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 Verrazano Nursing And Post-acute Center during CMS and state inspections, most recent first.
A resident with a history of mood disorder and anxiety informed a nurse supervisor of an intent to report abuse, which was relayed to the facility's MD. Despite this, neither the MD nor the nurse supervisor reported the abuse allegation to the DON or Administrator, and no documentation was made to state authorities as required by policy.
The facility failed to document the offering and education of COVID-19 immunizations for several residents, as required by their policy. Despite assessments indicating up-to-date immunization statuses, there was no evidence to support this. A transition in responsibility for monitoring immunizations contributed to this lapse.
The facility failed to offer and educate residents on Pneumococcal and Influenza immunizations, as required by their policies. Five residents were not provided with documented evidence of being offered or educated on these vaccines. The deficiency was due to a lapse in the immunization program following a personnel transition, resulting in residents not being up to date on their immunizations.
The facility failed to comply with the 2012 NFPA 101 Life Safety Code by installing alcohol-based hand rub (ABHR) dispensers directly above ignition sources, such as electrical outlets, in various corridors. This was observed during a recertification survey and confirmed through staff interviews.
The facility's egress stairs in both the East and West stairwells were found to lack the required contrasting colored marking stripe along the handrails, as per 2012 NFPA 101 standards. This deficiency was identified during a life safety survey, and staff acknowledged the issue.
The facility failed to develop comprehensive care plans for three residents, including one on diuretics, another receiving medical treatment, and a third on hospice care. The care plans lacked necessary focus, goals, and interventions, as confirmed by nursing staff and the Director of Nursing.
During a life safety survey, it was found that the facility did not have a sprinkler head on the basement side of a door interrupting the East stair on the first floor landing. This deficiency was acknowledged by the Maintenance Director, Administrator, and Environmental Services Director, violating NFPA standards.
A resident with cognitive impairments was physically abused by a CNA in the dining room after the resident threw water on the CNA. The incident was captured on video, showing the CNA slapping the resident. The facility's abuse prevention policy was not effectively implemented, leading to the incident being reported and investigated. The CNA was removed from the schedule following the investigation.
A resident developed a stage 4 pressure ulcer due to the facility's failure to implement a care plan and provide timely treatment. Despite being at mild risk, the resident's condition was not properly monitored, leading to infection and hospitalization. Staff interviews revealed communication lapses and high turnover as contributing factors.
The facility failed to report the results of an investigation involving alleged abuse between two residents to the State Survey Agency within the required 5 working days. The follow-up report was submitted 10 days after the incident, exceeding the mandated timeframe.
The facility failed to thoroughly investigate an alleged abuse incident involving two residents. The investigation did not include statements from staff members who may have witnessed the incident, and the conclusion was based solely on interviews with the residents involved.
A resident with serious mental illness was admitted without a completed PASRR screening. The facility staff failed to review preadmission documents properly, resulting in an incomplete screening process and lack of necessary evaluations before admission.
The facility failed to develop and implement comprehensive care plans for two residents following an allegation of sexual abuse. Despite the grievance form indicating no reasonable suspicion, no care plans were documented to address the abuse allegation.
A resident with multiple diagnoses was discharged without an effective discharge plan, despite the facility's social services team acknowledging their responsibility. The discharge process was complicated by pending guardianship proceedings, and no discharge care plan was created during the resident's stay.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse made by a resident was reported immediately to the appropriate authorities as required by policy and regulation. Specifically, a resident with diagnoses including mood disorder and anxiety informed a Registered Nurse Supervisor that they would tell a doctor at an outside appointment that they had been abused in the facility. The Registered Nurse Supervisor relayed this information to the facility's Medical Doctor, who later documented the resident's claim of abuse in a progress note. Despite this, neither the Medical Doctor nor the Registered Nurse Supervisor reported the allegation to the Director of Nursing or the Administrator, and there was no documentation that the incident was reported to the New York State Department of Health. The facility's policy required immediate reporting of all abuse allegations to the Administrator and Director of Nursing, and to the State Department of Health within two hours if serious bodily injury or abuse was involved. Review of records showed no incident or accident reports were initiated regarding the resident's complaint, and the Director of Nursing and Administrator were unaware of the allegation until months later. Interviews confirmed that the involved staff did not follow reporting procedures, and the required notifications and documentation were not completed at the time of the allegation.
Failure to Document COVID-19 Immunization for Residents
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 immunization, as observed during the Recertification Survey. This deficiency was identified in five residents who were sampled for immunizations. There was no documentation available regarding the screening, administration, declination, or education on the COVID-19 immunizations for these residents. The facility's policy required that all residents and their representatives be provided with education about the COVID-19 vaccination, and their decision to accept or decline the vaccination should be documented in the COVID Vaccination Care Plan. However, the facility was unable to provide evidence that these steps were followed for the sampled residents. The residents involved had varying levels of cognitive impairments, ranging from moderate to severe, and their Minimum Data Set assessments indicated that their COVID-19 immunization statuses were up to date. Despite this, the facility could not provide documentation to support these claims. Interviews with the Infection Preventionist and the Director of Nursing revealed that the responsibility for monitoring resident immunization statuses had transitioned from a former nurse to the Director of Nursing. This personnel change led to a lapse in maintaining the immunization program, resulting in the deficiency observed during the survey.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 and will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). The MDS Coordinator responsible for coding MDS comprehensive assessment on covid immunization was educated on improperly coding MDS (3/31/25). All Licensed nurses responsible for offering and educating residents the Covid vaccine were educated and re-inserviced on failure to offer, screen educate and document in the COVID Vaccination Care Plan (3/31/25). II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered COVID-19 vaccine upon admission with documentation in EMR related to the screening, administration or declination, and education on the COVID-19 immunizations. An audit was completed by the DNS on the COVID-19 Vaccination to ensure that all current residents in house were offered the COVID-19 Vaccination with signed consent/declination and education on file. Any identified issues will be addressed (3/25/25). III. Systemic Changes: The Policy and Procedure for COVID-19 Vaccination Administration for Residents was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received a re-inservice/education on ensuring that all residents are offered the COVID-19 vaccine upon admission. A matrix tracker was created to monitor the COVID-19 Vaccination status of all residents. Newly appointed Infection Control nurse was inserviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Covid vaccine, if appropriate, and vaccine status documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the COVID-19 vaccine upon admission. The DNS will conduct this audit weekly for 3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person responsible: DNS Date: 4/25/25
Failure to Offer and Educate on Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered and educated on Pneumococcal and Influenza immunizations, as required by their policies. This deficiency was identified during a recertification survey, where it was observed that five residents were not provided with documented evidence of being offered or educated on these immunizations. Specifically, Resident #23 was not offered or educated on the Influenza immunization, and Residents #11, #23, #57, #84, and #93 were not offered or educated on the Pneumococcal immunization. The facility's policies, last reviewed in 2023 and 2024, respectively, require that all residents be educated and offered these vaccines to prevent infections and reduce associated morbidity and mortality. The deficiency was attributed to a lapse in the facility's immunization program due to a personnel transition. The Director of Nursing, who assumed responsibility for monitoring resident immunization statuses after a nurse left the facility, acknowledged falling behind on maintaining the program. This oversight resulted in the sampled residents not being up to date on their immunizations. The report highlights that the facility was unable to provide documented evidence of the residents' immunization statuses or any medical contraindications that would prevent them from receiving the vaccines.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the Influenza vaccine. Education on benefits and potential risk was provided. Consent was received. Influenza vaccine was administered on (MONTH) 17th, 2025. Family and MD were informed. 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Declination was received secondary to resident’s hospice status. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered the Influenza and Pneumococcal vaccine upon admission and annually and provided with educational material for review. An audit of the entire house was completed by the DNS on the Influenza and Pneumococcal Vaccination to ensure that all new admission and readmissions were offered the Influenza vaccine for the 2024-2025 flu season and Pneumococcal Vaccination with signed consent/declination and education on file. All identified issues were addressed (3/26/25). The facility will ensure that each resident that was offered the Pneumococcal and Influenza immunizations will be followed with documented evidence in EMR to validate compliance. III. Systemic Changes: The Policy and Procedure for Conducting the Influenza Vaccination Program for Residents was reviewed by the DNS and found to be in compliance. The Policy and Procedure for Pneumococcal Vaccination for Residents was reviewed by the DNS and found to be in compliance. On 3/31/2025 all RNs and LPNs received in-service/education on ensuring that all residents are offered the influenza vaccine during the flu season and offered the pneumococcal vaccine upon admission if they meet the criteria and documented in EMR. A matrix tracker was created to monitor the Influenza and Pneumococcal vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring, documenting and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Flu and Pneumococcal vaccine, if appropriate, and documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the Influenza and Pneumococcal vaccine upon admission and annually. The DNS will conduct this audit weekly x3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25
Improper Installation of ABHR Dispensers Near Ignition Sources
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101 Life Safety Code regarding the installation of alcohol-based hand rub (ABHR) dispensers. During a recertification survey, it was observed that ABHR dispensers were installed directly above ignition sources, specifically electrical outlets, in several locations within the facility. These locations included corridors on the second to fourth floors near specific room numbers, as well as in the corridor outside of the kitchen on the first floor. This installation violates the requirement that ABHR dispensers should not be placed directly over or within one inch of ignition sources. The deficiency was confirmed through staff interviews during the survey process.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action The alcohol-based hand rub dispensers on first floor near kitchen, on second floor near room [ROOM NUMBER], on third floor near 309, on fourth floor near 409 were removed and placed away from ignition sources (3/14/25). Identification of others All residents have the potential to be affected by this deficient practice. A complete audit of the entire building was completed to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources (3/14/25). No other issues were identified. All Maintenance Staff will be in serviced on the importance of ensuring that all Alcohol Based Dispensers shall not be installed above an ignition source within a 1 in. radius from an ignition source (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on placement of Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1. All Maintenance staff will be in serviced on the importance of ensuring that appropriate placement of the Alcohol Based Hand-Rub Dispensers. All Alcohol Based Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources complying with requirements of 2012 NFOA 101. There will be a visual check of all alcohol-based hand rub (ABHR) dispensers weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person Maintenance Director is responsible. 4/25/25- date of correction.
Egress Stairs Handrail Marking Deficiency
Penalty
Summary
The facility failed to maintain egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey conducted on March 13, 2025, it was observed that the handrails in both the East and West stairwells lacked the required contrasting colored marking stripe along the entire length of the stairwells. This deficiency was noted between 9:00 am and 12:00 pm. The absence of the marking stripe was confirmed through observation and staff interviews, where the Director of Environmental Services and Director of Maintenance acknowledged the issue and stated that the rails would be painted.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action All handrails and handrail extensions were marked with a solid and continuous marking in egress stairs in both of the facility's stairwells (3/17/25). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all egress staircases was audited to ensure that it was maintained in accordance with 2012 NFPA 101 and that the handrails are painted with the required contrasting colored marking with a 1-inch width horizontal stripe for the length of the stairwell (3/17/25). All stairwell handrails have been painted with a 1-inch horizontal stripe to meet NFPA 101 egress requirements (3/17/25). All Maintenance staff will be in serviced on the importance of ensuring that all handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. Systematic Changes The Maintenance Director and Administrator reviewed the 2012 NFPA 101 manual and created a policy on Means of Egress Requirements. All Maintenance staff will be in serviced on the Means of Egress Requirements policy of Exit Stair Handrails (3/31/25). All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. QA The Maintenance Director and Administrator developed an audit tool to ensure that all exit stair handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. There will be a visual check of all exit stairwell handrails weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25 - date of correction.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for three residents during a recertification survey. Resident #28, who had diagnoses including hypertension and was prescribed a diuretic, did not have a comprehensive care plan addressing the use of the diuretic. The cardiac care plan initiated for this resident lacked focus, goals, and interventions. Registered Nurse #3 confirmed the absence of a comprehensive care plan for the diuretic medication. Resident #79, who was receiving medical treatment three times a week, had a care plan initiated but it lacked necessary interventions, rendering it incomplete. Registered Nurse #4 acknowledged the missing interventions in the care plan. Resident #93, who was severely cognitively impaired and receiving hospice care, did not have a comprehensive care plan related to hospice services. Registered Nurse #4 stated that hospice care plans were not developed at the facility, and communication was maintained through progress notes instead. The Director of Nursing confirmed that comprehensive care plans should be developed for hospice care and that care plans lacking goals or interventions were not considered complete. The facility's policy required an interdisciplinary team to develop individualized care plans to maximize residents' functional potential and quality of life.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Correction: 1) Resident #28 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for the use of diuretics. 2) Resident #79 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for [MEDICAL TREATMENT] care. 3) Resident #93 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for hospice care. 4) The RN Supervisor #3 who was responsible for initiating comprehensive care plans for resident #28 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. 5) The RN Supervisor #4 who was responsible for initiating comprehensive care plans for resident #79 and #93 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that for all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status and initiated and updated as needed. An audit was completed by the DNS on all outstanding comprehensive care plans on all residents on our current census to ensure that all diagnosis, services, plan of care and medications have an active complete comprehensive care plan including goals. Any identified issues will be addressed (4/25/25). III. Systemic Changes: The Policy and Procedure for Comprehensive Care Plan was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received in-service/education on initiating and updating comprehensive care plans upon admission/re-admission or change in status on all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status is initiated and updated as needed. All new and re admissions will be reviewed within 24 hours of admission. All charts will be reviewed by IDT to ensure that a comprehensive care plans were developed for each residents diagnosis, services, plan of care and medications. All in house residents charts will be reviewed by IDT prior to quarterly, annual and significant change care plan meetings to ensure compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have a complete comprehensive care plan with a focus, goal and interventions initiated that will address all active diagnosis, service, plan of care and medications. The DNS will conduct an audit weekly x3 months. Any identified issues related to a delay in care planning results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25
Sprinkler System Deficiency in Stairwell
Penalty
Summary
The facility failed to ensure that sprinkler heads were installed in all required areas of the building, specifically on the basement side of a door interrupting the East stair on the first floor landing. This deficiency was identified during a life safety survey conducted on March 13, 2025, at approximately 10:15 am. The absence of a sprinkler head in this location was observed and acknowledged by the Maintenance Director, Administrator, and Environmental Services Director. The requirement for sprinkler systems is outlined in the 2012 NFPA 101 and 2010 NFPA 13 standards, which mandate that sprinklers be provided on each side of separations in noncombustible stair shafts.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action A sprinkler head was installed on the basement side of the door ( ). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all areas of the building was completed to ensure that where noncombustible stair shafts are divided by walls or doors, sprinklers are provided on each side of the separation. (3/27/25) No other issues were found. All Maintenance staff will be in serviced on the importance of ensuring that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on the installation of Sprinkler Systems in residential occupancies up to and including four stories in height. All Maintenance staff will be in serviced on the policy which states that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation in accordance with 2010 NFPA 13 8.15.3.2.2 (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that Sprinkler Systems in residential occupancies where noncombustible stair shafts are divided by walls or doors, that sprinklers are provided on each side of the separation. There will be a visual check of all noncombustible stair shafts that are divided by walls or doors and ensure that sprinklers are provided on each side of the separation weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25- Date of Correction.
Resident Abuse by CNA in Dining Room
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred in the dining room when the resident threw a cup of water on the CNA's back, prompting the CNA to retaliate by slapping the resident on the back of the neck. This action was captured on the facility's video footage. The resident, who was moderately cognitively impaired with diagnoses including Non-Alzheimer's Disease, Bipolar Disorder, and Major Depressive Disorder, did not sustain visible injuries or report pain following the incident. The facility's policy on abuse prevention, which includes components such as screening, training, prevention, identification, investigation, protection, and reporting/response, was not effectively implemented in this case. The incident was reported by another CNA to the facility's Scheduler, who then informed the Director of Nursing. An investigation was initiated, and the video footage confirmed the physical abuse. The Director of Nursing and the Administrator were involved in reviewing the incident, and law enforcement was contacted, although they determined the act to be harassment rather than a criminal offense. Interviews conducted during the survey revealed discrepancies in the accounts of the incident. The CNA involved denied hitting the resident, while another CNA reported hearing yelling but did not witness the physical altercation. The Director of Nursing confirmed that the CNA slapped the resident and identified the cause of the incident as the resident's upset reaction to the television being turned off during mealtime, a routine practice in the facility. The facility concluded that abuse had occurred, and the CNA was removed from the schedule.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure that Resident #2 received timely and appropriate care to prevent and treat a pressure ulcer. Despite being identified as at mild risk for developing pressure ulcers, Resident #2 did not have a care plan in place to address this risk. The resident developed an unstageable pressure ulcer on the sacrum, which was not promptly assessed or treated, leading to a stage 4 pressure ulcer with infection and subsequent hospitalization. Resident #2 was admitted with diagnoses including Peripheral Vascular Disease, schizoaffective disorder, and Delusional Disorders. The resident was moderately cognitively impaired and required extensive assistance with daily activities. Initial assessments indicated intact skin and a mild risk for pressure ulcers, but no care plan was developed to mitigate this risk. Weekly skin assessments failed to document the pressure ulcer until it was unstageable, and there was no evidence of treatment or physician orders for the ulcer until several days later. Interviews with staff revealed a lack of communication and responsibility in managing Resident #2's condition. Registered nurses and the Director of Nursing were unaware of the pressure ulcer until it had significantly worsened. The facility did not have a wound care nurse at the time, and high turnover among nursing staff contributed to the oversight. The attending physician and wound care consultant both indicated that the pressure ulcer was preventable with proper measures in place, but these were not implemented, resulting in harm to the resident.
Failure to Timely Report Investigation Results of Alleged Abuse
Penalty
Summary
The facility did not ensure that the results of all investigations of alleged violations involving abuse were reported to the State Survey Agency within 5 working days of the incident. This deficiency was evident for two residents reviewed for abuse. Specifically, the facility received a report that one resident inappropriately touched another resident. The initial incident report was submitted to the New York State Department of Health on the same day the staff was made aware of the incident. However, the follow-up investigation report was not submitted until 10 days later, which exceeded the required 5 working days timeframe. The facility's policy on Accident and Investigation Reporting, last reviewed on 10/20/2023, documented that the Director of Nursing (DON) and Administrator are responsible for investigating allegations and reporting findings within 5 working days. Interviews with the current DON and Administrator confirmed that the responsibility for reporting abuse allegations lies with the DON. Despite this, the follow-up report for the incident involving the two residents was delayed, leading to non-compliance with the state regulations.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. Specifically, the facility received a report that one resident inappropriately touched another resident. Although the facility initiated an investigation, it did not gather statements from staff members who may have potentially witnessed the allegation. The investigation was primarily based on interviews with the two residents involved, and the Director of Social Services concluded that the allegation was unfounded without interviewing frontline unit staff members. The facility's policies on Abuse Prevention and Accident and Incident Investigation and Reporting require thorough investigations, including obtaining statements from all relevant staff. However, the Director of Social Services did not interview the staff in the unit where the incident allegedly occurred, and the Director of Nursing, who was responsible for conducting a thorough investigation, had recently started working at the facility and was not involved in the initial investigation. The Administrator confirmed that it was the responsibility of the nursing supervisor on duty to initiate the investigation and gather statements from the staff present at the time of the alleged incident.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) for individuals with mental disorders or intellectual disabilities was completed prior to admission. This deficiency was identified during an abbreviated survey, where it was found that a resident with diagnoses including Major Depressive Disorder and Schizophrenia was admitted without a completed Level I and Level II PASRR screening. The resident's Screen Form Department of Health-695 was dated after the admission date and was incomplete, lacking necessary responses to questions that would trigger a Level II evaluation. Additionally, the form was not signed by the resident or their legal representative, and there was no documented evidence of a Level II screening being conducted prior to admission. Interviews with facility staff revealed systemic issues in the preadmission screening process. The Director of Social Service admitted that preadmission documents were not reviewed before residents were admitted and that they were unsure how to proceed if the hospital did not complete the necessary forms. The Director of Admissions confirmed that it was their responsibility to ensure the completion and review of the Patient Review Instrument and Screen Form before admission. However, they acknowledged that the form for the resident in question was signed and dated after the admission, and critical questions were left unanswered, resulting in an incomplete screening process. The Administrator stated that the Director of Admissions was responsible for reviewing the Patient Review Instrument and Screen Form prior to admission to ensure appropriate placement. However, the Administrator did not personally review these documents, delegating the clinical review to the Director of Nursing. This lack of oversight and failure to adhere to the facility's policy led to the resident being admitted without the required PASRR evaluations, highlighting significant lapses in the facility's admission procedures.
Failure to Develop and Implement Abuse-Related Care Plans
Penalty
Summary
The facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident, as required by their policy. This deficiency was identified during an Abbreviated Survey, where it was found that two residents, who were reviewed for abuse, did not have a care plan related to abuse developed following an allegation of sexual abuse. Specifically, Resident #4 reported being sexually abused by Resident #5, but no care plan was created for either resident to address this allegation. Resident #4, who has diagnoses of Panic Disorder and Generalized Anxiety Disorder, and Resident #5, who has diagnoses of Acquired Absence of Right Leg Above Knee and Major Depressive Disorder, were both cognitively intact according to their Minimum Data Set assessments. Despite the grievance form documenting that there was no reasonable suspicion from the investigation, the facility failed to document any care plan addressing the abuse allegation. The Director of Nursing, who was new to the facility, stated that it was the responsibility of the Registered Nurses on duty to initiate and update care plans as soon as an abuse allegation was made.
Failure to Develop Effective Discharge Plan
Penalty
Summary
The facility failed to ensure an effective discharge plan was developed for a resident, focusing on the resident's discharge goals and preparation for post-discharge care. The resident, who had diagnoses including Failure to Thrive, Major Depressive Disorder, Bipolar Disorder, and Schizophrenia, was admitted to the facility and later discharged to the community without a discharge care plan. Despite the resident's intact cognition and limited assistance needs, no active discharge planning was documented in the Minimum Data Set, and a discharge care plan was not initiated during the resident's stay from admission to discharge. The facility's social services team, including the Director of Social Service and the Assistant Social Worker, acknowledged their responsibility for developing and implementing the discharge care plan but failed to do so. The resident's discharge process was complicated by pending guardianship proceedings, and although the resident expressed a desire to leave the facility and was eventually discharged to supported housing, the necessary discharge care plan was not created. Interviews with the social services staff revealed a lack of clarity and action regarding the discharge planning process, leading to the identified deficiency.
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 1,466 citations issued within 25 miles in the last 12 months — including the 22 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 Staten Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silver Lake Specialized Rehab And Care Center | 0.3 mi | ★★★★★ | 7 | 0 |
| Staten Island Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Richmond Ctr For Rehab And Specialty Healthcare | 1 mi | ★★★★★ | 11 | 0 |
| New Vanderbilt Rehabilitation And Care Center, Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Clove Lakes Health Care And Rehabilitation Center, | 2.6 mi | ★★★★★ | 10 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Verrazano Nursing And Post-acute Center.
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.