Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Lake Specialized Rehabilitation And Care Ce during CMS and state inspections, most recent first.
A resident with dementia, syncope, gait abnormalities, severe cognitive impairment, and a history of multiple falls, who required substantial/maximal assistance for transfers, was placed in a wheelchair in a hallway and left without direct supervision while staff provided morning care to others. The resident’s fall care plan, initiated years earlier and later updated only to add a chair tab alarm, was not revised with new interventions despite repeated falls, and there was no documented fall risk assessment or monitoring schedule in place. Staff interviews showed reliance on the chair alarm for supervision and lack of awareness among CNAs of the resident’s fall history or specific fall-prevention measures. The resident was later found on the floor after staff heard an alarm or loud thump, and facility video review showed the resident leaning forward from the wheelchair to reach for something on the floor before falling, resulting in a head laceration and cervical fracture.
Two residents’ comprehensive care plans were not reviewed and revised as required following assessments and clinical events. One resident with COPD and dementia continued to receive O2 therapy under a respiratory care plan that had not been updated after a quarterly MDS, despite facility policy requiring at least 90‑day evaluations. Another resident with dementia, syncope, gait abnormalities, severe cognitive impairment, and a history of falls and fracture had a falls care plan with generic interventions that were not modified after multiple documented falls, including a hallway fall with a laceration from a wheelchair. Staff interviews confirmed that nurse managers, LPNs, and RNs were responsible for quarterly and significant-change updates, yet no new interventions were added and the plans were not revised in line with residents’ changing needs.
Environmental Maintenance and Housekeeping Deficiencies: Surveyors observed peeling and torn wallpaper, chipped paint, wall damage, marks on doors and furniture, a hanging light fixture, and an unfinished baseboard area across several resident units. Maintenance logs showed no documentation for these concerns, and staff interviews confirmed that housekeeping handled cleaning while maintenance handled repairs, with the DON unaware of the issues and the Director of Housekeeping stating the problems were part of ongoing renovations.
A facility failed to maintain comprehensive care plans for three residents receiving anticoagulant or antiplatelet therapy. Two residents were on antiplatelet medications and one resident was on Eliquis, but records showed no active care plans with measurable goals and interventions to address the medication-related bleeding risk. RN, ADON, and DON interviews confirmed these care plans were required but had not been created or implemented.
Failure to Document and Offer COVID-19 Vaccination to Staff: The facility failed to document COVID-19 vaccination screening, administration or declination, and education for 9 of 10 staff reviewed. The policy stated COVID-19 vaccination was recommended but not mandatory, yet the facility could not show that the vaccine was offered or that staff had the opportunity to consent or decline. The IP stated the vaccine was no longer offered because the facility was no longer reimbursed, and the DON could not explain why staff were not being offered the vaccine.
A facility failed to maintain a working call bell system in resident rooms, bathrooms, and shower areas across multiple units. Residents and staff reported that call bells and call lights had been nonfunctioning for months to over a year, with residents using hand bells or dinner bells instead and some residents having to yell for staff assistance. Observations confirmed that multiple room, shower, and bathroom call devices did not activate audible or visual alerts, and the DON, ADON, unit managers, and Administrator all acknowledged the ongoing problem and the lack of a call bell policy.
A resident with dementia, syncope, and gait abnormalities, assessed as severely cognitively impaired, was found on the hallway floor after staff heard an alarm, with an unwitnessed fall from a wheelchair and a laceration above the right eyebrow. Hospital records confirmed an acute C2 (odontoid) fracture and recommended neurosurgery follow-up, indicating a major injury of unknown origin. The facility’s incident report described the event as unwitnessed, with the resident confused and unable to follow instructions, while nursing staff were occupied in the med room and providing care to other residents. The facility’s abuse investigation policy addressed investigation of injuries of unknown source but lacked protocols for reporting them to the State Survey Agency, and leadership interviews revealed uncertainty and misunderstanding about the requirement to report such major injuries, resulting in the incident not being reported to the state health department.
A ventilator-dependent resident with multiple comorbidities had a clearly documented allergy to Vancomycin in the care plan, physician orders, and EMR, and wore a red allergy bracelet. Despite this, a provider ordered IV Vancomycin for pneumonia, and an RN administered the dose without reconciling the order against the documented allergy. After administration, staff noted wheezing, increased work of breathing, facial and lip swelling, and abnormal lung sounds, and a medication error report later identified failure to check the allergy as the cause.
A resident with multiple chronic conditions and a documented allergy to Vancomycin received IV Vancomycin after a new order was written and processed. The allergy had been added to the care plan and physician orders, and the pharmacy profile reflected the allergy, but the pharmacy’s dispensing system was not updated to flag it, and the RN who administered the dose failed to check the allergy information. The resident subsequently developed increased work of breathing and facial and lip swelling while receiving the infusion, and a medication error report cited failure to check allergies as the cause.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed multiple times in the dining room with catheter tubing exposed and urine visible in the tubing. The care plan and facility policy required the tubing and drainage bag to be kept covered, and staff interviews confirmed the tubing had not been noticed and that leg bags or blankets were used to keep it concealed.
Failure to support a resident’s activity preferences. A resident with dx including dysphagia, anxiety disorder, and intracerebral hemorrhage was non-verbal but able to hear and had Mandarin as the preferred language. The resident’s representative said the facility never asked about activity preferences and that the resident liked Mandarin TV programs. Observations showed the resident sitting in a wheelchair in the room or dining room with no ongoing activities while the TV was on an English channel. Staff stated the facility only had English and Spanish TV channels, and there was no documented evidence that the resident’s preference to watch TV in a language they understand was established.
A resident with COPD and dementia received oxygen via nasal cannula tubing that remained dated 03/27/2026 during multiple observations, despite orders and the care plan requiring routine tubing changes. Staff interviews confirmed the tubing should have been replaced and that the resident should not have still been using the dated tubing, even though the TAR documented several tubing changes.
A resident with dementia and moderate cognitive impairment was physically abused by a CNA, who struck the resident on the head and arm following a verbal altercation in the dayroom. Surveillance footage confirmed the incident, and the CNA admitted to the actions, which violated the facility's abuse prevention policy.
A CNA was observed on surveillance footage striking a resident with dementia on the head and upper arm. Although the incident was reported to the Department of Health, it was not reported to local law enforcement as required by federal law and facility policy, resulting in a deficiency for failure to report suspected abuse within mandated timeframes.
The facility did not ensure a clean, comfortable, and homelike environment across all resident floors. Observations revealed stained walls, missing paint, torn wallpaper, and dirty AC units on the 1st Floor; rusty and mismatched tables on the 2nd Floor; missing baseboards and exposed wires on the 3rd Floor; and mismatched tables on the 4th Floor. Staff interviews indicated a lack of awareness and reporting of these issues.
The facility was found to have expired food items, including cottage cheese and thickened juices, in its kitchen and pantry refrigerators. Staff interviews revealed inconsistent procedures for checking and discarding expired items, with responsibilities shared between dietary and nursing staff. The Registered Dietitian and Food Service Director were aware of the issue but had not identified the expired items during their checks.
The facility failed to maintain infection control practices, with a resident's Foley catheter tubing found on the floor and inadequate hand hygiene observed in the Main Dining Room. Despite policies requiring catheter care and hand hygiene, staff interviews revealed lapses in monitoring and coordination, leading to these deficiencies.
A resident with a Foley catheter was observed with their drainage bag exposed and visible from the hallway, contrary to the facility's policy requiring dignity bag covers. Despite staff awareness of the policy, the resident's bag was not covered, and the tubing was on the floor. Interviews with a CNA, an LPN, and the ADON revealed a lack of adherence to the policy, with no explanation provided for the oversight.
A resident with anemia and paraplegia was not invited to participate in their Comprehensive Care Plan (CCP) meetings, despite being cognitively intact. Facility policy required resident participation in various CCP meetings, but staff interviews revealed that residents were not invited to quarterly meetings. The Director of Social Worker, Assistant Director of Nursing, and Director of Nursing were unaware of the need to include residents in all scheduled meetings, leading to the resident's exclusion from their care planning process.
A facility failed to accurately document a resident's use of bilateral hand mittens as a restraint in the MDS assessment. Despite physician orders and documentation indicating the use of mittens to prevent the resident from pulling at tubes, the MDS assessment did not reflect this. Observations confirmed the use of mittens, and the MDS Assessor admitted the omission was an oversight.
Unwitnessed Hallway Fall of High-Risk Resident Left Without Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment to prevent accidents for a resident with severe cognitive impairment and a history of multiple falls. The resident had diagnoses including dementia, syncope, and gait and mobility abnormalities, and required substantial/maximal assistance for sit-to-stand and transfers per the MDS. Despite this, the facility could not provide documentation of a fall risk assessment prior to the resident’s fall, and the existing fall/injury care plan, initiated in 2022 and updated in 2024 to include a wheelchair tab alarm, was not revised with new interventions after multiple documented falls in 2022, 2023, and early 2024. On the date of the incident, staff transferred the resident out of bed to a wheelchair in the early morning and left the resident sitting in the hallway. The resident was not on any documented monitoring or supervision schedule at that time. Staff interviews revealed that the CNA assigned to the resident placed the resident in the hallway and then went to other rooms to provide morning care, and the LPN on duty stated the resident was left in the hallway and that they relied on the chair alarm for supervision. The CNA assigned to the resident reported not being aware of the resident’s prior falls or any specific fall-prevention interventions beyond the alarm, and another CNA on the unit stated the resident was not on any supervision or monitoring schedule and that they were unaware if the resident had a wheelchair or bed alarm. At approximately 5:50 AM, staff heard an alarm and/or a loud thump and found the resident on the floor in the hallway with a laceration above the right eyebrow and active bleeding. The fall was unwitnessed, and the resident, who was confused and had impaired judgment and inability to follow instructions, was unable to explain how the incident occurred. Facility investigation and review of surveillance footage by nursing leadership showed the resident in a wheelchair in the hallway, leaning forward to reach for something on the floor and then falling forward. The resident was transported to the hospital, where imaging confirmed an acute fracture of the odontoid process of the second cervical vertebra, and the facility documented that the resident sustained a cervical fracture as a result of the fall.
Failure to Review and Revise Comprehensive Care Plans for Respiratory Care and Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and in response to changes in residents’ needs, as required by facility policy and regulation. The facility’s policy on comprehensive care plans, last reviewed in January 2026, states that individualized care plans with measurable objectives and timetables must be evaluated in response to significant changes in a resident’s status or at least every 90 days. Surveyors found that this process was not followed for residents receiving respiratory care and for a resident with a history of falls. For one resident with diagnoses including Chronic Obstructive Pulmonary Disease and non-Alzheimer’s dementia, a quarterly Minimum Data Set (MDS) assessment documented that the resident was receiving oxygen therapy. The resident’s Respiratory Conditions Comprehensive Care Plan, initiated in June 2023, included a goal to remain free from signs and symptoms of respiratory distress for 90 days, with interventions such as administering oxygen as needed and elevating the head of the bed due to shortness of breath when lying flat. This care plan was last updated in December 2025 and was not revised following the resident’s quarterly MDS assessment in March 2026. Interviews with the unit manager LPN, the Assistant Director of Nursing, and the Director of Nursing confirmed that nurse managers and supervisors were responsible for quarterly updates and that they were unaware or unable to explain why the respiratory care plan had not been updated. For another resident with dementia, syncope and collapse, and gait and mobility abnormalities, the MDS documented severe cognitive impairment, a history of falls, and a fracture related to a fall. A falls/injury comprehensive care plan was initiated in January 2022 for physical performance limitations, with interventions such as anticipating needs, monitoring activities, and monitoring risk factors. The care plan notes documented multiple prior falls over 2022–2024, but the interventions were not updated in response to these incidents. In June 2025, the resident sustained another fall in the hallway, resulting in a visible laceration above the right eyebrow, and the care plan documented that the resident had been leaning forward and fell from a wheelchair; however, there was no evidence that fall-prevention interventions were reviewed or revised after this event. The CNA assignment sheet from April 2025 showed the resident required extensive assistance of two staff for transfers and only listed a tab alarm on chair and bed for fall prevention. Interviews with nursing staff and leadership indicated that care plans were expected to be updated quarterly, annually, with significant changes, and as needed, but confirmed that no new fall-prevention interventions were added and that responsibility for updating care plans rested with unit managers, LPNs, and RNs.
Environmental Maintenance and Housekeeping Deficiencies
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on multiple resident units, including Units 1A, 3A, 3B, and 4A. Surveyors observed peeling wallpaper behind headboards in rooms [ROOM NUMBER]-A, 103-B, and 105-B, a hole in the wall behind the bed in room [ROOM NUMBER]-A, and a light fixture hanging from the ceiling in the 4th Floor Unit 4-B shower room. On the 3rd Floor, the double doors between Units 3-A and 3-B had chipped paint and black marks, the Unit 3-B shower room doorframe had chipped yellow paint, and the shower room door and bedside table had marks and chipped paint. Additional observations included torn wallpaper and multiple ceiling cracks in a Unit 3-B bathroom, torn and peeling wallpaper in the entryways of Rooms 333, 334, 337, and 338, and brown and black marks, chipped wood, and white marks on the bathroom area of a Unit 3-A room. Surveyors also observed that the blue baseboard on Unit 3-A ended part way through the hallway, leaving an exposed gap near the dining room and rooms 301 through 311. Review of the maintenance logs for Units 3-A and 3-B from 12/29/2025 through 04/09/2026 showed no documentation related to these concerns. Staff interviews indicated that housekeeping staff were responsible for cleaning floors and surfaces, while maintenance staff were responsible for repairing chipped paint, torn wallpaper, broken furniture, damaged walls, and similar issues. The DON stated that staff on the units were responsible for creating maintenance tickets when problems were identified, but was not aware of the environmental concerns on Units 3-A and 3-B. The Director of Housekeeping acknowledged awareness of the concerns and stated they were part of ongoing renovations, including baseboard replacement that had been delayed because materials had run out.
Missing Care Plans for Anticoagulant and Antiplatelet Medications
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans with measurable objectives and timetables were developed and implemented for residents receiving anticoagulant or antiplatelet medications. Record review showed that Resident #41, who had diagnoses including heart failure and hypertension, was prescribed Plavix 75 mg daily for prophylaxis and was receiving the medication, but there was no documented active comprehensive care plan addressing the goals and interventions associated with Plavix use. Resident #92, who had diagnoses including heart failure and coronary artery disease, was prescribed Clopidogrel 75 mg daily and was receiving it, but there was no documented active comprehensive care plan addressing the goals and interventions associated with Clopidogrel use. Resident #187, who had diagnoses including hypertension and hyperlipidemia, was prescribed Eliquis 5 mg every 12 hours for transient cerebral ischemic attack and was receiving it, but there was no documented active comprehensive care plan addressing the goals and interventions associated with Eliquis use. The facility policy stated that individualized comprehensive care plans must include measurable objectives and timetables and be developed within seven days after completion of the comprehensive assessment. Interviews with the RN supervisor, ADON, and DON confirmed that residents taking anticoagulant or antiplatelet medications required care plans to address bleeding risk, and that the residents on the unit should have had such care plans in place.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases by not documenting COVID-19 vaccination screening, administration or declination, and education for nine of ten staff members reviewed. The facility policy titled Immunization Recommendation for Health Care Professions stated that up-to-date COVID-19 vaccinations are recommended by the CDC but are not mandatory. During the recertification survey, the facility could not provide documentation showing that COVID-19 vaccination was offered, that education was provided, or that staff had the opportunity to consent or decline for Certified Nursing Assistant #3, Registered Nurse #6, Respiratory Technician #2, Dietary Technician #1, Housekeepers #2, #3, and #4, Clinic Transportation Coordinator #1, and Laundry Attendant #1. The Infection Preventionist stated that the facility had provided the COVID-19 vaccine during the height of the pandemic but no longer offered it because they were no longer reimbursed for the cost, and that employees instead completed an Annual Employee Health Screen advising them to speak with their doctor about the vaccine and received an annual in-service on immunizations. The DON stated awareness that the facility was required to offer the COVID-19 vaccination to employees but could not explain why it was not being done.
Nonfunctioning Call Bell System in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was available in resident bathrooms and bathing areas, and also failed to provide a policy on the call bell system. Record review showed Amazon orders for handbells and a proposal for a new nurse call system, but the proposal was not signed. During a resident council meeting, residents stated that call bells and lights on Unit 2-A were not working, that the facility was aware of the problem, and that the issue had been ongoing for about a year. Residents also stated they had been given hand bells and dinner bells to use instead of the call bell system. Observations confirmed multiple nonfunctioning call bells and call lights across several units. On Unit 2-A, call bells in resident rooms did not activate when pressed, and the nursing station did not emit sound. On Unit 1-A, shower call bell lights did not light up when pressed. On Unit 4-B, the emergency shower call bell did not light up or make a sound, and the nursing station call system had no alert sound when activated from resident rooms. On Unit 3-B, multiple resident rooms, two shower rooms, and a shared bathroom had call bells that did not produce audible sound or visible light when pressed. On Unit 6, the unit nursing supervisor stated that all call bells in resident rooms and common areas had been nonfunctioning for six months after the system overheated and was taken offline by Maintenance. Interviews with residents and staff showed the issue was longstanding and known to management. A resident stated their call bell had not worked for over a year and that they had to yell or use a dinner bell to get staff attention. Another resident stated the call bells had not worked for over six months and that multiple residents ringing hand bells at the same time was disruptive, while staff did not always hear the bells. Staff members, including unit managers, the DON, the ADON, the Director of Housekeeping, and the Administrator, acknowledged that multiple units had call bell problems, that residents had been given hand bells, and that the Administrator knew the system was outdated and partially obsolete. The Administrator stated the facility had received an estimate for a new system but had not installed it because of financial constraints.
Failure to Report Unwitnessed Fall With Major Injury to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving an injury of unknown source that resulted in serious bodily injury to the State Survey Agency, as required. A cognitively impaired resident with diagnoses including dementia, syncope and collapse, and gait and mobility abnormalities, and assessed as having severe cognitive impairment, was found on the floor in the hallway after staff heard an alarm. Nursing documentation shows that an LPN heard the alarm while in the medication room, found the resident on the floor, and called the nursing supervisor. An RN documented that the resident had an unwitnessed fall from a wheelchair with a visible laceration above the right eyebrow, and the resident was unable to state how the incident occurred. Hospital records and the transfer form documented that the resident sustained an acute fracture of the odontoid process (C2 cervical vertebra) and that neurosurgery follow-up was recommended, confirming a major injury. The facility’s Accident/Incident Report, completed several days later, described the event as unwitnessed, with the resident confused, having impaired judgment, and unable to understand and follow instructions, and noted that the floor nurse was in the medication room and CNAs were providing care to other residents at the time. There was no documented evidence that this unwitnessed fall with a major injury and unknown cause was reported to the New York State Department of Health. The facility’s abuse investigation policy required prompt investigation of injuries of unknown source but did not include protocols for reporting such injuries to the State Survey Agency, and interviews with the Assistant DON and DON showed uncertainty and misunderstanding about the requirement to report major injuries of unknown origin.
Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and documented medication allergies. The facility’s medication administration policy required nurses to verify allergies prior to giving medications. Resident #191 had multiple diagnoses including heart failure, seizure disorder, respiratory failure, and ventilator dependence, and wore a red allergy bracelet. The resident’s comprehensive care plan initially listed an allergy to mucomyst and was later updated to include an allergy to Vancomycin, with interventions such as monitoring for allergic reactions and use of a red charm bracelet. A physician’s order also documented the resident’s allergy to Vancomycin. Despite the documented allergy, a subsequent physician’s order was entered for Vancomycin 1 gram IV every 12 hours for 10 days, and the medication was administered by a registered nurse. The Medication Administration Record showed that Vancomycin was given on 06/30/2025 at 9:00 AM. At that time, the resident was ventilator-dependent and severely cognitively impaired, and the allergy information was available in the electronic medical record and indicated by the allergy bracelet. The failure to reconcile the new Vancomycin order with the existing allergy documentation and to verify allergies before administration led to the resident receiving a medication to which they were known to be allergic. Following the administration, clinical staff observed changes in the resident’s condition. A respiratory therapist documented scattered rhonchi, wheezing, and an oxygen saturation of 96%, and noted that the resident required suctioning for large amounts of thick yellowish secretions and received albuterol. An LPN later observed increased work of breathing, facial and lip swelling, and noted that the resident was receiving IV Vancomycin at that time. A medication error report documented that the error was due to failure to check the resident’s allergy, and interviews with nursing and respiratory staff confirmed that the resident had been given Vancomycin despite a known documented allergy and visible allergy alerts.
Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe medication dispensing and administration in accordance with professional standards, specifically related to a resident with a documented allergy to Vancomycin. The resident had multiple diagnoses including heart failure, seizure disorder, respiratory failure, and ventilator dependence, and was severely cognitively impaired and dependent for activities of daily living. A comprehensive care plan for medication allergies was initiated and later updated to include Vancomycin, and a physician’s order also documented the Vancomycin allergy. Despite this, a subsequent physician’s order was entered for IV Vancomycin, and the medication was dispensed by the pharmacy and administered by a registered nurse, who did not identify the documented allergy prior to administration. The facility was unable to provide a policy related to pharmacy services. Following administration of Vancomycin, the resident was observed by an LPN to have increased work of breathing, facial and lip swelling, and was noted to be receiving IV Vancomycin at that time. A medication error report documented that the error was due to failure to check the resident’s allergy. Interviews revealed that the prescribing physician stated the incident could have been prevented if staff at either the nursing home or the pharmacy had recognized the allergy. The pharmacy’s general manager reported that the resident’s medical profile showed a Vancomycin allergy and that the allergy was listed on the electronic physician order received by the pharmacy, but the pharmacy’s dispensing system did not prevent dispensing because the new allergy had not been updated in that system and therefore did not generate a flag. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident received Vancomycin despite the known allergy.
Exposed urinary catheter tubing observed in dining room
Penalty
Summary
Resident #140 was observed on multiple occasions in the main dining room with urinary catheter tubing exposed and visible light yellow urine noted in the tubing. The resident had diagnoses of non-Alzheimer's dementia, osteoporosis, and hypertension, and the quarterly MDS documented severely impaired cognition, always incontinent of urine, substantial assistance needed for lower body dressing, and dependence for toileting hygiene. A physician's order required urinary catheter care every shift, and the care plan directed that the catheter drainage tubing and drainage bag be kept covered at all times. The facility policy stated that catheter and drainage tubing must be kept covered at all times and that residents with urinary catheters would be checked every shift to ensure a dignity bag was present and the catheter drainage was well covered. During interviews, an LPN and an RN stated they had not noticed the exposed tubing and described the use of leg bags or blankets to keep tubing from being visible. The ADON stated that exposed urinary catheter tubing is a dignity and infection control issue and that nursing supervisors are responsible for making rounds to ensure privacy. The DON stated that leg bags and blankets must be used to cover exposed urinary catheter tubing and that the tubing must be concealed to maintain respect and dignity.
Failure to Support Resident Activity Preferences
Penalty
Summary
The facility failed to provide an ongoing program of activities that supported a resident’s choice of activities and met the resident’s assessed interests and preferences. Resident #43 had diagnoses of dysphagia, anxiety disorder, and other nontraumatic intracerebral hemorrhage, was non-verbal but able to hear, and had a preferred language of Mandarin. The resident’s representative stated the facility never asked about activity preferences and reported that the resident liked to watch Mandarin television programs when in the community. Observations from 04/09/2026 through 04/15/2026 showed Resident #43 sitting in a wheelchair in the room or dining room without ongoing activities, while the television was on an English channel. The annual MDS documented Mandarin as the preferred language and noted the importance of music and favorite activities as reported by the representative. The care plan included a goal for daily participation in programs of choice, and the recreation assessment documented that the resident spoke Mandarin and preferred music, television, and room visits. Facility staff stated the facility only provided English and Spanish television channels, and there was no documented evidence that the resident’s preference to watch television in a language they understand was established.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received oxygen tubing changes consistent with the physician’s order and the resident’s care plan. Resident #91 had diagnoses including Chronic Obstructive Pulmonary Disease and non-Alzheimer’s dementia, and the quarterly MDS documented shortness of breath while lying flat and oxygen therapy in the facility. The comprehensive care plan for respiratory conditions included administering oxygen as ordered and changing the oxygen tubing every three days. The physician’s order as of 04/02/2026 directed that the resident’s oxygen tubing be changed every 72 hours, while the facility policy stated that oxygen tubing was to be changed every 48 hours and dated/initialed when replaced. During observations on 04/09/2026, 04/10/2026, and 04/14/2026, the resident was seen receiving oxygen via nasal cannula with tubing dated 03/27/2026, including while connected to a portable oxygen tank and while the tubing was hanging exposed without protective covering. The treatment administration record documented tubing changes on 04/03/2026, 04/06/2026, 04/09/2026, and 04/12/2026, but staff interviews indicated the tubing should have been replaced and that the resident should not have still been using tubing dated 03/27/2026. The unit manager, ADONs, and DON all stated that the tubing should have been changed by nursing staff, and they did not know why the policy was not followed for the resident’s oxygen therapy care.
Resident Physically Abused by CNA in Dayroom
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident in the facility's dayroom. Surveillance footage captured the CNA approaching the resident, pulling a table away from the resident's wheelchair, and then striking the resident on the back of the head with an open hand, causing the resident's head to fall forward. Shortly after, the CNA pushed the resident's wheelchair to the dayroom exit and, following a verbal exchange and the resident throwing a cup of liquid at the CNA, the CNA struck the resident's upper arm twice with a paper plate. The incident was observed while reviewing surveillance footage for another matter. The resident involved had a history of dementia, restlessness, agitation, major depressive disorder, and obsessive-compulsive disorder, with documented moderate cognitive impairment. The resident's care plan included interventions to ensure safety and to remove the resident from the area of any aggressor. Despite these interventions, the CNA engaged in physical abuse following a verbal altercation, during which the resident used offensive language toward the CNA. The CNA admitted to slapping the resident on the head and stated awareness of the wrongdoing. Interviews with other residents assigned to the CNA revealed no similar complaints or witnessed abuse. Documentation showed that the CNA had received in-service training on abuse prevention. The facility's abuse prevention policy clearly stated residents' rights to be free from abuse, neglect, and corporal punishment, and required prompt reporting of any suspected abuse. However, the actions of the CNA violated these policies and resulted in the resident not being protected from abuse.
Failure to Timely Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to all required authorities within the mandated timeframes. Surveillance footage showed a Certified Nursing Assistant (CNA) approaching a resident in the dayroom, pulling a table away from the resident's wheelchair, and then striking the resident on the back of the head with an open hand. Later, the CNA was observed taking items from the resident's wheelchair and, after the resident threw a cup of liquid at the CNA, the CNA struck the resident's upper arm twice with a paper plate. The incident was discovered while reviewing surveillance footage for another matter. The resident involved had diagnoses including dementia, restlessness and agitation, major depressive disorder, and obsessive-compulsive disorder, with documentation of moderately impaired cognition. Although the CNA was immediately removed from the unit and the resident was evaluated with no injuries noted, the facility did not report the incident to local law enforcement as required by federal law and facility policy. The Administrator reported the incident to the Department of Health but did not believe it was necessary to notify law enforcement, resulting in a failure to meet reporting requirements for suspected abuse.
Facility Fails to Maintain Homelike Environment Across All Floors
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all four resident floors, as observed during the recertification survey. On the 1st Floor, issues included stained walls and curtains, missing and mismatched paint, missing baseboards, torn wallpaper, and a dirty air conditioning unit. Specific rooms had additional problems such as missing sink handles, cracked tiles, brown water stains on drapes, peeling paint, exposed wall outlets, and unpainted drywall patches. The pantry also had unpainted patches and missing veneer under the sink. On the 2nd Floor, the dining room had a rusty overbed table and several tables with mismatched and missing paint. The 3rd Floor had missing baseboards, mismatched and unpainted areas in the hallway, and cracked and missing veneer on pantry shelves. The ceiling light in the pantry was missing a cover, exposing wires and a light bulb. The dining room had tables with missing and mismatched paint. On the 4th Floor, rooms had overbed and bedside tables with mismatched and missing paint. Interviews with staff revealed a lack of awareness and reporting of these issues, with maintenance staff acknowledging the poor condition of the tables but being unable to address them due to other priorities.
Expired Food Items Found in Facility
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that a 5-pound container of expired cottage cheese was found in the kitchen refrigerator. Additionally, the 3rd floor pantry contained expired honey-thickened juices, and the 4th floor pantry had an expired quart of milk. These findings indicate a lapse in the facility's adherence to its policy on food supply storage and receiving, which mandates proper stock rotation and the provision of fresh food for residents. Interviews with staff revealed a lack of consistent procedures for checking and discarding expired food items. A dietary aide responsible for stocking the kitchen refrigerator did not notice the expired cottage cheese. A CNA on the 3rd floor, who was responsible for checking the dates on thickened beverages, did not include the pantry refrigerator in their routine checks. An LPN stated that the night shift was responsible for clearing expired items but admitted to not having time to do so. The Registered Dietitian and Food Service Director acknowledged that both nursing and dietary staff should collaborate on this task, but neither had identified the expired items during their checks.
Infection Control Deficiencies in Catheter Care and Dining Room Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two specific incidents. First, Resident #238, who has a history of myocardial infarction and heart failure and is moderately cognitively impaired, was observed multiple times with their Foley catheter tubing touching the floor. This is contrary to the facility's policy, which mandates that catheter tubing and drainage bags be kept off the floor. Despite the care plan and physician's orders requiring monitoring and care of the catheter every shift, the tubing was found on the floor during several observations. Interviews with the CNA, LPN, and DON confirmed that the tubing should not have been on the floor, but no explanation was provided for the oversight. The second incident involved a lack of hand hygiene practices in the Main Dining Room (MDR) during lunch service. Residents were not offered hand hygiene before being served beverages, and one resident was observed distributing bibs to others after licking their hand. Interviews with staff, including a CNA, DA, RN, and the ADON/IP, revealed a lack of coordination and responsibility for ensuring hand hygiene. The CNA responsible for assisting with meal service was on break when service began, and the DA, who served beverages, did not ensure residents' hands were clean. The ADON/IP acknowledged the oversight and noted that they did not observe the meal service on the day of the incident.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident with a urinary catheter, as observed during a recertification survey. Resident #238, who had a Foley catheter due to diagnoses of myocardial infarction and heart failure, was found with their catheter drainage bag exposed and visible from the hallway on multiple occasions. The facility's policy required that catheter bags be kept inside a dignity bag cover at all times, except during care, to maintain resident dignity. However, the resident's drainage bag was not contained in a dignity bag, and the tubing was observed on the floor. Interviews with staff revealed a lack of adherence to the facility's policy. A CNA confirmed that catheter care was provided every shift and that all residents with catheters should have their drainage bags covered with dignity bags. However, the CNA could not explain why the resident's bag was not covered. An LPN stated that they perform frequent rounds and that catheter bags should be contained in dignity bags, but they had not observed the resident's exposed bag. The ADON/Infection Control Preventionist acknowledged that staff were aware of the requirement to keep catheter bags in dignity bags and that supervisors were responsible for ensuring compliance.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to ensure a resident's right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified during a recertification survey, where it was found that a resident with diagnoses of anemia and paraplegia, who was cognitively intact, was not invited to attend their Comprehensive Care Plan (CCP) meetings since their admission. The facility's policy stated that residents and their health care agents or family members should be invited to participate in various CCP meetings, including admission, annual, significant change, and discharge meetings. However, it was noted that residents were not invited to quarterly CCP meetings. Interviews with facility staff, including the Director of Social Worker (DSW), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed a lack of awareness and adherence to the policy regarding resident participation in CCP meetings. The DSW confirmed that residents were invited to certain meetings but not to quarterly ones. The ADON and DON were unaware that residents should be invited to all scheduled meetings, indicating a gap in communication and understanding of the policy requirements. This oversight resulted in the resident not being involved in their care planning process, as required by regulations.
Inaccurate MDS Assessment of Resident's Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected the status of a resident, specifically regarding the use of physical restraints. This deficiency was identified during a recertification survey conducted from December 6, 2023, to December 13, 2023. The issue was observed in one resident who had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The MDS assessment dated November 30, 2023, did not document the resident's use of bilateral hand mittens, which were used as a restraint to prevent the resident from pulling at tubes. Despite the physician's order and documentation in the Certified Nursing Assistant (CNA) Accountability Record and Comprehensive Care Plan (CCP) indicating the use of hand mittens, the MDS assessment failed to capture this information. Observations made on December 6 and December 13, 2023, confirmed that the resident was wearing bilateral hand mittens. Interviews with a CNA and the MDS Assessor revealed that the mittens were used to prevent the resident from pulling at their gastrostomy and trach tubes. The MDS Assessor acknowledged that the omission of the hand mittens in the MDS assessment was an oversight, as the resident did not use the mittens at the time the assessment was completed. This oversight led to the inaccurate reflection of the resident's status in the MDS assessment, violating the regulatory requirement for accurate resident assessments.
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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.
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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) |
|---|---|---|---|---|
| Verrazano Nursing And Post-acute Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Staten Island Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Richmond Center For Rehabilitation And Specialty H | 1.1 mi | ★★★★★ | 11 | 0 |
| New Vanderbilt Rehabilitation And Care Center, Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Clove Lakes Health Care And Rehabilitation Center, | 2.4 mi | ★★★★★ | 10 | 2 |
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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 October 2026) and official state health department websites.