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 an interview on 08/04/2025
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)
335092 08/20/2025
Henry J.
Carter Skilled Nursing Facility 1752 Park Avenue Manhattan, NY 10035
During an interview on [DATE] at 2:40 PM, the Assistant Medical
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)
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.