Registered Nurse Supervisor #1 initially told federal inspectors she performed an oral assessment and removed solid bread from Resident #1's mouth after finding the person unresponsive on August 16, 2025. But on October 23, more than two months later, she called the surveyor at 2:59 PM to walk back her account.
The supervisor said she had reviewed the resident's chart and "came to realize that they did not document seeing food in Resident #1's mouth and would like to recant their interview statement of seeing/removing solid bread out of Resident #1's mouth."
Emergency medical teams arrived at the facility and pronounced Resident #1 dead at 12:27 AM on August 17. The supervisor told inspectors she was not in the room when the emergency medical service team was working on the resident.
The Director of Nursing learned about the unresponsive resident sometime during the night shift on August 16 when Registered Nurse Supervisor #1 called to report the emergency. Despite the severity of the incident, the nursing director decided not to investigate.
"The Director of Nursing stated that they collected statements from the staff who worked on the night shift but did not investigate because the staff responded immediately and appropriately," according to the inspection report.
The nursing director told inspectors that when a resident is found unresponsive, facility protocol typically requires calling a Code Blue, dialing 911, initiating cardiopulmonary resuscitation, and applying an Automated External Defibrillator.
Most significantly, the Director of Nursing said she "was not aware Resident #1 was found with food in their mouth." She added that if the resident had been found unresponsive during mealtime, staff would have been more likely to check their mouth.
The nursing director revealed that Resident #1 had a known behavior of taking other residents' food, and that staff would redirect the resident when this occurred.
The inspection found the facility failed to ensure that each resident received proper treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The discrepancy between the supervisor's initial account and her later recantation raises questions about the accuracy of the facility's emergency response documentation. The supervisor's decision to call back and change her story came only after she reviewed the resident's chart, suggesting the written record contradicted her memory of events.
The timing of the supervisor's recantation is particularly notable. She waited until October 23 to contact investigators, despite the inspection occurring on October 31. The call came just eight days before federal inspectors completed their review of the facility.
The nursing director's admission that she was unaware of the food found in the resident's mouth highlights a communication breakdown between the supervisor who responded to the emergency and the administrator responsible for overseeing patient care. This gap in information sharing may have contributed to the decision not to conduct a full investigation.
Resident #1's habit of taking food from other residents was known to staff, yet this behavioral pattern apparently was not considered during the emergency response or in any subsequent review of the incident. The facility's failure to connect the resident's food-seeking behavior to the circumstances of their death represents a missed opportunity to identify potential contributing factors.
The inspection report does not detail what investigation protocols the facility should have followed, but the nursing director's own description of typical emergency procedures suggests the response may have fallen short of standard protocols.
The case illustrates the challenges nursing homes face in documenting and investigating emergency situations, particularly when initial accounts from staff members later prove unreliable or incomplete.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peninsula Nursing and Rehabilitation Center from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Peninsula Nursing and Rehabilitation Center
- Browse all NY nursing home inspections