Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Cedar Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbances repeatedly refused care, expressed distress, and exhibited behaviors such as yelling and crying, but no behavior care plan was developed or implemented. Staff documented these behaviors in progress notes and reported them verbally, but the facility did not create a formal care plan to address the resident's needs, contrary to facility policy.
A resident with dementia and impaired mobility did not consistently receive needed assistance with ADLs, including toileting and hygiene, as required by their care plan. Multiple family grievances reported the resident being left in soiled briefs and denied toileting assistance. Documentation by CNAs was frequently incomplete or missing for elimination and hygiene care, and staff interviews confirmed lapses in both care provision and oversight. The resident was later hospitalized with sepsis, UTI, and other complications.
The facility failed to report alleged abuse incidents involving three residents in a timely manner, as required by federal and state regulations. Incidents included distressing sounds from a resident's room, a resident being tapped on the head by a CNA, and another resident being left in the shower and bopped on the head. Investigations were not reported to the New York State Department of Health within the mandated timeframe.
A resident with Asperger's syndrome and other conditions was physically abused by a CNA, who bopped them on the head. The incident was witnessed by another CNA who did not report it immediately due to fear of retaliation. The resident reported the abuse to a medical director, leading to an investigation that confirmed the abuse. The facility's response was inadequate, as the incident was not reported to the nursing supervisor or the licensing board promptly.
Failure to Develop and Implement Behavior Care Plan for Resident with Dementia
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive behavior care plan for a resident with a diagnosis of dementia and behavioral disturbances. Despite multiple nursing and respiratory progress notes, as well as staff interviews, documenting the resident's repeated refusals of care, expressions of wanting to go home, crying, yelling, and other behavioral symptoms, there was no documented evidence of a behavior care plan in the resident's records. The facility's policies require individualized, person-centered care plans and assistance with activities of daily living according to each resident's needs, but these were not followed in this case. The resident was noted to be moderately cognitively intact, used a wheelchair, required varying levels of assistance with daily activities, and was on multiple psychotropic medications. Staff interviews confirmed ongoing behavioral issues, including refusal of care, yelling, and expressions of distress, which were reported verbally to nursing staff but not formally documented in the electronic medical record or addressed through a care plan. The Director of Nursing acknowledged that a behavior care plan was not in place and that behaviors were only being documented in nursing progress notes.
Failure to Provide and Document Required ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), including toileting and hygiene, did not consistently receive the necessary care as outlined in their care plan. The resident, who had diagnoses including dementia, impaired mobility, and chronic kidney disease, was frequently incontinent and required maximum assistance with toileting and transfers. Multiple grievances were filed by the resident's family, citing instances where the resident was found soaked in urine and not changed by staff, as well as an incident where a certified nurse aide refused to assist the resident with toileting, resulting in distress for the resident. Documentation reviews revealed significant omissions in certified nurse aide records for bowel and bladder elimination, toilet transfers, and toilet hygiene across multiple shifts and dates. These gaps in documentation spanned both August and September, indicating a pattern of incomplete or missing records regarding the provision of essential care. Interviews with staff confirmed that documentation was not consistently reviewed or completed, with some staff citing workload and staffing shortages as barriers to proper documentation. The Director of Nursing and unit managers acknowledged the documentation issues and the lack of oversight in ensuring that ADLs were performed and recorded as required. The resident was ultimately transferred to the hospital with a diagnosis of sepsis, community-acquired pneumonia, urinary tract infection, and acute kidney injury. Family interviews and progress notes highlighted ongoing concerns about the resident's hygiene and the adequacy of care provided, including staff attitudes and responsiveness to the resident's needs. The facility's own policy required individualized assistance with ADLs, but the observed and documented failures led to the deficiency cited during the survey.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, in a timely manner as required by federal and state regulations. Specifically, incidents involving three residents were not reported to the administration immediately, nor were the results of investigations submitted to the New York State Department of Health within the mandated five working days. This deficiency was identified during an abbreviated survey, which reviewed the cases of three residents who experienced or were involved in incidents of potential abuse. In the first case, a Licensed Practical Nurse and a Housekeeper reported hearing distressing sounds from a resident's room, including a voice saying "shut up" and what sounded like slapping. Despite these observations, the incident was not reported promptly, and the investigation concluded that the resident was not harmed, although no investigative report was submitted to the Department of Health. The second case involved a resident who became aggressive during care, leading to a staff member allegedly tapping the resident on the head. This incident was only reported to the administration after a visitor witnessed it and reported it the following day. Again, no timely report was submitted to the Department of Health. The third case involved a resident who reported being left in the shower for an extended period and being bopped on the head by a staff member. Another staff member witnessed the incident but did not report it, assuming the resident would do so. The investigation confirmed the resident's account of being hit, but no report was submitted to the Department of Health within the required timeframe. The Director of Nursing stated that they typically only submit reports when requested by the Department of Health, indicating a misunderstanding of the reporting requirements.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) who physically abused a resident. The incident occurred when CNA #5 bopped the resident on the head with their knuckles while the resident was in a wheelchair. This act was witnessed by another CNA, who did not report the incident immediately. The resident, who has diagnoses including Asperger's syndrome, muscle weakness, and dysphagia, reported the incident to the Medical Director of Managed Long Term Care the following day. The facility's abuse policy clearly states that residents have the right to be free from abuse, including physical abuse such as hitting. Despite this policy, the incident was not reported to the nursing supervisor or administrator until the resident themselves reported it. The investigation revealed that CNA #7 witnessed the incident but did not report it due to fear of retaliation and the assumption that the alert and oriented resident would report it themselves. The investigation concluded that the resident's complaint of being left in the shower could not be corroborated, but the physical abuse was confirmed by the eyewitness account. The Director of Nursing did not report the abusive CNA to the licensing board, citing the resident's developmental challenges and fluctuating mood as factors. The resident, who is alert and oriented, expressed fear of retaliation and requested to be sent to the hospital. The investigation continued after the resident's departure to the hospital, but the facility's response to the incident, including the lack of immediate reporting and failure to notify the licensing board, highlights deficiencies in handling abuse allegations.
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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 Ossining
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Nursing Home Company Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Sunshine Children's Home And Rehab Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 3.6 mi | ★★★★★ | 6 | 0 |
| Briarcliff Manor Center For Rehab And Nursing Care | 3.7 mi | ★★★★★ | 0 | 0 |
| Tolstoy Foundation Rehabilitation And Nrsg Center | 4.8 mi | ★★★★★ | 40 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.