Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Restore Health Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, cognitive intactness, total incontinence, and substantial to maximum assistance needs for bed mobility was receiving incontinence/ADL care when they were turned and positioned near the edge of the bed. Despite a care plan calling for extensive assistance and fall risk interventions, a GNA relied on the resident holding a side rail, did not maintain hands-on control during turning, did not reposition the resident toward the bed’s center before a second turn, and left the bed in a high position with the opposite rail down. The resident let go of the rail, fell from the bed during care, and was later found to have sustained multiple fractures, with the facility identifying improper turning and repositioning as the root cause.
Surveyors identified that the facility failed to provide complete bathing and hygiene care and did not offer alternative shower methods for residents unable to use a shower chair. One resident who was incontinent and dependent for bathing received a bed bath in which the GNA omitted cleaning the ears, neck, hands, fingernails, and back, and the care plan did not specify bathing assistance or preferences. Another resident with impaired mobility and pain, documented as dependent for showering, reported never having received a shower; staff confirmed the resident only received bed baths due to inability to tolerate a shower chair and the lack of a shower bed. A third resident with diabetes, pressure-related wounds, and severe cognitive impairment was allowed by a wound physician to shower with protected dressings, yet staff reported the resident only received bed baths because of discomfort with a shower chair and no alternative shower equipment, and the care plan did not address bathing needs or preferences.
Staff inaccurately documented showers in the electronic medical record for two dependent residents when only bed baths were actually provided. One resident with hemiplegia, pain, and impaired mobility was recorded in point‑of‑care documentation as receiving multiple showers, while paper shower/skin worksheets and a GNA interview confirmed that only bed baths were given due to pain and inability to tolerate a shower chair. Another resident with severe cognitive impairment, diabetes, CHF, a tibia fracture, and pressure‑related skin issues had showers documented electronically on specific dates, but paper worksheets and multiple GNA interviews showed that only bed baths were provided because the resident could not safely use a shower chair and required a mechanical lift and at least two‑person assist. The care plan for this resident did not specify bathing assistance needs or preferences, and a GNA reported being instructed to chart showers in the system even when they were not performed.
Surveyors found that the facility did not develop or implement complete care plans for multiple residents, including those with recent falls, those receiving new or ongoing medications such as diuretics, antipsychotics, insulin, and anticoagulants, and those requiring oxygen therapy. These omissions were confirmed through staff interviews and record reviews, showing that residents' current medical needs were not reflected in their care plans.
A resident alleged rough treatment by staff during ADL care, which was documented in nursing notes and reported internally. However, the facility could not provide evidence that this abuse allegation was reported to the Office of Health Care Quality as required, and no investigative record was available when requested by surveyors.
A facility did not conduct or retain an investigation file for an alleged abuse incident involving a resident and a family member, despite self-reporting the incident and having documentation in the medical record. Only the initial and final self-reports were found, with no investigation file available for surveyor review.
The facility failed to provide written notice to the State LTC Ombudsman for a resident's discharge to home and did not ensure a physician completed a discharge summary for another resident who died in the facility. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
A resident with a known history of pressure ulcers was admitted with instructions to continue wound care, but initial nursing assessments failed to identify or document existing wounds, and no wound care was initiated until several days later when physician orders were obtained. Multiple pressure ulcers and DTIs were subsequently identified, indicating a delay in assessment and treatment.
A registered nurse administered a subcutaneous Heparin injection to a resident with Dementia and Diabetes Mellitus without closing the door or pulling the privacy curtain, resulting in a lack of privacy during the procedure. The nurse acknowledged the omission, and the DON confirmed that staff are required to provide privacy during such care.
Surveyors identified that two residents did not have timely updates to their care plans following significant changes in condition, including a fall and the initiation of a Foley catheter. The care plans were not revised to reflect these events or to add appropriate interventions, and updates were only made after surveyor involvement.
The facility did not ensure that nurse staffing information was posted with the correct and current date, as required. The posted information was observed to be outdated, and staff confirmed that the daily update process had not been followed correctly until the issue was identified and brought to their attention.
Surveyors found that food items stored in a dining area refrigerator were not consistently labeled with resident names or dates, and some items were expired. The Director of Dining Services confirmed that all food should be labeled and discarded after three days, in line with facility policy.
Surveyors identified that two residents had incomplete and inaccurate medical records, including conflicting mattress orders documented as completed despite only one being in use, and a physician order that did not appear on the TAR. Additionally, a nursing note indicated pain medication was given to another resident, but there was no documentation in the MAR or controlled drug records to confirm administration. Staff interviews confirmed these documentation lapses.
A registered nurse failed to perform hand hygiene before dispensing medications and after shaking hands with a visitor while administering medications to a resident with hypertension and myocardial infarction. The nurse only sanitized her hands after being prompted by a surveyor, despite facility policy requiring hand hygiene at these times.
Surveyors observed that a dining area cabinet beneath a non-operating ice and water dispenser was missing a handle, had a broken and crumbled pressed wood floor, brownish stains on the interior, and a broken pipe. The Director of Maintenance was unaware of the damage, and the Administrator confirmed the cabinet had been in this state for an extended period, with repairs pending due to cost.
Improper Bed Positioning and Supervision During ADL Care Leads to Fall With Multiple Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe positioning during ADL care for a dependent resident who required staff assistance with bed mobility. The resident had multiple medical diagnoses, including a prior right humerus fracture, chronic heart failure, atrial fibrillation, anemia, hypertension, chronic pain, obesity, and osteoarthritis. A quarterly MDS assessment documented that the resident was cognitively intact, always incontinent of bowel and bladder, dependent on staff for toileting hygiene, required partial/moderate assistance with bathing, and required substantial to maximum assistance for rolling left and right in bed. The care plan indicated the resident required extensive assistance with ADLs, including a three-person assist, and had fall risk interventions such as environmental supports and frequent monitoring. On the day of the incident, documentation and interviews showed that the resident fell from the bed during incontinence/ADL care. A nursing progress note stated the resident was found on the floor after reportedly letting go of a grab rail while being cleaned. The attending physician documented that the resident experienced a fall during care and later reported generalized pain. Subsequent nursing and physician notes described the resident as lethargic, in severe generalized pain, with abnormal arm positioning and increased pain with movement, leading to transfer to the hospital for further evaluation. Interviews with staff clarified the actions and inactions that led to the fall. Multiple GNAs reported that the resident could not turn independently and required hands-on assistance for repositioning. The GNA providing care at the time stated that they first pulled the resident toward them on one side of the bed, turned the resident onto their side, and provided care, then returned the resident to a supine position. The GNA then moved to the opposite side of the bed and turned the resident toward the door, instructing the resident to hold onto the side rail while care was provided. The GNA did not indicate that the resident was repositioned toward the center of the bed before this second turn, and stated that while cleaning the resident’s rectal area, they were not holding the resident and were positioned on the opposite side of the bed. The resident let go of the side rail and fell from the bed, which remained in the highest position, and the side rail on the side from which the resident fell was down. The DON and facility timeline identified the root cause as improper turning and repositioning during ADL care, with the resident positioned too close to the edge of the bed during linen removal, contrary to facility policies requiring safe positioning, maintenance of control during repositioning, and returning the bed to a safe position to prevent falls. Hospital documentation later confirmed the resident sustained multiple fractures, including bilateral humerus fractures and femur fractures.
Failure to Provide Complete Hygiene and Shower Alternatives for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide complete bathing and hygiene care and to offer appropriate shower alternatives for residents unable to use a shower chair. For one resident with Parkinson’s disease, epilepsy, dementia, chronic pain, and incontinence, the quarterly MDS showed the resident was cognitively intact, dependent for shower/bathing, and always incontinent of bowel and bladder. The care plan addressed limited transfer ability but did not specify the level of assistance needed for bathing or showering, nor did it address bathing or shower preferences. During observed bed bathing, the GNA washed only parts of the resident’s face and did not wash or rinse the ears, back of the ears, back of the neck, hands, fingers, fingernails, or back. The GNA later acknowledged missing those areas and stated that hands and fingernails were not routinely washed during bathing but instead cleaned at mealtimes. Another resident with hemiplegia, polyneuropathy, benign prostatic hyperplasia, hypertension, pain, depression, and atrial fibrillation was documented on the quarterly MDS as moderately impaired and dependent for shower/bathing. The care plan noted limited transfer ability related to impaired mobility but did not address the amount of assistance required for bathing or showering. Point-of-care documentation showed that only one GNA had documented providing a shower. That GNA reported the resident did not receive showers due to pain and inability to tolerate a shower chair and confirmed the resident had never received a shower and that no shower bed or other alternative method was available. The resident reported never having received a shower, that no one had attempted to provide one, and that this made them feel not clean. A staff nurse also stated that the resident could not tolerate a shower chair and that the facility did not have a shower bed. A third resident with diabetes, hypertension, congestive heart failure, benign prostatic hyperplasia, peripheral vascular disease, gastritis, xerosis cutis, osteoarthritis, and a pressure ulcer had an annual MDS indicating severe cognitive impairment, a PASRR Level II for intellectual disability, risk for pressure ulcers, and a diabetic foot ulcer with MASD. The care plan addressed limited transfer ability after a left tibia fracture but did not specify the assistance needed for bathing or address bathing or shower preferences or alternative shower methods. Wound physician consult notes over several months indicated the resident could shower if wound dressings were protected from moisture. However, GNAs reported that the resident only received bed baths and did not receive showers due to wounds and discomfort with a shower chair. A staff nurse stated that the resident’s wounds were always dressed appropriately, protected from moisture, and would not prevent showering, and another nurse and the DON confirmed that residents unable to tolerate a shower chair received bed baths because the facility did not have a shower bed.
Inaccurate Documentation of Showers Versus Bed Baths for Dependent Residents
Penalty
Summary
The deficiency involves inaccurate and misleading documentation of bathing care in resident medical records, where showers were recorded as provided despite staff interviews and paper records indicating only bed baths were given. For one resident with hemiplegia, polyneuropathy, benign prostatic hyperplasia, hypertension, pain, depression, and atrial fibrillation, the quarterly MDS showed moderate cognitive impairment and dependence for bathing. Electronic point-of-care records over a one‑month period documented multiple showers by a specific GNA, while the facility’s GNA shower/skin worksheet for the same dates showed that only bed baths were provided. In an interview, the GNA stated that this resident never received a shower due to pain and inability to tolerate a shower chair and confirmed that they were instructed to document showers in the electronic system while recording the actual care (bed baths) on a paper shower sheet. A second resident with diabetes, hypertension, congestive heart failure, benign prostatic hyperplasia, peripheral vascular disease, gastritis, xerosis cutis, osteoarthritis, and a pressure ulcer had an MDS indicating severe cognitive impairment, a PASRR Level II for intellectual disability, risk for pressure ulcers, and a diabetic foot ulcer with MASD. The care plan addressed limited transfer ability after a tibia fracture but did not specify the level of assistance needed for bathing or resident bathing preferences or alternatives. Electronic point-of-care records showed showers documented on two dates by the same GNA, while the GNA Q‑shift skin/shower worksheet indicated bed baths on those dates. In interviews, the GNA reported never providing showers to this resident, documenting showers in the system while actually giving bed baths, and stated the resident could not safely use a shower chair and required a mechanical lift and at least two‑person assist. Other GNAs also reported that this resident received only bed baths due to wounds and discomfort with a shower chair. The DON and Administrator both stated that staff were expected to document only care actually provided, and the Administrator reported that the nurse who instructed staff to document showers not performed was no longer employed at the facility.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. In one instance, a resident who experienced a fall in the bathroom did not have a care plan addressing the actual fall event, despite documentation of the incident and the resident's ongoing knee pain. The care plan only addressed the risk for falls, not the specific event or its aftermath, until after surveyor intervention. Another resident admitted for short-term rehabilitation was receiving both a diuretic (Lasix) and an antipsychotic (Seroquel), but the care plan did not reflect the administration or monitoring of these medications. The resident had been receiving Seroquel at home and Lasix was newly ordered at the facility, yet no care plan was developed or implemented to address the use of these medications or their potential effects. Additional deficiencies were found for residents requiring oxygen therapy and anticoagulant medications, as well as for a resident with insulin-dependent diabetes and anticoagulant use. In both cases, the care plans did not include these significant medical needs, despite clear documentation in the medical records and medication administration records. Staff interviews confirmed that these omissions were not in line with facility policy and that the care plans were not updated to reflect the residents' current conditions and treatments.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of suspected resident abuse to the Office of Health Care Quality (OHCQ) as required. On 11/10/2022, a resident alleged that staff members washed them in a rough manner while providing assistance with activities of daily living. Nursing progress notes documented the resident's refusal to be changed by two aides, stating they did not want to be abused, and that the incident was reported to the writer and the Assistant Director of Nursing (ADON). Further documentation described the resident as combative during care, with staff intervention including a shower, transfer with a Hoyer lift, and subsequent aggressive behavior by the resident. The police were called, and the resident refused to speak with the officer. The responsible party was notified, and a psychiatric consult was requested. Upon surveyor request, the facility was unable to provide an investigative record related to the incident, and the Administrator could not confirm that the allegation of abuse was reported to OHCQ. The Administrator acknowledged the expectation to report all abuse allegations in a timely manner but was unable to provide evidence that the required notification occurred. No additional documentation was provided to show that the OHCQ was notified of the resident's allegation.
Failure to Investigate Alleged Abuse by Family Member
Penalty
Summary
The facility failed to investigate an alleged violation of abuse involving a resident and the resident's family member. The Office of Healthcare Quality received a self-reported incident from the facility's Assistant Director of Nursing regarding an allegation that a resident's son yelled at the resident and possibly grabbed the resident's face during a visit. Progress notes in the resident's medical record documented the incident and the resident's responses to questions about feeling safe and whether the son had grabbed their face. Despite the self-report and documentation in the medical record, the facility was unable to produce an investigation file related to the alleged abuse when requested by the surveyor. The facility's policy requires the collection, retention, and safeguarding of all information and evidentiary material pertinent to investigations of alleged abuse or neglect. However, only the initial and final self-reports were located in the administrator's email, and no investigation file was provided to the surveyor.
Failure to Notify Ombudsman and Complete Physician Discharge Summary
Penalty
Summary
Facility staff failed to provide written notice to the Office of the State Long Term Care Ombudsman regarding the discharge of a resident who was admitted and later discharged home. Review of the clinical record and facility documentation revealed no evidence that the ombudsman was notified of this discharge, and staff interviews confirmed that while notifications were sent for hospital transfers, there was no confirmation or documentation for discharges to home. The facility was unable to provide any evidence of notification to the ombudsman for this resident's discharge at the time of the survey. Additionally, the facility did not ensure that a discharge summary was completed by a physician for another resident who was found unresponsive and later pronounced deceased. The medical record contained a nursing progress note and documentation of the release of remains, but lacked a physician's progress note or discharge summary. Interviews with the DON and Medical Records Coordinator confirmed that a physician note was expected but not present, and the responsible physician was no longer employed at the time of the survey.
Failure to Initiate Timely Wound Care for Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to initiate wound care upon admission for a resident with multiple pressure ulcers. Upon admission, the resident had a documented history of a right thigh decubitus ulcer, with hospital discharge instructions to continue wound care. Initial assessments by nursing staff noted bruises and dry skin, but did not identify or document any open wounds or pressure ulcers. No wound care orders or treatments were initiated at this time, and there was no documentation of wound care being provided prior to new physician orders being placed several days after admission. Subsequent assessments revealed multiple pressure ulcers and deep tissue injuries (DTIs) on the resident, including wounds on the right and left feet, right upper thigh, sacrum, and ischium. Wound care orders were eventually obtained and documented, but not until several days after admission, resulting in a delay in treatment. Interviews with facility leadership confirmed that wound care should have been started earlier and that any wounds identified upon admission should have been documented, assessed, and treated promptly.
Failure to Provide Privacy During Injection Administration
Penalty
Summary
Facility staff failed to provide privacy to a resident during the administration of a subcutaneous injection. A review of the clinical record showed the resident had diagnoses of Dementia and Diabetes Mellitus. During a medication pass, a registered nurse entered the resident's room to administer a Heparin injection but did not close the door or pull the privacy curtain. The nurse informed the resident about the injection, lifted the resident's gown, and administered the medication without ensuring privacy. The nurse later acknowledged not providing privacy during the procedure. The Director of Nursing confirmed that facility policy requires staff to provide privacy during injection administration, either by closing the door in a private room or drawing the curtain in a semi-private room. These actions resulted in a failure to honor the resident's right to privacy and dignity during a medical procedure, as observed and confirmed by both staff and facility leadership.
Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were revised and updated in a timely manner, as required. For one resident who experienced a fall while attempting to transfer from the toilet to a wheelchair, the care plan did not reflect the actual fall or include any new interventions following the incident. Although the resident had a care plan indicating risk for falls, no updates or additional interventions were added after the fall occurred, and the care plan was only updated after surveyor intervention. Another resident had a physician order for an indwelling Foley catheter due to urinary retention, but there was no corresponding care plan addressing the catheter. The lack of a care plan for the Foley catheter was confirmed during record review and acknowledged by the RN MDS Coordinator. Both deficiencies were substantiated through observation, interviews, and record review, and were acknowledged by facility leadership.
Failure to Post Accurate and Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information was accurate and current, as required. During an observation in the facility lobby, the surveyor noted that the nurse staffing information displayed at the receptionist desk was dated for the previous day, rather than the current date. This information is required to be posted daily at the beginning of each shift in a prominent and accessible location, and must be up-to-date and accurate. Interviews with staff revealed that the Administrator-In-Training was responsible for posting the daily nurse staffing information. When the surveyor pointed out the incorrect date to a staff member, the staff member obtained an updated form and replaced the outdated posting. The Director of Nursing was also informed of the issue and acknowledged that the incorrect date had been posted before it was corrected.
Failure to Properly Label and Store Resident Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards and its own policies. During an inspection of a refrigerator in one of the dining areas, multiple food containers were found that were either expired or lacked required labeling, such as the resident's name and the date the item was placed in the refrigerator. Specific items included a container for a resident dated five days prior, a plate of salad with no date, several containers and bags with missing names or dates, and some with only a room number. The Director of Dining Services confirmed that all items should be labeled with the resident's name and the date, and that items should be discarded after three days, as per facility policy. Review of the facility's nutrition policy also confirmed these requirements.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurate, as evidenced by discrepancies in physician orders and medication documentation. For one resident, there were conflicting orders for a pressure-relieving mattress and an air mattress, with both orders documented as completed on the Treatment Administration Record (TAR) despite only one type of mattress being present. Staff interviews revealed uncertainty about which order should be followed, and it was later clarified that the air mattress order should have been discontinued after a decision by the family and physician. Additionally, a physician order for the resident to be out of bed on specific days did not transfer to the TAR, resulting in the order not being visible or actionable for nursing staff. For another resident, a nursing progress note indicated that pain medication was administered at a specific time, but there was no corresponding documentation in the Medication Administration Record (MAR) or controlled drug records to confirm that any medication was given at that time. Staff interviews confirmed that medications should be documented in the MAR immediately after administration, and there was no evidence to support that the medication was provided as noted in the progress note. These findings demonstrate lapses in maintaining accurate and complete medical records in accordance with professional standards.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during medication administration for a resident admitted with diagnoses including hypertension and myocardial infarction. During a medication pass, a registered nurse took the resident's blood pressure, recorded it, and proceeded to dispense medication without performing hand hygiene. The nurse only sanitized her hands after the surveyor intervened and pointed out the omission. Later in the same medication pass, the nurse shook hands with a visitor and then continued to dispense medications without performing hand hygiene until prompted by the surveyor. In interviews, the nurse acknowledged the failure to perform hand hygiene at the required times, and the Director of Nursing confirmed that facility policy requires hand hygiene before and after resident care, after leaving a resident's room, before handling the medication cart, and after contact with visitors.
Failure to Maintain Sanitary and Functional Dining Area Environment
Penalty
Summary
The facility failed to maintain a functional and sanitary environment in one of its dining areas, specifically the Sycamore Café. During observations, a non-operating ice and water dispenser was found on the counter, and the cabinet below it was missing a handle on the right door. The floor inside the cabinet was broken and crumbled in the center, with brownish stains running down the interior walls and broken flooring. A broken pipe was also present inside the cabinet. The Director of Maintenance, who had been employed for about four and a half months, was unaware of the damaged cabinet and identified the crumbled flooring as pressed wood. The Administrator acknowledged that the cabinet had been in this condition for some time and stated that repairs were planned but described them as a significant expenditure.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near White Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waldorf Center | 1.3 mi | ★★★★★ | 27 | 0 |
| Green Acres Nursing And Rehab | 4.1 mi | ★★★★★ | 17 | 0 |
| Complete Care At Laplata Llc | 4.2 mi | ★★★★★ | 12 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 9.2 mi | ★★★★★ | 35 | 0 |
| George Washington Health & Rehabilitation | 11.2 mi | ★★★★★ | 0 | 0 |
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