Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Richmond Ctr For Rehab And Specialty Healthcare during CMS and state inspections, most recent first.
Elevator #4 was not maintained in safe working condition. Residents and staff reported that it skipped floors, bounced, and frequently malfunctioned, and a staff member became stuck inside until others assisted. An RN described being trapped and unable to get the elevator to open, while an CNA and an LPN said people had gotten stuck before and that there was no logbook to track the incidents. Dietary staff also reported the elevator serving the 4th floor sometimes failed, requiring meals to be carried up the stairs.
Failure to ensure resident and representative participation in care plan meetings. Two residents had inconsistent or missing documentation showing they were invited to and attended interdisciplinary care plan meetings. One cognitively intact resident stated they had not been invited in some time, while the other resident’s representative reported not receiving letters or calls and only getting late text messages. Staff interviews confirmed the invitation and attendance process was inconsistently followed and documented, with missing signatures, absent meeting notes, and no reliable proof that mailed invitations were sent or received.
Unclean and Worn Unit Environment: Surveyors found Unit 2 AB had heavily worn and damaged dining room and TV room furniture, stained and discolored floors, dust and grime on surfaces and equipment, and resident rooms with rusty bed frames, missing closet locks or handles, torn chairs, and dirty bathroom/shower tiles. Staff interviews confirmed the housekeeping and maintenance concerns were known, with no work requests documented for the observed issues and routine rounding in the area not yet completed by the DMS.
A resident with a history of constipation, CVA, malnutrition, and depression had bowel-related orders for a rectal enema, docusate, and senna, but no documented comprehensive care plan was developed to address bowel management. The NM stated the resident had constipation issues, took multiple meds, and sometimes needed encouragement to take meds and drink fluids, while the DON said the unit team reviews admissions and diagnoses to initiate care plans but was unaware the constipation care plan was missing.
An LPN administered meds through a resident’s G-tube without verifying tube placement before use, despite orders and the care plan requiring placement checks prior to administration. The resident had gastrostomy status, dysphagia, and altered mental status, and staff gave differing accounts of how tube functioning and placement should be verified, including flushing, checking bowel sounds, checking residuals, and measuring tube length.
Food was not kept at an appetizing temperature during lunch service on a neurobehavioral unit. Meals were served in disposable lunch boxes and appeared unappetizing and lukewarm, and a test tray showed hot items such as corn, ground chicken, mixed vegetables, chopped chicken, baked potato, and chicken tenders below the expected hot-holding range. Staff described a process of delivering hot foods in an insulated cart, plating them on a steam table, and opening the dining room after meals were checked, while the FSD acknowledged the hot foods were not maintained at the proper temperature.
Unsafe and Unsanitary Staff Bathrooms and Nurses Stations: The facility did not maintain a safe, functional, sanitary, and comfortable environment. Observations found the 1st and 2nd floor nurses stations with disrepair, brown discoloration, missing floor tile, and drawers leaning out of the desk. The Unit 4 B staff bathroom had a hanging toilet tissue holder cover, a soap dispenser hanging off the wall, a broken toilet seat liner holder, holes and brown stains on the wall, dust on multiple surfaces, broken floor tiles, and a detached light fixture base. The D of Maintenance and Housekeeping stated they had been in the role for two weeks and were responsible for daily rounds and ensuring toilets, soap, and cleanliness.
Elevator #4 Not Maintained in Safe Working Condition
Penalty
Summary
The facility did not ensure Elevator #4 was maintained in a safe working condition. The report states residents and staff complained that Elevator #4 skipped floors, bounced, and did not always work properly, and multiple completed service tickets showed repeated vendor service calls on 07/02/2025, 07/23/2025, 08/11/2025, 08/17/2025, 08/27/2025, 08/29/2025, and 09/04/2025. The facility policy titled "Maintenance Services" stated the facility provides maintenance service to the facility, grounds, and equipment. Resident #41 reported that Elevator #4 had ongoing problems, including skipping floors and bouncing, and staff later confirmed the elevator had been a recurring issue for months. During the survey, a staff member became stuck inside Elevator #4 and could not get out until other staff assisted. Registered Nurse #5 stated this was their first time being stuck in the elevator and described it as very scary because the elevator would not open after repeated button presses. Certified Nursing Assistant #5 and Licensed Practical Nurse #5 both stated people had gotten stuck in Elevator #4 before and that management knew it was not working well, but there was no logbook to record the incidents and staff instead called the front desk or used the help button. Dietary staff also reported that the elevator serving the 4th floor sometimes did not work, requiring food to be carried by foot up the stairs. The Director of Maintenance and Housekeeping stated they had recently learned the elevator had a broken board and shut Elevator #4 down until the issue could be figured out.
Failure to Ensure Resident and Representative Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or their representatives were afforded the right to participate in the care plan process for two residents reviewed for care planning. The deficiency was identified during record review and interviews and involved Resident #349 and Resident #348, both of whom had care plan meeting participation and documentation issues. The facility policy stated that the resident, family, legal representative, guardian, or surrogate are invited and encouraged to participate in the development and revisions to the resident’s care plan. Resident #349 was admitted with diagnoses including paraplegia and muscle spasms, and the quarterly MDS documented that the resident was cognitively intact and participated in assessment and goal setting. During interview, Resident #349 stated they used to be invited to care planning meetings but had not been invited and had not attended in some time. The record showed a Team Meeting note on 02/18/2025 with Resident #349 listed as attending and a signed attendance sheet. However, there was no Team Meeting note for the 05/20/2025 care plan meeting, and the attendance sheet for that meeting did not contain a signature for Resident #349 or the resident’s representative. For the 08/04/2025 and 10/04/2025 meetings, the Team Meeting notes documented Resident #349’s attendance, but the corresponding attendance sheets did not contain a signature for Resident #349 or the designated representative. Resident #348 was admitted with diagnoses including traumatic brain injury and benign prostatic hyperplasia, and the quarterly MDS documented severely impaired cognition with participation in assessment and goal setting. The resident’s representative stated they did not receive letters or telephone calls about care plan meetings and usually only received a text message, sometimes on the day of the meeting or after it was completed, and had not attended meetings in person or by telephone. The record showed inconsistent documentation of invitations and attendance: one meeting documented the resident and representative as invited, with the representative attending by telephone, while other meetings contained documentation that the representative was invited but either did not attend or there was no response. Several records also showed discrepancies between the meeting dates and the dates listed in social service notes, and there was no documented evidence that the representative was consistently sent invitation letters or emails for the care plan meetings reviewed. Interviews with the Director of Social Services, Nurse Manager #3, the Director of Nursing, Social Worker #3, and the Director of Social Work confirmed that care plan invitations were supposed to be sent by letter, email, and/or telephone call, but the process was not consistently followed or documented. Staff stated attendance sheets were sometimes not brought to meetings, signatures were sometimes forgotten, notes were sometimes not completed when staff were absent, and there was no reliable way to confirm that mailed letters were sent or received. The Director of Nursing also stated the care plan invitation process had not been working accurately and the documentation needed work.
Unclean and Worn Unit Environment
Penalty
Summary
The facility did not maintain a clean, comfortable, and homelike environment on Unit 2 AB in the neurobehavioral building. Survey observations found the dining room with heavily worn tables and chairs, chipped and broken edges, torn and stained upholstery, a stained and soiled accordion divider, discolored floors with stains and brown scruff marks, grime in floor corners, dust and dirt on radiators and vent grills, and three steam tables with nonfunctioning indicator lights, smudges, dried food residue/grease, mineral buildup, and rust. The television room was also observed with an exposed radiator without a cover, a sofa with a broken frame sagging to the floor, damaged tables, ripped chair cushions, and streaked, scruffed floors. Resident rooms on the unit were observed with discolored or stained floors, dusty privacy curtains and windowsills, closets missing locks or handles, peeled sticker residue, dusty or unsecured air conditioning equipment, rusty bed frames and legs, rusty handrails, torn or damaged chairs, missing dresser drawers, and bathroom or shower stall tiles discolored and ingrained with grime. Multiple rooms also had wooden closets with scratches, scruff marks, sticker residue, and missing locks. These conditions were documented across several rooms and common areas during repeated observations of the unit. Staff interviews confirmed that housekeeping and maintenance staff were aware of the environmental concerns. The housekeeper stated they cleaned resident rooms, bathrooms, and common areas daily and acknowledged that the building and furniture conditions still made the areas look dull and not clean. The maintenance worker stated no work requests had been received for the observed issues and that worn furniture or structural damage requiring major construction would be addressed by administration. The Director of Maintenance and Housekeeping acknowledged the environmental and maintenance concerns and stated they had not yet completed routine rounding in the neurobehavioral building, while the Administrator stated the team had been discussing the concerns and had work to do to fix the areas.
Missing bowel management care plan
Penalty
Summary
A comprehensive, person-centered care plan was not developed and implemented to meet Resident #6’s bowel management needs. Resident #6 was admitted with diagnoses including Cerebrovascular Accident, Malnutrition, and Depression, and stated during interview that they had a long history of constipation and sometimes required an enema or laxative. The physician’s orders included Fleet Oil Rectal Enema as needed for constipation, Docusate Sodium 100 mg three capsules daily for bowel regimen, and Sennosides 8.6 mg three tablets each evening for bowel regimen, with holds for diarrhea or loose bowel movements. Despite these bowel-related orders and the resident’s reported constipation history, there was no documented evidence that a comprehensive care plan was developed to address bowel management. The Nurse Manager stated the resident had constipation issues, was on multiple medications, could be noncompliant at times, and needed encouragement to take medications and drink extra fluids, and also stated the resident should have had a care plan with interventions related to preventing complications. The DON stated unit nurse managers review admission documents, medications, and diagnoses to initiate appropriate care plans, and that additional care plans are reviewed based on incidents or changes, but was not aware that a constipation care plan had not been created for Resident #6.
G-tube Placement Not Verified Before Medication Administration
Penalty
Summary
The facility did not ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications of enteral feeding. Resident #184 had diagnoses including gastrostomy status, dysphagia, and altered mental status, and the quarterly MDS documented that the resident received 51% or more of calories through tube feeding. The physician’s order required the gastrostomy tube placement to be checked before any administration, and the care plan also directed staff to check tube placement prior to administration. During an observation of medication administration, an LPN gave medications through the resident’s gastrostomy tube without verifying the tube’s functioning before administration. The LPN stated the tube had been checked earlier by flushing with water and listening for bowel sounds, and said residuals were checked after feeding but not before or after medication administration. The LPN also stated they had not been in-serviced on other methods of verifying tube functioning. Interviews with the Nurse Manager, DON, and Regional Clinical Director showed differing descriptions of how tube placement and functioning should be verified, including checking bowel sounds, checking residuals, measuring tube length, and aspirating contents.
Food Served at Improper Temperature During Meal Service
Penalty
Summary
Food and drink were not maintained at palatable and appetizing temperatures during lunch meal service on neurobehavioral Unit 2 AB. The facility’s Meal Service policy stated meals would be served promptly to maintain adequate temperature and appearance, and the Meal Delivery Schedule Sheet showed lunch for Unit 2 AB was scheduled for 12:00 PM. During a dining observation, meals served in disposable lunch boxes appeared unappetizing and lukewarm. A test tray later obtained for the unit showed hot food items below the expected serving temperature, including corn at 113 degrees Fahrenheit, ground chicken at 105 degrees Fahrenheit, mixed vegetables at 117 degrees Fahrenheit, chopped chicken at 103 degrees Fahrenheit, baked potato at 126 degrees Fahrenheit, and chicken tenders at 110 degrees Fahrenheit. Staff interviews described the meal service process for the unit as hot foods being delivered in an insulated food cart, set up in a steam table about 30 minutes before meal service, then plated by dietary staff while cold foods were assembled by CNAs. RN #2 stated the nurse completed a final check before the dining room was opened for residents. The FSD stated hot foods should be held and served at least at 140 degrees Fahrenheit and acknowledged the hot foods were not maintained in the appropriate temperature range for the 12/15/2025 meal service.
Unsafe and Unsanitary Staff Bathrooms and Nurses Stations
Penalty
Summary
The facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During multiple observations from 12/11/2025 to 12/18/2025, the 1st Floor staff bathroom was observed with walls in disrepair and stained with a blackish, brown substance, a white metal trash bin with brown discoloration and exposed gray material, and the 1st Floor Nurses Station had blue drawers with brownish discoloration, drawers leaning out of the desk, and white paint underneath the station thick with brown discoloration. The 2nd Floor Nurses Station also had missing floor tile and blue desk drawers in disrepair with brown discoloration. Additional observations of the staff bathroom on Unit 4 B from 12/17/2025 to 12/18/2025 found the toilet tissue holder cover hanging down and exposing the tissue, the soap dispenser hanging off the wall, the toilet seat liner holder broken and hanging at an angle, holes in the wall above the hand towel dispenser, brown stains on the wall under the hand towel dispenser, dust on the shelf above the sink, dust on the top of the mirror and air vent, broken tiles on the floor under the sink, and the base of the light fixture above the sink dusty and detached on the right side. The Director of Maintenance and Housekeeping, interviewed on 12/18/2025 at 2:33 PM, stated they had been in the position for two weeks and that their responsibilities included making rounds on the units daily, ensuring toilets were functioning, hand sanitizer and soap were available, and all spaces were clean; they also stated they had made rounds in the building and were compiling a list of items needing attention.
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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.
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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 | 0.2 mi | ★★★★★ | 0 | 0 |
| Verrazano Nursing And Post-acute Center | 1 mi | ★★★★★ | 0 | 0 |
| Silver Lake Specialized Rehab And Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Staten Island Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Carmel Richmond Healthcare And Rehabilitation Cent | 1.9 mi | ★★★★★ | 4 | 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.