Henry J. Carter Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Henry J. Carter Skilled Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, patternF695Aug 20, 2025

  Based on observation, interviews, and record review conducted during an abbreviated survey (NY00380551), the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and in accordance with the residents' goals and preferences. This was evident for one (1) of three (3) residents (Resident #1) sampled for respiratory care and treatment. Specifically, on [DATE] at 4:01 PM, Resident #1 returned from the certified dialysis unit located within the facility. Resident #1 was on a portable ventilator accompanied by Escort #1 and Respiratory Therapist #1. […]

• No harm, potential for more than minimal, patternF761Jan 23, 2024

  Based on observation, interview, and record review conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure drugs were labeled in accordance with currently accepted professional principles. This was evident for 2 (2nd Floor and 3rd Floor) of 5 units observed for medication storage. Specifically, 1) the 3rd Floor medication cart contained undated eye drops, and 2) the 2nd Floor medication cart contained an unlabeled inhaler. The findings are: The facility policy titled Safe Medication Use dated [DATE] documented licensed nurses verify medications have not expired. The undated facility policy titled Long Term Care Pharmacy documented store Brinzolamide/Timolol at room temperature and discard after 4 weeks of opening. […]

• No harm, potential for more than minimal, isolatedF689Aug 20, 2025

  Based on observation, record review, and interviews during an abbreviated survey (NY00374171), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of three (3) residents (Resident #2) sampled for elopement. Specifically, a nursing note, by Registered Nurse #1, dated 03/02/2025 at 6:14 PM documented that Resident #2's adult child visited at around 3:00 PM and reported Resident #2 was not in their room. The Hospital Police and staff searched the building and Resident #2 was not found. The facility video surveillance footage dated 03/02/2025 showed Resident #2, who had a tracheostomy tube and was at high risk for elopement, exited the facility at 1:24 PM undetected by staff. […]

• No harm, potential for more than minimal, isolatedF572Jan 23, 2024

  Based on observation, interviews, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure a resident received notice of their rights and services upon admission. This was evident for 1 (Resident #56) of 31 total sampled residents. Specifically, Resident #56 was not provided with an Admission Agreement explaining their rights as a resident and services provided by the facility upon admission. The findings are: The facility policy titled Coordinated and Formal Resolution of Resident Complaints and Grievances dated 10/7/2021 documented the admission packet was provided to all residents. Resident #56 was admitted to the facility on [DATE] with diagnoses of alcohol dependence and traumatic subdural hemorrhage. […]

• No harm, potential for more than minimal, isolatedF585Jan 23, 2024

  Based on observation, interviews, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure a resident's right to voice care and treatment grievances with a prompt effort to resolve grievances. This was evident for 1 (Resident #56) of 31 total sampled residents. Specifically, Resident #56's missing property grievance was not investigated. The findings are: The facility policy titled Coordinated and Formal Resolution of Complaints and Grievances dated 10/7/2021 documented a resident's right to voice grievances regarding lost clothing was supported and the facility actively seeks a resolution, keeping the resident appropriately apprised of its progress. […]