Henry J Carter Skilled Nursing Facility
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
they and Registered Nurse #1 were at the nurse's station when Resident #2's adult child approached them and reported Resident #2 missing and they started searching for the resident. 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 REDACTED] 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)
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Henry J Carter Skilled Nursing Facility
1752 Park Ave Manhattan, NY 10035
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated that the ventilator screen was black and turned off.During an interview on [DATE REDACTED] at 9:52 AM, the Director of Nursing stated they received a call from the Assistant Director of Nursing on [DATE REDACTED] late evening (unsure of time) that a code was called for Resident #1. The Assistant Director of Nursing told them that Resident #1 had returned from dialysis and was found unresponsive. The Director of Nursing stated that Resident #1 was disconnected from the portable ventilator and connected to the bedside ventilator by Respiratory Therapist #1, however, Respiratory Therapist #1 did not remove the ventilator off standby mode. The Director of Nursing stated that the facility's investigation concluded that Registered Nurse #1, Registered Nurse #3and Respiratory Therapist #1 failed to follow procedures after Resident #1 returned from dialysis. During an interview on [DATE REDACTED] at 2:30 PM, the Administrator stated they were informed by the Risk Manager on [DATE REDACTED] (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 REDACTED] 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 REDACTED] at 2:48 PM, Registered Nurse #2 stated that on [DATE REDACTED] 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 REDACTED], prior to surveyors' onsite visit on [DATE REDACTED].
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 REDACTED], 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 REDACTED], Policy and Procedure
on Respiratory Care Services was reviewed and revised. On [DATE REDACTED], facility in-serviced the Registered Nurses on the process of endorsement of residents on a ventilator from dialysis. On [DATE REDACTED], the facility in-serviced the Respiratory Therapists on the updated [DATE REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED]. 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 REDACTED] to discuss the circumstances of this incident, ventilator issues and protocol, corrective actions, and preventive measures. Subsequent meetings were held on [DATE REDACTED] and [DATE REDACTED].
Attendance sheets observed. As of [DATE REDACTED], 61/68 Registered Nurses (89%) received in-service and 47/50 Respiratory Therapists (94%) received in-service. 10 NYCRR 415.12(k)(5)(4)
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HENRY J CARTER SKILLED NURSING FACILITY in MANHATTAN, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MANHATTAN, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HENRY J CARTER SKILLED NURSING FACILITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.