Inspection Reports for Silver Lake Specialized Rehabilitation and Care Center
275 Castleton Avenue, Staten Island, NY, 10301
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 23, 2025, found deficiencies related to failure to protect a resident from abuse by staff and failure to timely report the abuse to local law enforcement. Earlier inspections showed a pattern of deficiencies involving resident care planning, infection control, environmental maintenance, and medication management. Complaint investigations substantiated abuse in the latest report, while previous complaints were mostly unsubstantiated or corrected promptly. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows recurring issues with resident protection and care processes, with some corrective actions taken but ongoing challenges in these areas.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 23, 2025
Visit Reason
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in abuse incident involving Resident #1 |
| Director of Nursing | Director of Nursing | Reviewed surveillance footage, evaluated Resident #1, and removed CNA from unit |
| Director of Social Service | Director of Social Service | Interviewed Resident #1, viewed footage, and suspended CNA |
| Administrator | Administrator | Reported incident to Department of Health but did not report to local law enforcement |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 27, 2024
Visit Reason
One standard health citation for permitting residents to return to facility; no actual harm but potential for more than minimal harm; corrected.
Findings
One standard health citation for permitting residents to return to facility; no actual harm but potential for more than minimal harm; corrected.
Deficiencies (1)
Permitting residents to return to facility
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 13, 2023
Visit Reason
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding Foley catheter care for Resident #238 |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding rounds and Foley catheter care |
| Assistant Director of Nursing | ADON/Infection Control Preventionist | Interviewed about staff awareness of catheter care and infection control |
| Director of Social Worker | DSW | Interviewed about resident participation in care planning |
| Director of Nursing | DON | Interviewed about care planning and infection control practices |
| Certified Nursing Assistant #10 | CNA | Interviewed about Resident #68's use of hand mittens |
| MDS Assessor | Interviewed about assessment accuracy for Resident #68 | |
| Dietary Aide #1 | DA | Interviewed about food storage and expiration date checks |
| Certified Nursing Assistant #9 | CNA | Interviewed about checking expiration dates on thickened liquids |
| Licensed Practical Nurse #4 | LPN | Interviewed about pantry refrigerator maintenance |
| Registered Dietitian | RD | Interviewed about food safety responsibilities |
| Food Service Director | FSD | Interviewed about food safety and expired food checks |
| Certified Nursing Assistant #5 | CNA | Interviewed about meal service and hand hygiene practices |
| Dietary Aide #3 | DA | Interviewed about beverage service and hand hygiene |
| Registered Nurse #6 | RN | Interviewed about hand hygiene during meal service |
Inspection Report
Abbreviated Survey
Deficiencies: 1
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented Resident #1's return to facility and discharge papers lacking doctor's note |
| Assistant Director of Nursing | Assistant Director of Nursing | Documented Resident #1's behavioral issues and hospital transfer |
| Director of Nursing | Director of Nursing | Provided statements regarding court-mandated readmission and facility policies |
| Director of Social Service | Director of Social Service | Provided statements regarding family notification and discharge appeal |
| Director of Admission | Director of Admission | Responsible for admitting and readmitting residents, provided statements on discharge notices and appeal |
| Administrator | Administrator | Participated in court hearing and provided statements on discharge decisions and policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Nov 28, 2022
Visit Reason
Two standard health citations for free from abuse and neglect and reporting of alleged violations; no actual harm but potential for more than minimal harm; both corrected.
Findings
Two standard health citations for free from abuse and neglect and reporting of alleged violations; no actual harm but potential for more than minimal harm; both corrected.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Deficiencies: 0
Date: Sep 20, 2021
Visit Reason
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
Annual Inspection
Deficiencies: 4
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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing wound care with improper hand hygiene |
| Social Worker | Interviewed regarding resident participation in care plan meetings | |
| Secretary to the Administrator | Responsible for sending care plan meeting invitations | |
| Licensed Practical Nurse #1 | LPN | Interviewed about resident alertness and family visits |
| Assistant Recreation Manager | Interviewed about recreation staff and in-room activities | |
| Director of Recreation | Interviewed about recreation staffing and in-room visits | |
| Staff #6 | Recreation Staff | Interviewed about room visits and activity schedule |
| Certified Nursing Assistant #1 | CNA | Interviewed about resident's out of bed schedule |
| Activity Staff #7 | Interviewed about room visits and resident interactions | |
| RN #5 | RN Manager | Interviewed about resident care and activity provision |
| Psychiatrist | Interviewed about psychotropic medication management | |
| RN #6 | Registered Nurse | Interviewed about behavioral notes and resident behavior |
| Medical Director | Interviewed about psychotropic medication oversight | |
| Director of Nursing | Interviewed about dementia care and psychotropic drug use | |
| Registered Nurse Unit Manager #2 | RNUM | Interviewed about oxygen tubing and nasal cannula handling |
| Infection Control Preventionist | ICP and Assistant Director of Nursing | Interviewed about infection control training and observations |
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