Clove Lakes Health Care And Rehab Center, Inc
Inspection Findings
F-Tag F0806
F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
were served chicken and underneath the chicken were mushrooms. They stated that they immediately felt itching in their throat, and they notified Registered Nurse Supervisor #1.During an interview on 09/12/2025 at 2:40 PM Dietician #1 stated when a resident is admitted to the facility, they are responsible for reviewing their chart and then follow up with an interview about any food allergies. They stated on 07/18/2024, during
an interview with Resident #6, Resident #6 verbalized that they were not allergic to anything. However, sometime in January of 2025, Resident #6 verbalized to them that they did not like mushrooms. They stated that [NAME] sauce contains mushrooms, and that chicken [NAME] was served to Resident #6 on the day (06/05/2025) of the incident, and they became aware of the mushroom allergy after the incident. They stated they are unsure about the care plan that was initiated on 04/21/2025 stating Resident #6 was allergic to mushrooms. They stated the electronic medical record does not generate an alert for allergy unless the resident is a readmission or new admission. They stated the allergy should have been verbally discussed with them and that the meal ticket was updated post incident to include Resident #6 allergy. They stated that the Dietary Supervisor is responsible for ensuring that the meal ticket matches what is being served on
the tray. During a telephone interview on 09/25/2025 at 10:07 AM, Registered Nurse # 1 stated Resident #6 reported allergic reaction to mushrooms and that they observed mushrooms on Resident #6's meal tray that was still in their room. They immediately reported it to Registered Nurse Supervisor #1. During an
interview on 09/12/2025 at 3:01 PM, Registered Nurse Supervisor #1 stated they entered Resident #6's room at 1:20 PM on 06/05/2025 while Resident #6 was eating. They stated that Resident #6 picked up the chicken that was on the plate and showed them the mushroom that was under the chicken and pasta. They stated Resident #6 reported that their tongue was feeling tingly, and both their arms were itching. They stated Resident #6's arms were observed to be slightly red with raised rash. During a telephone interview
on 09/26/2025 at 12:29 PM, Certified Nursing Assistant #2 stated that Resident #6 reported to them that
they were feeling weird after eating from the tray. They stated they observed mushrooms on the resident's plate. They checked the meal ticket on the tray, and it states allergies and dislike to mushrooms. During a telephone interview on 09/29/2025 at 11:30 AM, Director of Nursing stated their investigation concluded that Resident #6's alleged allergy to mushroom was not verified. They stated on admission; Resident #6 had a dislike for mushroom and the hospital records did not document mushroom as an allergy. They stated
the allergy was updated in March 2025 and they do not know why the system did not update the meal ticket to include the allergy when it was updated. During a telephone interview on 11/18/2025 at 9:28 AM, Physician #1 stated as per nursing documentation, several attempts were made to contact them about the allergic reaction incident, however, they do not recall that. They stated the nursing staff contacted another Physician, and orders were put in place. They stated it was documented in Resident #6's chart that they are allergic to mushroom, however, they do not believe Resident #6 received mushroom from the facility because Resident #6 buys food from outside routinely. They stated they evaluated Resident #6 on 06/06/2025 or 06/07/2025 and Resident #6 reported that they received mushroom from the facility. They stated when they evaluated Resident #6, their symptoms had cleared. 10 NYCRR 415.14(d)(4)
Event ID:
Facility ID:
If continuation sheet
CLOVE LAKES HEALTH CARE AND REHAB CENTER, INC in STATEN ISLAND, 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 STATEN ISLAND, 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 CLOVE LAKES HEALTH CARE AND REHAB CENTER, INC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.