Henry J. Carter SNF: Ventilator Left on Standby - NY
Federal inspectors classified what happened as Immediate Jeopardy, the most serious level of harm designation available under Medicare's inspection system, meaning the failure created a situation likely to cause serious injury or death.
The resident, identified in inspection records only as Resident #1, had returned from dialysis. At some point during the transition back to their room, a nurse and a respiratory therapist switched the resident from a portable ventilator to the bedside unit. The bedside ventilator was left in standby mode. It was not delivering air.
Registered Nurse #2, reached by telephone, told inspectors that on the day of the incident, at around 4:31 in the afternoon, Certified Nursing Assistant #1 called them to the room. The nurse assessed Resident #1 and found the resident unresponsive and pulseless. They checked the ventilator. The screen read standby.
The nurse immediately contacted Respiratory Therapist #1. The inspection report does not describe what happened after that call, what interventions were attempted, or what condition the resident was in when emergency response arrived. The report does not state whether Resident #1 survived.
That absence is itself a fact worth sitting with. A federal inspection document describing an Immediate Jeopardy event, one serious enough to require the facility to demonstrate correction before surveyors even arrived on site, does not say whether the person at the center of it lived or died.
The administrator told inspectors they learned about the incident from the Risk Manager. The administrator said they were unsure of the time they were informed. The Assistant Medical Director said they had been told by the Medical Director, who was on vacation at the time of the inspection, that there had been an incident involving Resident #1. The Medical Director, according to the Assistant Medical Director, did not provide any details.
Two senior clinical leaders, and neither one could give inspectors a complete account of what had happened to a resident who had been found without a pulse in their facility.
Inspectors determined the violation was Immediate Jeopardy Past Non-Compliance, a specific designation meaning the facility had already taken corrective steps before surveyors arrived on site. Under that classification, the facility was not required to submit a formal Plan of Correction. But the designation does not soften what the underlying event was. A ventilator-dependent resident, someone whose continued breathing depends entirely on a machine, was left connected to a machine that was not running.
The failure involved at least two clinicians. The inspection report names Registered Nurse #3 and Respiratory Therapist #1 as the staff who failed to follow proper procedures after Resident #1 returned from dialysis. The transition from a portable ventilator used during transport to the bedside unit in the resident's room is a defined clinical handoff. Both the nurse and the respiratory therapist were present. Neither caught the error before the resident was left alone.
The facility's own corrective actions, which inspectors reviewed and accepted as evidence of substantial compliance, reveal how much of the basic safety infrastructure around this specific situation had not existed before the incident. A policy on Respiratory Care Services was reviewed and revised. A new form, called a Ticket to Ride, was created to document the moment a resident is removed from standby mode and the moment they are confirmed connected and stable. The form requires a signature from both the nurse and the respiratory therapist, a dual verification step that did not exist when Resident #1 came back from dialysis.
Before that form existed, there was no required written confirmation that a ventilator-dependent resident had been successfully transitioned between machines. The handoff happened, or it didn't, and there was no document that forced two clinicians to stop, confirm, and sign.
A Quality Review Report meeting was held after the incident to discuss what had happened and what the facility would do to prevent it from happening again. The policy revision followed. Then came staff training. Registered nurses were in-serviced on the process of endorsing ventilator-dependent residents returning from dialysis. Respiratory therapists were in-serviced on the updated transport protocol. By the time inspectors reviewed the corrective actions, 61 of 68 registered nurses, 89 percent, had completed the training. Forty-seven of 50 respiratory therapists, 94 percent, had received it. That means at the point of the inspection's review, seven nurses and three respiratory therapists had not yet been trained on the updated protocol.
The facility also began monitoring the one resident on a ventilator who also receives dialysis, reviewing the communication report three times per week during dialysis weeks. Monthly Quality Assurance meetings were scheduled to revisit the incident, discuss ventilator protocol, and track preventive measures. Attendance sheets were observed by inspectors.
Henry J. Carter Skilled Nursing Facility is a public hospital-based skilled nursing facility operated by NYC Health + Hospitals, the city's public health system. It serves a population that includes many residents with complex medical needs, among them people who are ventilator-dependent and who require ongoing dialysis, two of the most resource-intensive care needs a long-term care resident can have. The combination of those two conditions, ventilator dependency and dialysis, requires a choreographed handoff every time the resident leaves the unit and returns. That choreography failed.
What the inspection record shows is a gap between the complexity of the care being provided and the safeguards that existed to support it. Residents on ventilators who also receive dialysis leave the unit regularly. They are transported on portable ventilators, transferred to dialysis machines, and then transported back. At each transition, the ventilator connection has to be managed. The Ticket to Ride form that now exists, the dual-signature requirement, the explicit step confirming the ventilator is no longer in standby mode, all of it was created in response to this event. None of it was in place before Resident #1 came back from dialysis that afternoon.
The inspection was triggered by a complaint. Someone reported what happened. Inspectors came, reviewed the corrective actions the facility had already taken, and determined that the facility had returned to substantial compliance before surveyors arrived on site. The Immediate Jeopardy designation stands in the record. The Plan of Correction was waived.
Registered Nurse #2 found Resident #1 unresponsive and pulseless at 4:31 in the afternoon. They looked at the ventilator screen. It said standby.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Henry J. Carter Skilled Nursing Facility from 2025-08-20 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 22, 2026 · Our methodology
Henry J. Carter Skilled Nursing Facility in Manhattan, NY was cited for violations during a health inspection on August 20, 2025.
The resident, identified in inspection records only as Resident #1, had returned from dialysis.
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.