Staten Island, NY

Clove Lakes Health Care And Rehab Center, Inc

4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

25 Fanning Street, Staten Island, NY

(718) 289-7900

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

576

Certified beds

Average residents

472

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinite Care

Operator or chain grouping

Approved since

1969-06-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.94

Registered nurse staffing

LPN hours / resident day

0.51

Licensed practical nurse staffing

Aide hours / resident day

2.14

Nurse aide staffing

Weekend hours

3.20

Weekend nurse staffing

RN turnover

35%

Annual RN turnover

Total nurse turnover

30%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.7 About the same	1.9 0.2 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.3 0.2 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	68.5%	91.2% 22.7 pts worse	93.4% 24.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	81.8%	95.3% 13.5 pts worse	95.5% 13.7 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.0% 1.7 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	57.6%	18.5% 39.1 pts worse	11.4% 46.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	5.7%	6.1% 0.4 pts better	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.9%	13.5% 1.4 pts worse	19.6% 4.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	8.1%	14.8% 6.7 pts better	16.7% 8.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.6%	0.2% 0.4 pts worse	0.1% 0.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	7.0%	15.1% 8.1 pts better	16.3% 9.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	9.2%	15.5% 6.3 pts better	14.9% 5.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.6% 0.3 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.1%	1.4% 0.3 pts better	1.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.1%	20.8% 3.3 pts worse	19.8% 4.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	9.1%	6.9% 2.2 pts worse	5.1% 4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	28.7%	76.7% 48 pts worse	81.7% 53 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	10.4%	9.7% 0.7 pts worse	12.0% 1.6 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.2% 0.5 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	37.9%	78.8% 40.9 pts worse	79.7% 41.8 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.5%	20.6% 4.1 pts better	23.9% 7.4 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-16 · Fire 2024-10-16

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2022-11-10 · Fire 2022-11-10

16 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2020-01-23 · Fire 2020-01-23

5 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-10-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-12-15

E · Potential for more than minimal harm 2022-11-10

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-01-09

C · Minimal harm 2022-11-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-01-09

E · Potential for more than minimal harm 2020-01-23

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2020-03-22

E · Potential for more than minimal harm 2020-01-23

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-03-22

C · Minimal harm 2020-01-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-03-22

C · Minimal harm 2020-01-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-03-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-18

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2026-01-09

D · Potential for more than minimal harm 2025-02-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-04-05

D · Potential for more than minimal harm 2024-10-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-10-25

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-10-16

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-08

D · Potential for more than minimal harm 2024-10-16

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-08

E · Potential for more than minimal harm 2022-11-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-01-09

E · Potential for more than minimal harm 2022-11-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-01-09

D · Potential for more than minimal harm 2022-11-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-01-09

E · Potential for more than minimal harm 2020-01-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2020-03-22

D · Potential for more than minimal harm 2020-01-23

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2020-03-22

Penalties and ownership