Clove Lakes Rehab: Oxygen Fire Risk in Smoking Room - NY
The April 2026 complaint inspection found that Resident 7, who was on continuous oxygen, had entered the facility's designated smoking room. The medical director told inspectors that smoking in a room with continuous oxygen is dangerous. He also said he could not determine whether Resident 7 was a safe smoker, and that he was not the appropriate person to answer questions because he was not the resident's direct caregiver.
The Director of Nursing said the facility had Resident 7 on hourly safety checks. After each smoking incident, staff did not increase the frequency of those checks. They did not reassess whether Resident 7 could smoke safely. The director told inspectors the facility had no idea other residents had smoking materials in their rooms, and no idea there was a problem with smoking at all, until surveyors arrived.
Nobody had been watching.
The Director of Recreation said a smoking monitor should have been present in the smoking room during smoking hours and should have removed the oxygen before Resident 7 entered. That did not happen. After the incident, the Recreation Department conducted room searches of all 35 identified smokers. Materials found were confiscated and turned over to Recreation for safekeeping. Resident 7 received what the director called counseling for noncompliant behavior. The director could not describe what type of counseling that was.
The Director of Social Work told inspectors that her department had handed off smoking assessments to Recreation in October 2025 and was no longer involved in them. After the room searches, the social work and nursing departments provided what they described as reeducation and had residents sign smoking agreements.
The administrator told inspectors the facility's response to each incident was to sit down with Resident 7 and review the smoking policy and the smoking agreement. Smoking assessments, the administrator said, are completed on admission and as needed.
The medical director's position was that if a resident has noncompliant behavior, the facility should keep educating them.
What the record shows is a resident on oxygen entering a room designated for smoking, repeatedly, while staff rotated through explanations of whose job it was to prevent that. Recreation said a monitor should have been there. Nursing said they were doing hourly checks but didn't increase them after incidents. Social work said they handed off smoking oversight months ago. The medical director said he wasn't the right person to ask.
The facility serves residents across a population of many, in the words of the inspection report, affected by the conditions found. The smoking room remained in operation throughout.
After inspectors arrived, room searches happened. Agreements were signed. Education was delivered. The oxygen, according to the Director of Recreation, should have been removed before Resident 7 ever walked in.
It wasn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clove Lakes Health Care and Rehabilitation Center, from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Clove Lakes Health Care And Rehabilitation Center, in Staten Island, NY was cited for violations during a health inspection on April 27, 2026.
The April 2026 complaint inspection found that Resident 7, who was on continuous oxygen, had entered the facility's designated smoking room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.