Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Marys Hospital For Children during CMS and state inspections, most recent first.
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
A resident with Spastic Quadriplegic Cerebral Palsy and Epilepsy did not receive the prescribed wrist cock-up splints during daytime hours as ordered by a physician. Despite the facility's policy and physician's order, staff applied the splints only when the resident was out of bed, citing fragile skin as a concern. The Occupational Therapist emphasized the need for the splints to maintain joint integrity, but the issue was not communicated to the physician for order adjustment, resulting in a deficiency.
A facility failed to protect a resident from physical abuse when a CNA was witnessed slapping the resident's arm twice. The RN who witnessed the incident did not report it immediately or remove the CNA from patient care. The facility's investigation confirmed the abuse, leading to the CNA's termination.
A resident with severe cognitive impairment was slapped twice by a CNA, an incident witnessed by an RN who reported it the following day, beyond the required 2-hour window. The facility reported the abuse to NYSDOH but failed to notify local law enforcement, contrary to their policy and state regulations.
A facility failed to report an alleged abuse incident within the required 2-hour timeframe. A C.N.A was witnessed slapping a resident's arm twice, but the incident was not reported to the NYSDOH until the following morning. The resident, who had severe cognitive impairment, was assessed and found to have no injuries. The RN who witnessed the incident did not report it immediately, citing insufficient training on reporting requirements. The facility's investigation found the abuse allegation credible, resulting in the C.N.A's termination.
A facility failed to develop and implement a Comprehensive Care Plan (CCP) related to abuse prevention for a resident following a substantiated abuse allegation. The resident, who had multiple diagnoses and severely impaired cognition, was slapped twice by a CNA. Despite the incident being reported and the CNA being terminated, no CCP addressing abuse prevention was created.
The facility failed to ensure that comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This deficiency was evident in two residents whose CCPs for alteration in urinary elimination were not updated as required. Interviews with staff indicated that the new EMR system may have contributed to the oversight.
The facility failed to ensure residents were free from accidents, resulting in injuries to two residents from improperly monitored hot compresses. One resident sustained redness and blistering on the abdomen, while another suffered a second-degree burn on the thigh. Staff did not follow the facility's policy for hot pack application and monitoring.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Apply Wrist Splints as Ordered for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the necessary services and equipment to maintain or improve their range of motion. Specifically, a resident with diagnoses including Spastic Quadriplegic Cerebral Palsy and Epilepsy had a physician's order for bilateral wrist cock-up splints to be applied during daytime hours. However, during multiple observations, the resident was found without the splints applied, contrary to the physician's order. The facility's policy required assessments and interventions for residents with osteopenia, including the use of assistive devices, but these were not properly implemented for this resident. Interviews with facility staff revealed a lack of adherence to the physician's order. A CNA and RN both stated that the splints were only applied when the resident was out of bed, despite the order specifying all-day application. The RN cited the resident's fragile skin as a reason for not applying the splints for the full duration. The Occupational Therapist confirmed the importance of the splints in maintaining joint integrity and preventing contractures. The Director of Nursing acknowledged that any issues with tolerance should have been communicated to the physician for order adjustment, which was not done, leading to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility did not ensure that a resident was free from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with severe cognitive impairment and multiple medical conditions. On the evening of 10/03/22, a Registered Nurse (RN) witnessed the CNA slapping the resident's arm twice while the resident was reaching for a nebulizer treatment. Despite witnessing the incident, the RN failed to remove the CNA from patient care and allowed the CNA to continue working until the end of the shift. The resident was assessed and found to have no injuries from the incident. The facility's investigation confirmed the abuse, leading to the termination of the CNA. Interviews with the involved staff revealed that the RN did not report the incident immediately, citing a lack of awareness about the requirement to report abuse promptly. The RN also mentioned a prior dispute with the CNA, which may have influenced the delay in reporting. Another CNA in the room did not witness the slapping but heard the accused CNA speaking loudly to the resident. The Director of Nursing (DON) and the Administrator both acknowledged that the incident should have been reported immediately and that the accused CNA should have been removed from resident care pending the investigation. The facility's policy mandates immediate reporting and removal of the accused staff member in cases of suspected abuse. The failure to adhere to these protocols resulted in a deficiency in protecting the resident from abuse.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH) and local law enforcement (LLE). Specifically, a resident with severe cognitive impairment and multiple diagnoses, including Generalized Epilepsy and Developmental Delays, was slapped twice on their right hand by a Certified Nursing Assistant (CNA). The incident was witnessed by a Registered Nurse (RN) who reported it to the Assistant Director of Nursing (ADON) the following day, well beyond the required 2-hour reporting window. The facility subsequently reported the violation to NYSDOH but failed to notify local law enforcement as required by their policy and state regulations. The facility's policy mandates that any allegation of abuse must be reported immediately, but not later than two hours after being informed of the allegation. Despite this, the RN who witnessed the abuse did not report it until the end of their shift the next day, citing a lack of awareness about the immediate reporting requirement. The Director of Nursing (DON) confirmed that the abuse allegation was credible and acknowledged that the RN should have reported the incident immediately. The Administrator also admitted that the incident should have been reported right away and that the failure to report to local law enforcement was due to uncertainty about the occurrence of the abuse.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours of the alleged violation to the New York State Department of Health (NYSDOH). Specifically, a Certified Nurse Assistant (C.N.A) was witnessed slapping a resident's arm hard twice while the resident was reaching out to the nebulizer treatment. The incident occurred at approximately 8:30 PM, but the report was not submitted to the NYSDOH until the following morning, exceeding the required 2-hour reporting window. The resident involved had severe cognitive impairment and required total assistance for activities of daily living. The resident was assessed for trauma, and no injuries were found, but the delay in reporting the incident was a clear violation of the facility's policy and state regulations. The Registered Nurse (RN) who witnessed the incident did not report it to the supervisor until the following day, citing a lack of detailed training on the immediate reporting requirements. The Director of Nursing (DON) and the Administrator confirmed that the facility's policy mandates immediate reporting of abuse allegations and that all staff undergo mandatory abuse training during hire and annually. The RN's failure to report the incident promptly and remove the C.N.A immediately contributed to the deficiency. The facility's investigation concluded that the abuse allegation was credible, leading to the termination of the C.N.A involved.
Failure to Develop Abuse Prevention Care Plan
Penalty
Summary
The facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the needs of a resident following a substantiated abuse allegation. Specifically, a CCP related to abuse prevention was not created for a resident who had been slapped twice on the arm by a Certified Nursing Assistant (CNA). The incident was witnessed by a Registered Nurse (RN) and was reported to the appropriate state agencies. The CNA involved was terminated from employment. Despite the incident, there was no documented evidence that a CCP addressing abuse prevention was developed for the resident. The resident involved had multiple diagnoses, including Generalized Epilepsy, Developmental Delays, Cortical Blindness, and required total assistance for Activities of Daily Living (ADLs). The resident was observed to have severely impaired cognition and was unable to make their needs known to staff. Following the abuse incident, physical assessments by both an RN and a Nurse Practitioner (NP) found no signs of trauma or changes to the resident's baseline condition. However, the Director of Nursing (DON) confirmed that a CCP related to abuse prevention was not initiated for the resident, despite the facility's policy requiring such plans to be kept current and updated as needed.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This deficiency was identified during an abbreviated survey and was evident in two of three residents reviewed for care planning. Specifically, the CCPs for alteration in urinary elimination for two residents were not reviewed and revised at each quarterly assessment and after a change in resident condition. The facility's policy required that CCPs be kept current and updated by all disciplines on an ongoing basis, but this was not adhered to in these cases. Resident #2, who had diagnoses including Congenital Malformation of Corpus Callosum, Congenital Deformity of Spine, and Epilepsy, had a CCP for alteration in urinary elimination initiated on 09/20/14. However, there was no documented evidence that this CCP was reviewed and revised at each quarterly assessment or after a change in condition. Similarly, Resident #3, with diagnoses of Congenital Laryngomalacia, Epilepsy, and Dysphagia, had a CCP for alteration in urinary elimination initiated on 10/18/22, but it was not reviewed and revised at each quarterly assessment thereafter. Interviews with facility staff revealed that the responsibility for initiating, reviewing, and revising care plans lay with the RN, but the new Electronic Medical Record (EMR) system may have contributed to the oversight in updating the CCPs.
Failure to Monitor Hot Compresses Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents were free from accidents, as evidenced by incidents involving two residents who sustained injuries from improperly monitored hot compresses. Resident #2, who had severely impaired cognition and multiple diagnoses including congenital malformations and epilepsy, was observed with redness on the right lower abdomen after a hot compress was applied by an LPN without a physician's order. The LPN left the resident unattended, and the compress was not monitored or removed according to the facility's policy, resulting in redness and blistering of the skin. The investigation concluded that neglect had occurred in this case. Resident #3, also with severely impaired cognition and multiple diagnoses, was observed with a blister on the upper right thigh after a hot compress was applied by an RN. Although there was a physician's order for the use of a warm pack, the order did not specify the duration and frequency of application. The RN did not follow the facility's policy for monitoring and removing the hot pack, leading to a second-degree burn. The investigation concluded that the blister was caused by the hot pack and that the incident was an accident. Interviews with staff revealed that the facility's usual practice involved using warm compresses to promote voiding without proper physician orders or adherence to monitoring protocols. The Director of Nursing and the Administrator confirmed that the facility's policy required a physician's order for hot pack application and that the hot pack should be covered with a barrier, monitored, and removed according to specific guidelines. However, these protocols were not followed in the cases of Resident #2 and Resident #3, leading to their injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,131 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bayside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ozanam Hall Of Queens Nursing Home Inc | 0.8 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Queens | 1.8 mi | ★★★★★ | 0 | 0 |
| Bridge View Nursing Home | 1.8 mi | ★★★★★ | 0 | 0 |
| Elmhurst Care Center, Inc, | 2.1 mi | ★★★★★ | 0 | 0 |
| Long Island Care Center Inc | 2.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Marys Hospital For Children.
100% money-back within 48 hours.
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.