Henry J Carter Skilled Nursing Facility
HENRY J CARTER SKILLED NURSING FACILITY in MANHATTAN, NY — inspection on August 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a telephone interview on 08/04/2025 at 03:32 PM, Registered Nurse #1 stated that Resident #2 was readmitted to the facility from the hospital on [DATE] and was assessed to be at high risk for elopement.
Registered Nurse #1 stated that an Aero Scout Bracelet was applied to Resident #2's left wrist by the Hospital Police (#1) in their presence on 03/02/2025 at 9:00 AM.
Registered Nurse #1 stated that they became aware that Resident #2 was not in their room on 03/02/2025 (unsure of date) and they all searched for the resident.
The Hospital Police and contacted 911.
Registered Nurse #1 stated that Resident #2 had a tracheostomy but was not on oxygen treatment and was stable.
Registered Nurse #1 stated that staff generally made rounds everyone (1) to two (2) hours, or more frequently for high-risk residents.
Registered Nurse #1 stated that the staff document their rounds on the Certified Nursing Assistant 's task sheet in the Electronic Medical Record.
During an interview on 08/04/2025 at 12:28 PM, Hospital Police Officer #2 stated that they were on duty on 03/02/2025 and was assigned to area 1B, closer to the designated exit side of the lobby.
Hospital Police #2 stated that Hospital Police Officer #1 was assigned to the entrance side of the lobby.
Hospital Police Officer #2 stated that they were informed (unsure of time) on 03/02/2025, by their supervisor (Chief of Police), that Resident #2 had left the facility.
Hospital Police Officer #2 stated that they participated in the search at 3:00 PM on 03/02/2025.During a telephone interview on 08/06/2025 at 10:41 AM, Hospital Police Officer #1 stated that they were answering questions from a visitor (in the visitor's section located behind the Hospital Police desk) and that their back was turned to the hallway; they did not see Resident #2 exit the facility.
They left the facility when their shift ended (work from 7:30 AM to 4:00 PM) for the day and did not participate in the search.During a telephone interview on 08/20/2025 at 10:02 AM the facility's Chief of Hospital Police stated that Hospital Police Supervisor #1 received a call at 3:53 PM on 03/02/2025, from Registered Nurse #1 stating that Resident #2 was missing.
The Chief of Hospital Police stated that Hospital Police Officer #1 and #2 had already gone for the day (3:49 PM) and did not participate in the search for Resident #2.
Chief of Hospital Police stated that Hospital Police Officer #1 and #2 were not paying attention when Resident #2 exited the facility.
The Chief of Hospital Police stated that the Officers stationed on the entrance side of the lobby are required to log visitors as they enter, and Officers on the exit side of the lobby are to log them out as they exited the facility.
The Chief of Hospital Police stated that the designated entrance and exit indicators (arrows and wordings) were at the lobby desk months prior to the incident.
During a telephone interview with the Director of Nursing on 08/20/2025 at 11:50 AM, they stated that Resident #2 was not admitted with the outfit that they wore out of the facility on 03/02/2025 at 1:24 PM when they exited the facility.
The Director of Nursing stated that they do not know where Resident #2 get the outfit that was seen on the camera.
The Director of Nursing stated that there was no monitoring documentation on the Document Survey Report for 03/02/2025. 10 NYCRR 415.12(h) (2)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Henry J Carter Skilled Nursing Facility
1752 Park Ave Manhattan, NY 10035
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on [DATE] at 2:30 PM, the Administrator stated they were informed by the Risk Manager on [DATE] (unsure of time) that a resident had returned from dialysis and was switched from the portable ventilator to the bedside ventilator, but that the bedside ventilator was left in standby mode.
During an interview on [DATE] at 2:40 PM, the Assistant Medical Director stated that they were informed by the Medical Director, who is currently on vacation, that there was an incident with Resident #1.
The Assistant Medical Director stated that the Medical Director did not give them any details of the incident.
During a telephone interview on [DATE] at 2:48 PM, Registered Nurse #2 stated that on [DATE] at around 4:31 PM, Certified Nursing Assistant #1 called them to Resident #1's room.
Registered Nurse #2 stated that they assessed Resident #1 who was unresponsive and pulseless.
Registered Nurse #2 stated they checked the ventilator and observed the screen was on standby mode, and they immediately informed Respiratory Therapist #1.Based on the corrective actions taken by the facility, which are listed below, there was sufficient evidence the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on [DATE], prior to surveyors' onsite visit on [DATE].
Considering that the surveyors' investigation has determined this matter to be Immediate Jeopardy (IJ) Past Non-Compliance the facility will not be required to submit a Plan of Correction (POC).Corrective Actions On [DATE], a Quality Review Report meeting was held to discusses the incident and corrective actions the facility would be implementing to prevent a reoccurrence of the incident. On [DATE], Policy and Procedure on Respiratory Care Services was reviewed and revised. On [DATE], facility in-serviced the Registered Nurses on the process of endorsement of residents on a ventilator from dialysis. On [DATE], the facility in-serviced the Respiratory Therapists on the updated [DATE] policy/procedure for inhouse transport of residents on oxygen/ventilator when they return from dialysis.
Respiratory Care Service Policies and Procedures In House Transport of Residents on Oxygen/Ventilator was revised [DATE] to include that the Respiratory Therapist and Nurse will refer to the Ticket to Ride form and ensure that resident's ventilator is connected, and resident is stable.
Ticket to Ride Report form (communication report) was developed on [DATE] to communicate when a resident is removed from standby mode, and when a resident is connected to the ventilator and is stabilized.
Form must be signed by both nurse and therapist.
One (1) resident on a ventilator and dialysis had dialysis hand-off done and communication report (ticket to ride) reviewed three (3) times a week each week beginning the week of [DATE].
Additionally, residents on a ventilator that were transported off the unit had communication report (ticket to ride) reviewed.
Quality Assurance Meeting to be held monthly starting [DATE] to discuss the circumstances of this incident, ventilator issues and protocol, corrective actions, and preventive measures.
Subsequent meetings were held on [DATE] and [DATE].
Attendance sheets observed. As of [DATE], 61/68 Registered Nurses (89%) received in-service and 47/50 Respiratory Therapists (94%) received in-service. 10 NYCRR 415.12(k)(5)(4)
Facility ID: