible abuse, neglect, or mistreatment related to a resident’s death. The facility’s abuse/neglect policy required that all alleged or suspected incidents be thoroughly investigated, documented, and reported. On the date of the incident, a registered nurse (RN) arrived on the unit at 4:15 PM and was informed by staff that the resident had a visitor. The RN did not check on the resident again until 9:40 PM when attempting to administer medications and was unable to locate the resident. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse and no respirations, and was later pronounced deceased by Emergency Medical Services. The resident had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus, with intact cognition and a need for supervision/touching assistance with ADLs, and was on continuous oxygen therapy. Nursing progress notes and the accident/incident investigation form showed no documentation that the resident was missing between 4:15 PM and 9:48 PM, and there was no evidence that the nursing supervisor or physician were notified during that period. The accident/incident form concluded the event appeared related to a medical event and documented that the resident was found lying on the floor beside the bed, unresponsive, with no measurable vital signs, and that CPR and EMS were initiated. It also documented that the call bell was within reach but not activated, the bed was in the lowest locked position, the floor was clean and dry, and that no visible injuries were initially noted, although a large skin tear on the right cheek was later observed during postmortem care. Interviews revealed that key information about the incident was not included in the investigation or communicated to leadership. The Assistant DON, who was responsible for incident completion and accuracy, stated they first learned from the incident report and a statement the next day and that it was their first time hearing that the resident had been reported missing, that the adult child had been called by the RN to look for the resident, and that the position in which the resident was found on the floor should have been included. The DON stated they were not notified that the resident had been reported missing prior to being found and only learned this information the day before the interview; they also noted that the facial injury and explanation that it may have occurred during EMS intubation attempts were not documented in the nursing notes. The Administrator similarly reported first learning of the incident via a hospitalization chat after midnight and was not aware that the resident had been initially missing, not monitored hourly, had no record of dinner intake, and had not received medications between 4:00 PM and 9:00 PM, or that the RN had contacted the adult child and RN supervisor about the resident being missing. Leadership stated that, had all this information been known and investigated, the conclusion of the investigation would have been different, demonstrating that the facility did not conduct a thorough investigation into how the resident was found unresponsive.
Failure to Include Smoking Monitor Competencies in Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that evaluated staff competencies necessary to meet resident needs, as required by regulation. Surveyors found that the facility’s assessment, dated 09/2025, did not include the specific knowledge, training, and skills required for Activity Aides who were assigned to monitor residents who smoke. Although the facility’s policy and assessment referenced identifying resident acuity levels, providing continuous care through consistency, and basing staffing plans on resident population and needs, the assessment did not address competencies related to safe smoking monitoring and oxygen safety for the Activities staff who were functioning as smoking monitors. During the abbreviated survey, it was determined that one of four smoking monitors lacked documented evaluation of competencies necessary to provide the level and type of care needed for residents who smoke. The facility had designated Activities staff, including a Recreation Transporter, to assess residents’ smoking practices and to monitor residents during smoking activities, including residents using oxygen. In an interview, the Administrator stated that newly hired smoking monitor staff receive specific training and are evaluated by demonstration on proper monitoring of residents in the smoking room and residents with oxygen, and that noncompliant resident smoking behavior prompts ongoing staff re-education. The Administrator also stated that smoking was identified as a special care need in the facility assessment and referenced under other special needs and services related to buildings, but acknowledged that the assessment did not elaborate on the actual training required for safe smoking monitoring, resulting in a deficient facility assessment under 10 NYCRR 415.5(h)(2).
Failure to Accommodate Documented Food Allergy Results in Resident Reaction
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to mushrooms was served a meal containing mushrooms. The resident's medical records, including the Minimum Data Set, dietary assessment, care plan, and physician orders, all indicated an allergy to mushrooms. However, the resident's meal tickets did not reflect this allergy, and the resident was served chicken with mushrooms hidden underneath, which led to the resident consuming the allergen. Following the ingestion, the resident experienced an allergic reaction, including a red rash on both arms, swelling of the lips, and tingling of the tongue. Nursing staff responded by administering Solumedrol and Benadryl as ordered by a physician. The incident was observed and documented by multiple staff members, who confirmed the presence of mushrooms on the resident's tray and the resident's symptoms after eating the meal. Interviews with facility staff revealed inconsistencies in the communication and documentation of the resident's allergy. The dietician stated that the allergy was not initially reported and that the meal ticket was only updated after the incident. The electronic medical record system did not generate an alert for the allergy, and the dietary supervisor was responsible for ensuring meal tickets matched resident needs. Despite the care plan and orders indicating a mushroom allergy, the failure to update the meal ticket and communicate the allergy resulted in the resident being served an unsafe meal.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was evident during an abbreviated survey. The deficiency was identified for a resident who was noted with macerated skin around the stoma. Despite the Nurse Practitioner evaluating the resident and ordering Maalox suspension to be applied to the affected area, there was no documented evidence of a care plan being developed to address this issue. The facility's policy on Comprehensive Person-Centered Care Planning requires the development of an individualized interdisciplinary care plan based on Care Area Assessment, but this was not adhered to in this case. The resident, who was admitted with diagnoses including malignant neoplasm of the colon, ileostomy, and diabetes, also had documented short and long-term memory problems and severely impaired cognitive decision-making. Despite these conditions, the care plan was not updated when the resident was noted with maceration around the stoma and later with a rash on the abdomen. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that the responsibility for developing and updating the care plan was not fulfilled, leading to the deficiency.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a nursing home staff member. The incident involved a resident with diagnoses including Hypertensive Heart Disease, Chronic Kidney Disease, and Depression, who had intact cognition. On the specified date, surveillance footage captured a Certified Nursing Assistant (CNA) roughly pulling incontinent briefs away from the resident, who was seated in a wheelchair in the hallway. The CNA was seen holding the resident's arm while attempting to retrieve the briefs, which the resident was reluctant to relinquish. The facility's policy on abuse prevention, last updated in November 2022, mandates that residents must not be subjected to abuse by anyone, including staff. Despite this, the incident occurred, and the resident reported feeling upset and expressed a desire to retaliate physically against the CNA, although no injuries or pain were reported. The facility's investigation into the incident was inconclusive, and the CNA involved resigned after being shown the surveillance footage. The incident was reported to the police, and the facility conducted interviews with other residents, who reported no issues with the CNA. The Director of Nursing reviewed the video and confirmed the physical contact between the CNA and the resident. Despite the lack of visible injuries, the incident highlights a failure in the facility's duty to protect residents from abuse, as outlined in their policies.
Failure to Report Sexual Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report a sexual abuse allegation involving two residents to local law enforcement. On February 18, 2024, a visitor reported to a Certified Nursing Assistant (CNA) that they observed one resident putting their hand in another resident's pajama pants. The facility's policy did not include reporting such suspicions to local law enforcement, and the incident was not reported to them. The facility's investigation concluded there was no reasonable suspicion of a crime, as the resident involved denied the allegation and claimed they were helping the other resident with their clothing. The incident involved two residents, one with intact cognition and the other with moderately impaired cognition due to dementia and depressive disorder. The CNA who witnessed the incident immediately intervened and reported the situation to a nurse. The Director of Nursing stated that there was no evidence to support that sexual abuse had occurred, and the resident with impaired cognition could not recall the incident. The facility's policy required reporting suspicions of crimes resulting in serious bodily injury within two hours and those without injury within 24 hours, but it did not address reporting to law enforcement, leading to the deficiency.
Inaccurate MDS Assessments for Resident with Psychiatric Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the psychiatric behaviors of a resident, leading to a deficiency in assessment accuracy. The resident, who was admitted with diagnoses including a fracture, anxiety disorder, and depression, exhibited numerous psychiatric behaviors such as refusing medication, hiding medications, calling the police, talking to themselves, and displaying agitated and verbally abusive behavior. Despite these behaviors being documented in behavior notes and a psychiatric assessment diagnosing the resident with psychosis, the MDS assessments consistently failed to reflect these behaviors, indicating a significant oversight in accurately assessing the resident's status. Interviews with facility staff, including registered nurses, a certified nursing assistant, and the Director of Nursing, confirmed that the resident's behaviors were well-known and frequently discussed in staff meetings. The MDS Coordinator and the Director of Social Services acknowledged that the Social Services department was responsible for inputting MDS information related to mood and behavior, yet the behaviors were not coded in the assessments. This oversight suggests a breakdown in communication and documentation processes within the facility, as the staff were aware of the resident's behaviors but failed to ensure they were accurately reflected in the MDS assessments.
Failure to Coordinate PASARR Assessments for Resident with Serious Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with a new diagnosis of a serious mental disorder. Specifically, a resident who was admitted with diagnoses including a fracture, anxiety disorder, and depression, later exhibited behaviors indicative of a serious mental illness. Despite these behaviors, which included medication refusal, agitation, and verbal abuse, the facility did not refer the resident for a PASARR Level II evaluation. The facility's policy did not include procedures for referring residents with new serious mental health diagnoses for such evaluations. The resident's psychiatric condition was documented in multiple behavior notes and a psychiatric assessment, which diagnosed the resident with psychosis. Despite this, the facility did not conduct a PASARR Level II screen, as the Director of Social Services stated that such screens are only completed if a resident is transferred to a psychiatric hospital. Interviews with staff revealed awareness of the resident's psychological issues, yet no referral was made, highlighting a gap in the facility's process for handling psychiatric changes in residents.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the case of a resident who did not receive their prescribed anti-seizure medication, Brivaracetam, in accordance with the physician's orders. The resident, who had a history of encephalitis, non-traumatic brain dysfunction, respiratory failure, and tracheostomy status, was moderately cognitively impaired. The medication was not administered on 10 out of 36 occasions due to it not being available, and there was no documented evidence that the physician was notified of this issue. The facility's policy requires that any medication not administered be documented, including the reason and physician notification, which was not adhered to in this case. Interviews with nursing staff revealed a lack of communication and follow-up regarding the medication's unavailability. The Registered Nurse Supervisor acknowledged that the physician should have been notified and that the medication should have been reordered before the supply was depleted. Despite a system in place to signal when a refill is needed, the medication was not reordered in a timely manner, leading to a lapse in administration. The Director of Nursing stated that all staff are responsible for reordering medications, but this responsibility was not fulfilled, resulting in the resident missing their medication for several days.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency was identified for a resident with a diagnosis of Hyperlipidemia and Thyroid Disorder, who had a physician's order to administer Levothyroxine Sodium at 6 AM daily. However, the medication was administered late on multiple occasions, sometimes as late as 1 PM, contrary to the facility's policy and the physician's order. The resident, who is cognitively intact, expressed concerns about the late administration of the medication and reported the issue to the Department of Health. Interviews with staff revealed that the medication was often missed by the night nurse because it was stored in an orange container rather than the usual blister pack, leading to confusion and delays. The Day shift Registered Nursing Supervisor and other staff members were aware of the issue and attempted to administer the medication as soon as they were informed of the oversight. Despite these efforts, the medication was not consistently given at the prescribed time, resulting in a failure to meet the resident's needs as per the professional standards of practice.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Brivaracetam, a medication for seizures. The resident, who had a history of encephalitis, non-traumatic brain dysfunction, respiratory failure, and tracheostomy status, did not receive the medication as ordered by the physician due to its unavailability. The Medication Administration Record indicated that on 10 out of 36 occasions, the medication was not administered, and there was no documented evidence that the physician was notified about the unavailability of the medication. Interviews with nursing staff revealed a lack of communication and follow-up regarding the medication's availability. A family member reported the absence of the anti-seizure medication for three days, and the nursing staff acknowledged the oversight in notifying the physician and reordering the medication in a timely manner. The Director of Nursing stated that medications should be reordered when supplies are running low, but this protocol was not followed, leading to the deficiency.
Failure to Provide Language-Appropriate Communication for Resident
Penalty
Summary
The facility failed to ensure that a resident was fully informed of their health status in a language they understood, as required by their policy. This deficiency was identified during a recertification survey, where it was observed that a resident with End Stage Renal Disease and Hyperlipidemia, who primarily speaks Cantonese, was not provided with appropriate communication tools or interpreter services. Despite the facility's policy to provide interpretive services and communication boards, the resident was left to communicate with staff using simple English words, body language, and gestures, which they did not fully understand. Interviews with staff revealed a lack of awareness and implementation of available communication resources. A Certified Nurse Aid admitted to not using a communication board for the resident, and a Registered Nurse Manager was unaware of the communication tools available. The facility's administrator acknowledged the importance of using interpreters and mentioned alternative solutions like Google translator and phone services, but these were not effectively utilized for the resident in question. The oversight in providing necessary communication support led to the resident not being fully informed of their health care status.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their specific medical needs. Resident #147, who was admitted with multiple diagnoses including anemia, hypertension, renal failure, and bipolar disorder, was on hemodialysis, antipsychotic, and anticoagulant medications. Despite these complex medical needs, the facility did not have documented care plans for hemodialysis, psychotropic medications, or anticoagulant therapy. This oversight was confirmed by the Registered Nurse Manager, who acknowledged the absence of these care plans and could not provide an explanation for the omission. Similarly, Resident #391, who was admitted with conditions such as asthma, COPD, and tobacco use, did not have a care plan addressing their smoking habits. The resident was observed smoking in the designated smoking room, and this behavior was documented by the recreation staff. However, the care plan for smoking was not initiated upon admission or after the smoking assessment, as confirmed by the Director of Nursing. The lack of a smoking care plan was attributed to an oversight, despite the resident being compliant with the facility's smoking rules. The deficiencies highlight a failure in the facility's process for developing and updating care plans to address residents' specific needs. Both the Registered Nurse Manager and the Director of Nursing acknowledged the lapses in care planning, which were not rectified despite previous discussions about care plan delays. The facility's policy requires individualized care plans with measurable objectives, but these were not implemented for the residents in question, leading to the identified deficiencies.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the current status of residents, as evidenced during a recertification and complaint survey. Specifically, one resident's care plan related to Advance Directives was not updated to reflect a change in orders from Full Code to Do Not Resuscitate and trial of non-invasive intubation and mechanical ventilation. This oversight was acknowledged by the social worker responsible for updating the care plans, who admitted that the care plan should have been revised and documented in the progress notes. Another deficiency was identified for a resident whose care plans related to physical restraints and tracheostomy were not reviewed and revised after the completion of the Minimum Data Set Assessment. The care plans had not been updated since February 2024, despite the requirement for quarterly reviews and updates when there are changes in the resident's condition. The Registered Nurse Supervisor and Director of Nursing both confirmed that care plans should be reviewed quarterly and updated as needed, but this was not done for the resident in question. The facility's policy on Comprehensive Person-Centered Care Planning mandates that care plans be reviewed and updated at least quarterly or as needed. However, the survey revealed that this policy was not adhered to, resulting in outdated care plans that did not accurately reflect the residents' current medical directives and needs. This lack of timely updates in care plans could potentially impact the quality of care provided to the residents.
Expired Medication Administered Due to Lack of Expiration Date Checks
Penalty
Summary
The facility failed to ensure that medications provided by the pharmacy were not expired, as evidenced by the delivery and administration of an expired Serevent Diskus inhalation device to a resident. The resident, who was admitted with acute and chronic respiratory failure with hypoxia, was prescribed the inhalation device for shortness of breath. The medication, which had an expiration date of September 2024, was delivered and opened for administration in October 2024. The facility's policy on medication administration did not include procedures for checking expiration dates before accepting or administering medications. During the survey, it was observed that a Licensed Practical Nurse retrieved the expired medication from the medication cart, and upon interview, stated that the error was due to a pharmacy mistake. The nurse acknowledged the responsibility of checking expiration dates before administration but noted that the nurse who received the medication likely assumed the pharmacy would not send expired medications. The Director of Nursing confirmed that the facility did not have a policy for checking expiration dates upon receipt and that medications were delivered directly to the floor by the pharmacy. The Vendor Pharmacy Supervising Pharmacist was informed of the issue and stated that both the pharmacy technician and pharmacist are required to check expiration dates, but could not confirm if their policy was followed in this instance.
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What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Golden Gate Rehabilitation & Health Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Sea View Hospital Rehabilitation Center And Home | 1.2 mi | ★★★★★ | 0 | 0 |
| Carmel Richmond Healthcare And Rehabilitation Cent | 1.9 mi | ★★★★★ | 4 | 0 |
| Archcare At Eger Health Care And Rehabilitation Ce | 2.1 mi | ★★★★★ | 0 | 0 |
| Silver Lake Specialized Rehab And Care Center | 2.4 mi | ★★★★★ | 7 | 0 |
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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 July 2026) and official state health department websites.