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 Nyack Ridge Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with significant mobility impairments was injured during a transfer when two CNAs, who had not received training on a newly introduced mechanical lift, improperly operated the device, causing it to tilt and strike the resident's head. The incident resulted in a head laceration requiring emergency care. Facility records and staff interviews confirmed that the CNAs had not been in-serviced on the new lift prior to the event, leading to the deficiency.
The 3rd Floor of the facility was found to have pervasive odors of urine and feces, stained and worn shower chairs, and soiled bathrooms, compromising the residents' right to a safe and homelike environment. Staff interviews revealed a lack of effective communication and follow-up on maintenance issues, despite existing policies. The Director of Housekeeping and the Administrator acknowledged the concerns and mentioned planned renovations, but these had not been executed.
The facility failed to complete discharge summaries and communicate effectively with residents and their families, leading to deficiencies in discharge planning. A resident was discharged without a summary, another without education on injectable medications, and a third with incomplete instructions. These failures resulted in inadequate post-discharge care and communication issues.
The facility was found to be consistently understaffed, failing to meet the required nursing staff ratios, leading to delayed responses to resident needs. Residents reported long waits for assistance, including a three-hour delay for pain medication. Family members noted residents with saturated briefs and bed linens. Staff frequently worked overtime to cover shortages, and the facility relied on staffing agencies to fill gaps. The Director of Nursing acknowledged the staffing challenges and ongoing efforts to address them.
Two residents experienced significant weight loss due to inadequate nutritional interventions and monitoring. One resident with dementia was often left confused during meals without assistance, while another resident with schizophrenia was dissatisfied with meals and not offered alternatives. Both residents' care plans lacked reassessment and modification, leading to poor nutritional outcomes.
The facility failed to store and prepare food according to professional standards, with undated and expired food items found in storage areas and improper food temperatures observed. Personal food was also improperly stored in facility refrigerators. The Food Service Director acknowledged these issues but could not explain them.
A resident with cataracts did not receive prescribed eye drops as ordered after surgeries. The facility failed to administer prednisolone drops on time due to medication changes and communication issues with the pharmacy. The resident expressed dissatisfaction with the timing of administration, leading to refusal of the drops. Additionally, ciprofloxacin drops were administered earlier than scheduled before the second surgery.
The facility failed to provide a dignified dining experience for three residents, as staff were observed standing over them while assisting with meals, contrary to policy. Aides acknowledged the inappropriate practice, citing multitasking and staffing shortages. The Nurse Educator confirmed the need for staff to be seated and facing residents to ensure safety and dignity.
A facility failed to properly notify a resident's representative about changes in Medicare coverage due to the resident's moderate cognitive impairment. The resident, diagnosed with dementia and a psychotic disorder, was given notices they could not understand. The Social Work Assistant did not successfully contact the resident's daughter and failed to mail the notices, leading to a deficiency.
The facility did not ensure residents were aware of the grievance process, as all 16 residents at a Resident Council meeting were unaware of how to file a grievance. Observations showed missing postings of grievance procedures, and staff interviews revealed inconsistencies in handling grievances. The Director of Social Services acknowledged the lack of individual resident notification about the grievance process.
A resident with severe cognitive impairment and a high fall risk was found to be using a concave mattress as a restraint without a physician's order or documented consent. The facility's policy requires restraints only for medical symptoms when less restrictive measures fail, but staff used the mattress to prevent falls, not recognizing it as a restraint.
A facility failed to complete a PASRR screening for a resident with bipolar disorder, schizoaffective disorder, and parkinsonism. The SCREEN DOH 695 form was missing documentation for items necessary to determine the need for Level II services. Staff interviews revealed that the oversight was due to a missed review by the Director of Social Services, with the Director of Nursing confirming the Social Worker's responsibility in the process.
A resident with pressure injuries did not receive necessary pressure-relieving devices as ordered by the physician. Despite orders to offload the resident's heels with a pillow, observations showed the absence of a pillow under the resident's legs. Interviews with staff revealed a lack of awareness and adherence to care instructions, contributing to the deficiency in pressure ulcer care.
A resident with severe cognitive impairment and on aspiration precautions was fed a mechanically altered diet by an unqualified transporter due to the absence of licensed nursing staff supervision during mealtime. The transporter, lacking the necessary training, fed the resident in the 3rd Floor Dayroom, where no LPN or RN was present to oversee the meal. The RN Manager, responsible for supervision, left the facility without notice, leading to the deficiency.
Two residents in the facility received oxygen therapy inconsistent with physician orders. One resident with COPD and other conditions was given 3 liters per minute instead of the prescribed 2 liters, with no documentation in the Treatment Administration Record. Another resident with hypertension and respiratory issues was also given 3 liters instead of 2, and their nasal cannula and humidified water bottle were not dated as required by facility policy. LPNs and the DON confirmed these discrepancies.
The facility did not conduct annual performance reviews for CNAs, as required. Six CNAs, employed since 2000 to 2018, lacked documented evaluations within the past year. Interviews with staff revealed that evaluations had not been conducted for several years, with some done sporadically. One CNA reported their last evaluation was in 2012.
A facility failed to provide appropriate dementia care for two residents, lacking individualized activities and proper implementation of care plans. One resident exhibited distressing behaviors without receiving meaningful engagement or prescribed interventions, while another was left disengaged and without recommended medication adjustments. Staff were unaware of necessary interventions, and the facility was short-staffed, impacting care quality.
During a survey, deficiencies were found in the medication storage room of a facility's second floor unit. Unlabeled and expired items, including medications and supplies, were present, and the refrigerator was above the acceptable temperature range. Staff interviews revealed that nurses were responsible for checking these areas every shift, but failed to do so, leading to the deficiencies.
The facility failed to maintain an effective infection control program, as evidenced by improper PPE use for a resident on enhanced barrier precautions, a catheter bag left on the floor for a resident with a history of UTIs, and inadequate hand hygiene by a Wound Care Nurse during treatment of a resident with pressure injuries.
The facility failed to implement an effective antibiotic stewardship program, as they could not provide adequate documentation of antibiotic use tracking for several months. The Infection Control Preventionist, responsible for monitoring antibiotic use, provided an incomplete list lacking critical information such as infection onset dates and laboratory test results. The Director of Nursing confirmed that the Infection Control Preventionist was behind in tracking antibiotic use, indicating a failure in the facility's antibiotic stewardship efforts.
The facility did not maintain an effective pest control program, as evidenced by live and dead roaches found in the kitchen. Despite having a policy for ongoing pest control and bi-weekly treatments, the Food Service Director acknowledged the issue. Pest Management Service reports noted minimal activity and recommended improved sanitary practices. The Director of Maintenance confirmed monthly pest control services.
The facility failed to submit 11 out of 30 resident assessments to CMS within the required 14-day period. Despite a policy mandating timely submission, assessments completed in November were only submitted in January. The MDS Coordinator acknowledged the delay but could not explain it, while the DON was unaware of the issue, highlighting a lack of communication and oversight.
A resident with severe cognitive impairment was involved in an alleged abuse incident with a podiatrist, which was not reported to the state as required. The resident exhibited physical behavioral symptoms and refused care, but the podiatrist continued. The facility's Director of Nursing and Administrator did not report the incident to the state, considering it a complaint rather than a reportable incident.
A facility failed to investigate an alleged abuse incident involving a resident and a podiatrist. The resident, with severe cognitive impairment, became combative during a podiatry procedure. The Director of Nursing did not document a skin assessment or file an incident report, considering it a complaint. The Administrator, informed by the wound doctor, did not report the incident to the state. The Director of Social Services, informed a week later, did not document or refer the resident, who showed no trauma signs. The facility's lack of documentation and reporting led to the deficiency.
A facility failed to document an incident and assessment in a resident's medical record following an alleged abuse incident during a podiatry consult. Despite staff overhearing the incident, no accident or incident report was completed, and the Director of Nursing concluded no abuse occurred. The resident, with severe cognitive impairment, exhibited usual behaviors of resisting care. The lack of documentation and adherence to policy led to the deficiency.
Resident Injury Due to Untrained Use of New Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to diagnoses including amyotrophic lateral sclerosis, muscle weakness, and chronic obstructive pulmonary disease, was injured during a transfer using a new mechanical lift. The resident required two-person assistance and was to be transferred according to facility policy and manufacturer guidelines, which mandated that both staff members be trained on the specific lift in use. However, during the transfer, the mechanical lift tilted and struck the resident's head, resulting in a laceration that required emergency hospital care and staples. Certified Nurse Aides involved in the transfer reported that they had not received in-service training on the new mechanical lift prior to the incident. Both aides described the lift tilting unexpectedly during the transfer, with one aide noting that the base of the lift was not properly expanded and the other stating that the resident was holding onto the bar when the lift began to shake and tilt. The incident was corroborated by the resident, who communicated that one of the aides did not know how to operate the new lift, leading to the bar hitting and cutting their head. Facility records and interviews confirmed that the new mechanical lifts had been assembled and tested by the maintenance team, and that leadership was notified of their arrival. However, the staff involved in the incident had not yet received documented training on the new equipment at the time of the event. The lack of training and unfamiliarity with the new mechanical lift directly contributed to the improper use of the device and the resulting injury to the resident.
Deficient Environmental Conditions on 3rd Floor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 3rd Floor, as observed during a recertification and abbreviated survey. The survey revealed pervasive and strong odors of urine and feces throughout the floor, particularly in the dayroom where residents gathered for meals. The environment was further compromised by stained and worn shower chairs, hanging ceiling tiles, and soiled and stained bathrooms in multiple resident rooms. Additionally, the dayroom contained soiled bins of dolls and stuffed animals, marked floors, and damaged walls. Interviews with staff and residents highlighted the inadequacies in maintaining the environment. A resident described their room as shabby and gloomy, while a Certified Nurse Aide acknowledged the need for reporting stains and damages to the maintenance department. A Registered Nurse noted the difficulty in addressing environmental issues due to residents' preferences, and the Director of Housekeeping admitted to the unacceptable state of cleanliness in shared bathrooms. The Director of Maintenance was aware of the conditions but had not received recent repair requests from the 3rd Floor staff. The facility's policies on maintaining a homelike environment and addressing maintenance issues were not effectively implemented. Despite having an electronic ticket system for reporting repairs, there was a lack of communication and follow-up between staff and the maintenance department. The Director of Housekeeping and the Administrator acknowledged the environmental concerns and stated that renovations and repairs were planned, but these had not yet been executed, leaving the 3rd Floor in a substandard condition.
Incomplete Discharge Summaries and Communication Failures
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for three residents reviewed for discharge, leading to deficiencies in communication and planning. Resident #124, who had diagnoses including end-stage renal disease and bladder cancer, was discharged without a documented discharge summary in their electronic medical record. Despite discussions and arrangements for home care services, the discharge summary was not completed, and the responsibility was attributed to the physician, who claimed it was in the hard chart, but it was not located. Resident #247, who was severely cognitively impaired and required insulin and Epogen injections, was discharged without adequate communication with the family regarding the administration of injectable medications. The family reported receiving no education on medication administration, and attempts to contact the facility for guidance were unsuccessful. The discharge occurred on a Saturday, and the nursing staff failed to provide the necessary education, leading to the resident's hospitalization following a fall. Resident #245, with diagnoses of cerebral infarction and anxiety disorder, was discharged with incomplete discharge instructions. The instructions lacked details on follow-up care, safety precautions, and occupational therapy recommendations. The resident's representative expressed concerns about the discharge process, stating that the resident was not ready for discharge and that financial issues were not adequately addressed. The facility's failure to provide a comprehensive discharge plan and communicate effectively with the resident's representative contributed to the deficiency.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. This deficiency was identified during the Recertification and abbreviated surveys conducted from January 6 to January 14, 2025. Multiple residents reported during a Resident Council Group meeting that the facility was short-staffed, leading to delayed responses to call bells. Specifically, one resident reported waiting three hours for pain medication after requesting it. Family members of residents also expressed concerns, noting instances where residents were found with saturated briefs and bed linens. The facility's staffing schedule analysis revealed that from December 6, 2024, to January 6, 2025, the facility was understaffed on all shifts, failing to meet the minimum staffing levels documented in the Facility Assessment. Interviews with nursing staff and the Human Resources/Staffing Coordinator highlighted the facility's reliance on overtime and staffing agencies to fill gaps. Several staff members reported working double shifts, particularly on weekends, to cover shortages. The Human Resources/Staffing Coordinator acknowledged the facility's staffing challenges, particularly for the 7 AM-3 PM shift, and mentioned ongoing efforts to recruit and retain nursing staff. The Director of Nursing also confirmed the staffing challenges and indicated that discussions with upper management were underway to address the issue.
Failure to Maintain Nutritional Status for Two Residents
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status, leading to significant weight loss. Resident #80, diagnosed with dementia and osteoarthritis, experienced a weight loss of 15.68% over several months. Despite being on a mechanically altered diet and receiving supplements, there was no documented evidence of reassessment or modification of the care plan to address the weight loss. Observations revealed that Resident #80 often sat confused during meals without staff intervention or assistance, which contributed to poor food intake. Resident #25, with diagnoses including schizophrenia and bipolar disorder, also experienced significant weight loss. The resident's care plan included dietary supplements and a mechanically altered diet, but there was no evidence of reassessment or modification of the care plan following the weight loss. Observations showed that Resident #25 was dissatisfied with meals and did not receive alternatives when requested, leading to inadequate food intake. Both residents' care plans lacked adequate monitoring and documentation of food intake and weight changes. Staff interviews indicated a lack of consistent assistance and encouragement during meals, contributing to the residents' nutritional deficiencies. The facility's failure to implement and monitor effective interventions resulted in significant weight loss for both residents.
Food Storage and Temperature Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food safety practice. During a recertification survey, it was observed that opened and undated food items were stored in the refrigerators, freezer, and dry storage room. Additionally, personal food belonging to an employee was improperly stored in the facility's freezer and reach-in refrigerator, which were not designated for employee food storage. Expired food items were also found in the emergency food supply and reach-in refrigerator, indicating a lack of proper monitoring and rotation of food items. Furthermore, the facility did not maintain appropriate food temperatures, as hot food was held below the required 135 degrees Fahrenheit on the steam table, and cold turkey was found at 51 degrees Fahrenheit, above the safe temperature of 41 degrees Fahrenheit. These observations were made during a tour of the kitchen and interviews with the Food Service Director, who acknowledged the issues but could not provide explanations for the presence of undated and expired food or the improper food temperatures.
Failure to Administer Eye Drops as Ordered Post-Cataract Surgery
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident #107, who had diagnoses including Dry Eye Syndrome, Edema of unspecified eye, and Diabetic Cataracts, did not receive their prescribed eye drops as ordered by the physician following cataract surgeries. The resident was scheduled to receive prednisolone eye drops post-operatively, but the medication was not administered as per the physician's orders. The April 2024 Medication Administration Record indicated that the eye drops were documented as refused on the day of the surgery, and there was a delay in administering the first dose due to a change in the medication order. Additionally, the resident expressed dissatisfaction with the timing of the medication administration, which led to a refusal of the eye drops. Further issues arose with the administration of ciprofloxacin eye drops, which were intended to be started three days prior to the resident's second cataract surgery. However, the medication was administered earlier than scheduled. Interviews with the resident and the Director of Nursing revealed that there were communication issues with the pharmacy regarding medication availability and changes in orders, contributing to the delay in administration. The Director of Nursing acknowledged that the physician's orders should have been followed and mentioned difficulties with the resident during this period, although no documentation of a plan for nursing staff was provided.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during the recertification survey. Observations revealed that staff members were standing over residents while assisting them with meals, contrary to the facility's policy which mandates that staff should be seated to maintain dignity and ensure safety. Resident #48, who has severe cognitive impairment and requires assistance with eating, was observed being fed by a Certified Nurse Aide who stood over them. Similarly, Resident #345, also with severe cognitive impairment and dependent on staff for eating, was assisted in the same manner. The aide involved acknowledged the inappropriate practice, citing multitasking and staffing shortages as reasons. Resident #30, diagnosed with vascular dementia and requiring assistance with eating, was observed being fed by a Certified Nurse Aide who stood next to the resident without making eye contact. The aide later acknowledged the need to be seated while feeding the resident. The Nurse Educator/Infection Control Preventionist confirmed that staff should be seated and facing residents to monitor for signs of aspiration and ensure the residents are alert while eating. These observations indicate a failure to adhere to the facility's policies on maintaining resident dignity during meal times.
Failure to Properly Notify Resident's Representative of Medicare Coverage Changes
Penalty
Summary
The facility failed to ensure that a resident with moderate cognitive impairment was properly informed about changes in Medicare coverage. Specifically, the resident, who had diagnoses including dementia and a psychotic disorder, was given a Notice of Medicare Non-Coverage and an Advanced Beneficiary Notice of Non-Coverage. These notices were provided despite the resident's inability to comprehend the content due to their cognitive condition. The resident was unable to sign the notices, and the facility's policy required that such notices be communicated to the resident's family or representative when the resident is unable to understand them. The Social Work Assistant, responsible for delivering these notices, acknowledged that they did not successfully contact the resident's daughter, who was the information source for the resident's assessments. The Social Work Assistant left a voicemail but did not send the notices via mail to ensure the daughter received them. The Director of Social Work confirmed that the notices should have been sent to the resident's daughter instead of being presented to the resident. The facility did not use certified mail to confirm delivery of the notices, which contributed to the deficiency.
Lack of Resident Awareness of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and their rights to file grievances without discrimination or reprisal. During a Resident Council meeting, all 16 residents in attendance reported not knowing how to file a grievance. The facility's grievance policy, last reviewed in October 2021, stated that residents would be informed orally and in writing of their right to make complaints. However, there was no evidence in the Resident Council minutes from October to December 2024 that the grievance process was reviewed with its members. Additionally, observations revealed that information about the grievance process, ombudsman contact, and complaint hotline was not adequately posted throughout the facility. Interviews with various staff members, including registered nurses, licensed practical nurses, certified nurse aides, and the Director of Social Services, indicated a lack of awareness and consistency in handling grievances. Staff members generally reported that they would inform supervisors or specific departments about complaints but were not aware of any formal grievance forms for residents. The Director of Social Services, who is the Grievance Officer, acknowledged that residents were not individually informed about the grievance process and that grievance forms were available in the social service binder on each unit. The Director also noted that the information boards would be updated to include necessary grievance process details.
Improper Use of Restraints for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. This deficiency was identified during a recertification survey, where it was observed that a concave mattress was used for a resident to prevent falls, despite the absence of a physician's order. The resident, who had a history of schizophrenia, bipolar disorder, and chronic obstructive pulmonary disease, was noted to have severe cognitive impairment and a high risk for falls. The concave mattress was intended to prevent the resident from getting out of bed, which was considered a restraint as it restricted the resident's freedom of movement. The facility's policy on the use of restraints specifies that such devices should only be used when necessary to treat a medical symptom and when less restrictive interventions are not effective. However, the use of the concave mattress for the resident was not documented as a physician-ordered intervention, nor was there evidence of consent from the resident or their family. Interviews with facility staff revealed that the concave mattress was used as a safety precaution to prevent falls, but it was not recognized as a restraint by the staff, indicating a lack of adherence to the facility's restraint policy.
Incomplete PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a complete preadmission screening for a resident with a mental disorder, as required by the Preadmission Screening and Resident Review (PASRR) program. This deficiency was identified during a recertification survey, where it was found that the SCREEN DOH 695 form for a resident with bipolar disorder, schizoaffective disorder, and parkinsonism was incomplete. Specifically, the form lacked documentation for items 27 through 30, which are necessary for determining the need for Level II services when a serious mental illness is indicated. Interviews with facility staff revealed that the Director of Social Services and the Director of Nursing acknowledged the oversight. The Director of Social Services admitted to missing the review of the PASRR SCREEN for the resident, while the Director of Nursing confirmed that the Social Worker was responsible for reviewing the SCREEN form before accepting the resident. The incomplete form was not identified until the survey, indicating a lapse in the facility's process for coordinating assessments with the PASRR program.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, a resident with schizophrenia, pressure injuries, and chronic obstructive pulmonary disease did not receive pressure-relieving devices as ordered by the physician to promote pressure ulcer healing. The resident had two unstageable pressure injuries upon admission, which later included a Stage 3 injury on the right heel. Despite physician orders to offload the resident's heels with a pillow, observations on multiple occasions revealed that the resident did not have a pillow under their legs while in bed. Interviews with facility staff, including a CNA and LPN, confirmed that the resident had orders for heel offloading with a pillow, but the staff failed to ensure compliance with these orders. The CNA was unaware of where to find care instructions and relied on verbal reports from nurses. The Wound Care Nurse also observed the absence of a pillow under the resident's legs and had to request nursing staff to find one. This lack of adherence to the care plan and physician orders contributed to the deficiency in providing appropriate pressure ulcer care.
Resident Fed by Unqualified Staff Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards, as evidenced by an incident involving Resident #44, who was fed a mechanically altered diet by unqualified and unsupervised staff. Resident #44, who had diagnoses including dementia, seizures, and vomiting, was severely cognitively impaired and totally dependent on staff for eating. The resident was on a mechanically altered diet and required close supervision for oral intake due to aspiration precautions. However, on 1/6/2025, the resident was fed by Transporter #23, who was not trained or certified to provide feeding assistance to residents with swallowing impairments. The facility's policies and job descriptions outlined the responsibilities of staff in providing appropriate care and supervision during meals. The Licensed Practical Nurse was responsible for overseeing meal delivery and consumption, while the Registered Nurse Manager was tasked with supervising the Floor Dayroom during resident meals. Despite these guidelines, there was no Licensed Practical Nurse or Registered Nurse present to supervise the 3rd Floor Dayroom while residents ate, leaving Transporter #23 to feed Resident #44 without the necessary training or supervision. Transporter #23, who was hired approximately four months prior, stated that their job responsibilities did not include feeding residents and that they did not possess the credentials to be a Certified Nursing Assistant or meet the paid feeding assistant training requirements. The absence of qualified nursing staff during the meal led to Transporter #23 feeding Resident #44, placing the resident at risk for aspiration. The Registered Nurse Manager, who was scheduled to supervise the dinner, left the facility without informing anyone and subsequently resigned, contributing to the lack of supervision during the incident.
Deficiency in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for two residents. Resident #46, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Bipolar Disorder, was observed receiving oxygen therapy at 3 liters per minute, contrary to the physician's order of 2 liters per minute. There was no documentation of oxygen therapy in the Treatment Administration Record from October 2024 to January 2025, as confirmed by Licensed Practical Nurse #9 and the Director of Nursing. Resident #107, with diagnoses including hypertension, wheezing, and cough, was also provided oxygen at 3 liters per minute, despite a physician's order for 2 liters. Additionally, the nasal cannula and humidified water bottle were not dated, which was against the facility's policy. Licensed Practical Nurse #10 and the Assistant Director of Nursing acknowledged the oversight, noting that the nasal cannula tubing should have been changed and dated weekly.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance reviews at least once every 12 months, as required. During the recertification survey, it was found that six randomly selected CNAs, who had been employed at the facility for periods ranging from 2000 to 2018, did not have documented performance evaluations within the past year. Interviews with the Human Resources/Staffing Coordinator, Nurse Educator, and Director of Nursing revealed that performance evaluations had not been conducted for several years, with some evaluations occurring sporadically. One CNA reported that their last performance evaluation was in 2012, despite having worked at the facility since 2007.
Inadequate Dementia Care and Lack of Individualized Activities
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, as evidenced by the cases of two residents. Resident #30, who had diagnoses of unspecified dementia and anxiety disorder, did not receive person-centered, individualized care or meaningful activities that aligned with their preferences and customary routines. Despite having a comprehensive care plan that included therapeutic activities and interventions for restless behavior, there was no documented evidence of meaningful activities being provided. Observations showed Resident #30 in distress, with behaviors such as screaming and physical agitation, and without the prescribed knee pads to prevent injury from crawling. Additionally, there was a lack of communication and implementation of a recommended gradual dose reduction of quetiapine, as suggested by a psychiatry consult. Resident #122, also diagnosed with unspecified dementia and depression, was found to be severely cognitively impaired and had highly impaired vision. The care plan for Resident #122 included interventions such as 1-to-1 room visits and therapeutic activities, but observations revealed the resident was often left alone in their room, disengaged, and without meaningful activities. The resident's television was off or not in their line of sight, and there was no music or other forms of engagement provided. Despite a psychiatry consult recommending a reduction in olanzapine dosage, there was no evidence of this being communicated or implemented. The facility's policies and procedures for dementia care and the Reflection Group were not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the interventions and recommendations for residents with dementia. The Director of Social Work and other staff members were not fully informed or involved in the development and implementation of individualized care plans. Additionally, the facility was short-staffed, and there was a lack of trained personnel to facilitate activities for residents with dementia, leading to inadequate care and engagement for these residents.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with accepted professional standards, as observed during a recertification survey. In the second floor unit medication storage room, surveyors found several deficiencies, including an unlabeled tube of bacitracin zinc ointment, an open unlabeled flush bag, and expired items such as three bags of Nutren 2.0 feeding, two Pleurx Drainage Kits, two boxes of COVID-19 Antigen Self Tests, and one disposable sampling kit. Additionally, the medication storage refrigerator was found to be at 50 degrees Fahrenheit, which is above the acceptable temperature range, with the last recorded temperature check being outdated. Interviews with staff revealed that the nurses were responsible for checking the medication storage room every shift to ensure expired and unlabeled items were removed. Licensed Practical Nurse #9 acknowledged the presence of expired and unlabeled items and the refrigerator's temperature issue, indicating that these should have been addressed. Nurse Manager #1 confirmed that the nursing staff should routinely check feedings, medications, and equipment, and report any temperature discrepancies to maintenance. The failure to adhere to these protocols resulted in the observed deficiencies.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Resident #69, who was on enhanced barrier precautions due to a Stage 3 pressure ulcer and other medical conditions, did not have the appropriate signage outside their room until several days after the precautions were ordered. A certified nurse aide was observed providing care to this resident without wearing the required personal protective equipment (PPE), despite being aware of the enhanced barrier precautions. The Infection Control Preventionist acknowledged the lapse in ensuring staff awareness and compliance with PPE requirements. Resident #121, who had a history of urinary tract infections and an indwelling urinary catheter, was found with their catheter bag lying directly on the floor, contrary to the facility's policy and physician orders. The catheter bag was also not covered with a privacy bag as required. Interviews with the resident and staff confirmed the recurrent issue of urinary tract infections and the improper handling of the catheter bag, which should have been kept off the floor to prevent infection. Resident #25, who had multiple pressure injuries, received wound care from the Wound Care Nurse who did not adhere to proper infection control practices. The nurse failed to wash their hands adequately, did not use soap, and did not don a gown as required for enhanced barrier precautions. Additionally, the nurse handled non-sterile surfaces and personal items without proper hand hygiene, and left soiled bandages and gloves in an open garbage container. These actions were contrary to the expected standards of care and infection control protocols, as acknowledged by the Wound Care Nurse during an interview.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required, which was identified during a recertification survey. The deficiency was noted when the facility could not provide adequate documentation of antibiotic use tracking for the months of November 2024, December 2024, and January 2025. The facility's policy on antibiotic stewardship, updated in 2024, outlined the need to monitor antibiotic use among residents, including the communication of laboratory results and clinical situations to prescribers. However, the Infection Control Preventionist, responsible for tracking antibiotic use, provided an incomplete list of residents on antibiotic therapy that lacked critical information such as infection onset dates, laboratory test results, frequency and duration of antibiotic therapy, and the indication for antibiotic use. Interviews with the Infection Control Preventionist and the Director of Nursing revealed that the Infection Control Preventionist was behind in tracking antibiotic use and maintaining the necessary documentation. The Director of Nursing confirmed that the Infection Control Preventionist was the primary person responsible for the Antibiotic Stewardship Program, which included maintaining the line list, obtaining laboratory information, and coordinating with physicians and nurse practitioners. The lack of complete and accurate documentation indicated a failure in the facility's antibiotic stewardship efforts, as required by 10 NYCRR 415.19 (a)(1,3).
Pest Control Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live and dead roaches in the kitchen. During a kitchen observation, a live roach was seen crawling on the wall, and a dead roach was found on the floor next to the kitchen tray line. The facility's policy, updated in December 2024, stated that there should be an ongoing pest control program to keep the building free of insects and rodents. However, the Food Service Director acknowledged the presence of roaches and mentioned that the facility had bi-weekly pest control treatments. Pest Management Service Inspection Reports from October to December 2024 indicated that on one occasion, the kitchen was closed and locked, preventing service, and on another occasion, minimal activity was observed with a recommendation to increase sanitary practices in the kitchen. The Director of Maintenance stated that pest control services were provided monthly, including all kitchen areas.
Delayed Submission of Resident Assessments
Penalty
Summary
The facility failed to ensure timely submission of completed resident assessments to the Centers for Medicaid and Medicare Services (CMS) within the required 14-day period. Specifically, 11 out of 30 Minimum Data Set (MDS) assessments were not submitted on time. The facility's policy, revised in January 2024, mandates that each department complete their responsibilities no later than 14 days from the Assessment Reference date. However, the review revealed that assessments for several residents, with completion dates ranging from November 14, 2024, to November 22, 2024, were all submitted on January 5, 2025, well beyond the stipulated timeframe. Interviews conducted during the survey revealed a lack of awareness and accountability regarding the delay. The Minimum Data Set Coordinator acknowledged the issue but could not provide a reason for the delay, stating it was the first occurrence of such an issue. The Director of Nursing was unaware of the delay and indicated that the responsibility for timely submission lay with the Minimum Data Set Coordinator. This lack of communication and oversight contributed to the failure in meeting regulatory guidelines.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident and a podiatrist to the New York State Department of Health within the required timeframe. The incident was reported to the Director of Nursing and the Administrator, but there was no documented evidence that it was reported to the state agency as required by the facility's policy. The policy mandates immediate reporting of all alleged violations to the Administrator, State Agency, and other required agencies within specific timeframes. The incident involved a resident with severe cognitive impairment, who was admitted with diagnoses including metabolic encephalopathy and hemiplegia. The resident had a care plan indicating a potential for abuse. During the incident, the resident exhibited physical behavioral symptoms and kicked at the podiatrist during care. Staff present during the incident reported that the resident was refusing care, but the podiatrist continued. Despite this, the Director of Nursing concluded that there was no abuse substantiated based on interviews and observations, noting no evidence of injury or adverse effects. Interviews with staff revealed that the incident was not reported to the state because it was considered a complaint rather than an incident warranting a report. The Director of Nursing and the Administrator both stated that they did not believe the incident met the criteria for reporting to the state. The Administrator was informed of the incident on the day it occurred but was not present at the facility. The lack of reporting to the state agency constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident and a podiatrist. On the day of the incident, the Director of Nursing and the Administrator were informed of the alleged abuse, but there was no documented evidence of an accident/incident report being completed. Additionally, there was no documented skin assessment by a Registered Nurse, no interviews conducted with other residents seen by the podiatrist on the day of the incident, and the complainant was not interviewed until the following day. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 00/15. The podiatry consult noted that the resident became combative during the procedure, which was stopped. Despite this, the Director of Nursing did not document a skin assessment in the resident's medical record, and no incident report was filed because it was considered a complaint rather than an incident. The Administrator, who was not present at the facility on the day of the incident, was informed by the wound doctor about the resident's distress but did not report the incident to the New York State Department of Health. Interviews with staff revealed that the Director of Nursing and the Administrator did not return calls regarding the incident until the following day. The Director of Social Services, informed about the incident a week later, did not document any notes in the resident's chart or make any referrals, as the resident showed no signs of trauma and was unaware of the incident. The facility's failure to document and report the incident, as well as to conduct a thorough investigation, led to the deficiency.
Failure to Document Incident and Assessment in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurately completed and contained a record of the assessment performed, as required by professional standards. Specifically, on March 28, 2024, an incident involving alleged abuse occurred during a podiatry toenail trimming consult for Resident #1, who was admitted with diagnoses including metabolic encephalopathy, hemiplegia, and adult failure to thrive. Despite the incident being overheard by staff, there was no documented assessment in the electronic medical record of Resident #1. The facility's Accident/Incidents reporting policy requires that a licensed nurse document the facts and sequence of events in the nurse's notes. However, there was no documented evidence of an accident or incident report for Resident #1 from January to March 2024. Interviews revealed that the Director of Nursing and the Registered Nurse Unit Manager did not document their findings of the examination because they did not observe any injuries, and they did not believe the incident warranted an incident report. The Director of Nursing conducted an investigation and obtained verbal statements from involved staff, concluding that there was no abuse substantiated. The investigation revealed that Resident #1 exhibited behaviors such as resisting care, which was considered usual for them. The family was not notified, and the incident was not reported to the state, as it was deemed a complaint rather than an incident. The lack of documentation and failure to follow the facility's policy for incident reporting led to the deficiency.
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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 Valley Cottage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tolstoy Foundation Rehabilitation And Nrsg Center | 0.8 mi | ★★★★★ | 40 | 2 |
| Northern Manor Geriatric Center Inc | 3.7 mi | ★★★★★ | 0 | 0 |
| Tarrytown Hall Care Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Kendal On Hudson | 5.1 mi | ★★★★★ | 0 | 0 |
| Friedwald Center For Rehab And Nursing, L L C | 5.2 mi | ★★★★★ | 4 | 0 |
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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.