Inspection Reports for
Silver Lake Specialized Rehabilitation and Care Center

275 Castleton Avenue, Staten Island, NY, 10301

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6 Reports

1 state, 5 CMS 2019–2026

Inspection Report — Apr 16, 2026

Complaint Investigation State
Date: Apr 16, 2026

Visit Reason
State-compiled facility profile showing 6 inspections from 2022 to 2026 with citation and complaint history including enforcement actions and fines.

Complaint Details
The state logged 55 complaints about this facility; 8 led to on-site inspections. Complaint surveys issued 12 citations in total.
Findings
Across 6 inspections, 81 citations were issued including 26 standard health and 55 Life Safety Code citations. Most citations were minor potential harm, with some actual harm noted, and one enforcement action with fines recorded.

Citations (49)
Standard Health Citation — quality of care: Activities did not meet interest or needs of each resident.
Standard Health Citation — quality of care: Care plan timing and revision deficiencies noted.
Standard Health Citation — quality of care: Covid-19 immunization protocols were deficient.
Standard Health Citation — quality of care: Failed to develop and implement a comprehensive care plan.
Standard Health Citation — quality of care: Facility was not free of accident hazards or lacked proper supervision/devices.
Standard Health Citation — quality of care: Infection control deficiencies identified.
Standard Health Citation — quality of care: Pharmacy services, procedures, pharmacist, or records were deficient.
Standard Health Citation — quality of care: Quality of care issues noted.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Resident call system was inadequate.
Standard Health Citation — quality of care: Resident rights and exercise of rights were not fully respected.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were deficient.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Discharge from exits was deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems - other issues noted.
Life Safety Code Citation — NFPA requirements: Exit signage was deficient.
Life Safety Code Citation — NFPA requirements: Means of egress - general deficiencies found.
Standard Health Citation — quality of care: Free from abuse and neglect violations found.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Accuracy of assessments was deficient.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and sanitary conditions were deficient.
Standard Health Citation — quality of care: Infection prevention and control deficiencies noted.
Standard Health Citation — quality of care: Resident rights and exercise of rights were deficient.
Standard Health Citation — quality of care: Right to participate in planning care was deficient.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Cooking facilities were deficient.
Life Safety Code Citation — NFPA requirements: Corridors - construction of walls was deficient.
Life Safety Code Citation — NFPA requirements: Egress doors were deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment - power cords and extensions were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems - essential electric system had potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Electrical systems - maintenance and testing had potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Electrical systems - other issues noted.
Life Safety Code Citation — NFPA requirements: Elevators had potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Emergency lighting had potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Exit signage was deficient.
Life Safety Code Citation — NFPA requirements: Fire alarm system - testing and maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Fundamentals - building system categories had potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Hazardous areas - enclosure was deficient.
Life Safety Code Citation — NFPA requirements: HVAC was deficient.
Life Safety Code Citation — NFPA requirements: Illumination of means of egress was deficient.
Life Safety Code Citation — NFPA requirements: Means of egress - general deficiencies found.
Life Safety Code Citation — NFPA requirements: Number of exits - story and compartment was deficient.
Life Safety Code Citation — NFPA requirements: Portable fire extinguishers were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system - installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system - maintenance and testing was deficient.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures were deficient.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces - smoke barrier was deficient.
Life Safety Code Citation — NFPA requirements: Vertical openings - enclosure was deficient.
Standard Health Citation — quality of care: Permitting residents to return to facility was deficient.
Report Facts
Total inspections: 6 Total citations: 81 Standard Health citations: 26 Life Safety Code citations: 55 Complaints received: 55 On-site complaint inspections: 8 Citations from complaints: 12 Enforcement actions: 1 Total fines: 2000

Inspection Report — Dec 23, 2025

Abbreviated Survey CMS
Date: Dec 23, 2025

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The abbreviated survey was conducted to investigate allegations of abuse involving Resident #1 at Silver Lake Specialized Rehab and Care Center.

Complaint Details
The complaint investigation found substantiated abuse by Certified Nursing Assistant #1 against Resident #1, confirmed by surveillance footage and staff interviews. The facility investigation concluded there was cause to believe abuse occurred. The CNA was removed and suspended. Resident #1 denied pain and fear but reported being hit. The facility failed to report the incident to local law enforcement as required.
Findings
The facility failed to ensure Resident #1 was free from abuse by Certified Nursing Assistant #1, who was observed hitting the resident multiple times. The facility also failed to timely report the alleged abuse to local law enforcement, although it was reported to the Department of Health. Resident #1 was evaluated with no visible injury and did not feel fearful. The facility concluded there was cause to believe abuse occurred and took corrective actions including removal and suspension of the CNA.

Citations (2)
Failure to protect residents from all types of abuse including physical abuse by staff.
Failure to timely report suspected abuse to proper authorities including local law enforcement.
Report Facts
Residents sampled for abuse: 7 Residents affected: 1 Date of incident: Dec 11, 2025 Date of survey completion: Dec 23, 2025 Years CNA employed: 3.5

Employees mentioned
NameTitleContext
Certified Nursing Assistant #1Certified Nursing AssistantNamed in abuse incident involving Resident #1
Director of NursingDirector of NursingReviewed surveillance footage, evaluated Resident #1, and removed CNA from unit
Director of Social ServiceDirector of Social ServiceInterviewed Resident #1, viewed footage, and suspended CNA
AdministratorAdministratorReported incident to Department of Health but did not report to local law enforcement

Inspection Report — Dec 13, 2023

Annual Inspection CMS
Date: Dec 13, 2023

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The inspection was a Recertification Survey conducted from 12/06/2023 to 12/13/2023 to assess compliance with regulatory requirements for Silver Lake Specialized Rehab and Care Center.

Findings
The facility was found deficient in multiple areas including resident dignity related to urinary catheter care, resident participation in care planning, environmental maintenance, accuracy of resident assessments, food safety, and infection control practices. Deficiencies included exposed Foley catheter bags, failure to invite residents to care plan meetings, poor maintenance of resident floors and furniture, inaccurate documentation of physical restraint use, expired food items, and inadequate infection prevention measures such as catheter tubing on the floor and lack of hand hygiene before meals.

Citations (6)
Resident #238 had a Foley catheter bag exposed and visible from the hallway, not contained in a dignity bag as required by facility policy.
Resident #121 was not invited to attend their scheduled Comprehensive Care Plan meetings, violating their right to participate in care planning.
Facility did not maintain a clean, comfortable, and homelike environment on 4 resident floors, with stained walls, missing paint, torn wallpaper, dirty AC units, and damaged furniture.
The Minimum Data Set assessment for Resident #68 did not accurately reflect the resident's use of bilateral hand mittens as physical restraints.
Expired food items were found in the kitchen and pantry refrigerators, including cottage cheese, honey-thickened juices, and milk.
Infection control practices were not maintained; Foley catheter tubing for Resident #238 was touching the floor, and hand hygiene was not performed for multiple residents before meal service in the Main Dining Room.
Report Facts
Residents sampled: 39 Residents reviewed for urinary catheter: 2 Residents reviewed for physical restraint: 1 Floors reviewed for environment: 4 Expired honey-thickened juice containers: 15 Expired honey-thickened cranberry juice containers: 2 Tables with missing or mismatched paint: 7 Tables with missing or mismatched paint: 5

Employees mentioned
NameTitleContext
Certified Nursing Assistant #1CNAInterviewed regarding Foley catheter care for Resident #238
Licensed Practical Nurse #2LPNInterviewed regarding rounds and Foley catheter care
Assistant Director of NursingADON/Infection Control PreventionistInterviewed about staff awareness of catheter care and infection control
Director of Social WorkerDSWInterviewed about resident participation in care planning
Director of NursingDONInterviewed about care planning and infection control practices
Certified Nursing Assistant #10CNAInterviewed about Resident #68's use of hand mittens
MDS AssessorInterviewed about assessment accuracy for Resident #68
Dietary Aide #1DAInterviewed about food storage and expiration date checks
Certified Nursing Assistant #9CNAInterviewed about checking expiration dates on thickened liquids
Licensed Practical Nurse #4LPNInterviewed about pantry refrigerator maintenance
Registered DietitianRDInterviewed about food safety responsibilities
Food Service DirectorFSDInterviewed about food safety and expired food checks
Certified Nursing Assistant #5CNAInterviewed about meal service and hand hygiene practices
Dietary Aide #3DAInterviewed about beverage service and hand hygiene
Registered Nurse #6RNInterviewed about hand hygiene during meal service

Inspection Report — Apr 27, 2023

Abbreviated Survey CMS
Date: Apr 27, 2023

Visit Reason
The inspection was conducted as an abbreviated survey to evaluate the facility's compliance with policies regarding permitting residents to return after hospitalization, specifically focusing on Resident #1's discharge and readmission process.

Findings
The facility failed to establish and follow a written policy for permitting residents to return after hospitalization, as evidenced by the case of Resident #1 who was discharged to the hospital due to behavioral issues and was initially not readmitted despite a court order. The facility's discharge planning policy lacked documented evidence about readmission after hospitalization. Interviews and record reviews confirmed the facility's failure to properly manage Resident #1's discharge and readmission, resulting in a minimal harm level deficiency.

Citations (1)
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Report Facts
Residents Affected: Few Dates: Apr 18, 2022 Dates: Apr 19, 2022 Dates: Jun 10, 2022 Dates: Jun 29, 2022

Employees mentioned
NameTitleContext
Registered Nurse Supervisor #1Registered Nurse SupervisorDocumented Resident #1's return to facility and discharge papers lacking doctor's note
Assistant Director of NursingAssistant Director of NursingDocumented Resident #1's behavioral issues and hospital transfer
Director of NursingDirector of NursingProvided statements regarding court-mandated readmission and facility policies
Director of Social ServiceDirector of Social ServiceProvided statements regarding family notification and discharge appeal
Director of AdmissionDirector of AdmissionResponsible for admitting and readmitting residents, provided statements on discharge notices and appeal
AdministratorAdministratorParticipated in court hearing and provided statements on discharge decisions and policies

Inspection Report — Sep 20, 2021

CMS
Date: Sep 20, 2021

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The document is a statement of deficiencies and plan of correction for Silver Lake Specialized Rehab and Care Center, summarizing the findings of a regulatory survey completed on 09/20/2021.

Findings
No health deficiencies were found during the survey.

Inspection Report — Sep 13, 2019

Annual Inspection CMS
Date: Sep 13, 2019

Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations regarding resident care, activities, medication use, infection control, and care planning.

Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate activities programming for residents confined to rooms, improper use and monitoring of psychotropic medications, and lapses in infection prevention and control practices such as improper hand hygiene and oxygen equipment handling.

Citations (4)
Failure to ensure resident or representative participation in development, review, and revision of comprehensive care plans, with residents not invited to care plan meetings.
Failure to provide an ongoing activities program to meet the interests and support the physical, mental, and psychosocial well-being of residents, especially those confined to their rooms.
Failure to ensure residents were free from unnecessary psychotropic medications, with inadequate clinical indications, lack of behavioral monitoring documentation, and no evidence of gradual dose reductions.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene during wound care and improper handling and storage of oxygen tubing and nasal cannulas.
Report Facts
Residents reviewed for Participation in Care Planning: 3 Residents reviewed for Activities: 1 Residents reviewed for Unnecessary Medications: 2 Residents affected by infection control deficiencies: 3

Employees mentioned
NameTitleContext
RN #1Registered NurseObserved performing wound care with improper hand hygiene
Social WorkerInterviewed regarding resident participation in care plan meetings
Secretary to the AdministratorResponsible for sending care plan meeting invitations
Licensed Practical Nurse #1LPNInterviewed about resident alertness and family visits
Assistant Recreation ManagerInterviewed about recreation staff and in-room activities
Director of RecreationInterviewed about recreation staffing and in-room visits
Staff #6Recreation StaffInterviewed about room visits and activity schedule
Certified Nursing Assistant #1CNAInterviewed about resident's out of bed schedule
Activity Staff #7Interviewed about room visits and resident interactions
RN #5RN ManagerInterviewed about resident care and activity provision
PsychiatristInterviewed about psychotropic medication management
RN #6Registered NurseInterviewed about behavioral notes and resident behavior
Medical DirectorInterviewed about psychotropic medication oversight
Director of NursingInterviewed about dementia care and psychotropic drug use
Registered Nurse Unit Manager #2RNUMInterviewed about oxygen tubing and nasal cannula handling
Infection Control PreventionistICP and Assistant Director of NursingInterviewed about infection control training and observations

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