Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Schaffer Extended Care Center during CMS and state inspections, most recent first.
A resident at risk for pressure ulcers developed a sacral wound that progressed from Stage 3 to unstageable due to the facility's failure to implement and document required interventions such as offloading, incontinence care, and use of an appropriate pressure-relieving wheelchair cushion. Despite repeated physician recommendations and facility protocols, staff did not update care plans or communicate with the rehabilitation department in a timely manner, resulting in actual harm.
The facility did not complete annual performance reviews for several CNAs as required by policy and regulation. Leadership interviews revealed a lack of compliance and awareness regarding the annual appraisal requirement, resulting in missed reviews for multiple staff members.
Surveyors found that food items in the kitchen and unit pantry were often unlabeled, undated, or expired, and staff did not consistently follow policies for labeling, dating, and discarding food. Additionally, a dietary staff member was observed failing to perform proper hand hygiene before preparing food, despite facility policies and prior staff education. Interviews with the Food Service Director and DON confirmed these lapses in food safety and hygiene procedures.
The facility did not ensure its infection surveillance plan was properly implemented, as the Antibiotic list used for tracking residents on antibiotic therapy lacked essential documentation such as infection onset dates, clinical signs and symptoms, lab results, and outbreak assessment. The DON/Infection Preventionist confirmed these omissions during interviews.
Surveyors identified that the facility did not ensure comprehensive, measurable care plans for several residents, including one who was incontinent without a documented incontinence care plan, another who lacked an ADL care plan despite high dependency, and a third with a G-tube whose care plan was incomplete. Staff interviews revealed issues with care plan initiation, completion, and lack of documented in-service education.
The facility did not maintain a working call bell system on one floor, leaving all rooms without an audible or centralized alert for staff, and some rooms without functioning visual indicators or manual tap bells. Multiple residents reported long waits for assistance and concerns about the effectiveness of the interim manual bells. Staff and facility leadership confirmed the system had been nonfunctional for about a year, with replacement delayed by a lengthy approval process.
A resident with severe cognitive and physical impairments was found by a CNA to have a swollen, warm, and tender arm, later diagnosed as a fracture of unknown origin. Despite facility policy requiring immediate reporting of such injuries, the incident was not reported to the state agency within the mandated two-hour window, but instead was reported the following day. Interviews with the DON, RN Unit Manager, and Administrator revealed confusion and delay in the reporting process.
A resident with multiple medical conditions reported their wheelchair was too small and in disrepair, but staff failed to document or act on the request for repairs for several months. The wheelchair was observed with a shredded wheel and a non-functioning lock, and multiple staff confirmed the issue had been reported but not addressed or documented according to facility policy.
A resident with dementia experienced a significant decline in swallowing ability, requiring a change to NPO status and aspiration precautions. Despite this, the facility did not complete the required Significant Change MDS assessment within 14 days, instead waiting until the next quarterly assessment, resulting in noncompliance with assessment regulations.
A resident with a history of hemiplegia, morbid obesity, and heart failure did not consistently receive a physician-ordered ace wrap to the left foot for 12 hours daily, nor were their legs elevated as directed. Observations showed the resident without the ace wrap and with un-elevated, edematous legs on several occasions. The resident reported repeated requests for assistance with leg elevation and timely wrapping, which were not addressed. Staff interviews confirmed delays and lack of awareness regarding the resident's care needs.
A resident with dementia and on antipsychotic medication did not have required lab monitoring ordered or obtained, despite the consultant pharmacist's recommendation and physician agreement. Staff interviews confirmed that the labs were neither ordered nor documented, and there was no record of resident refusal.
Two residents with physician-ordered dietary restrictions did not receive food and liquids in the required form. One resident was served a regular fruit cup instead of a minced and moist texture, and another was given a pitcher of regular water despite needing nectar-thick liquids. Staff interviews revealed a lack of training and unclear communication regarding diet orders.
Failure to Implement Pressure Ulcer Prevention and Management Interventions
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure ulcers due to diagnoses including schizophrenia, depression, and severe obesity, developed a sacral wound that progressed from a Stage 3 to an unstageable pressure ulcer. Despite being identified as at risk and having a care plan in place, there was no documented evidence that interventions such as offloading, an incontinence schedule, or appropriate incontinence care were implemented to prevent further deterioration of the wound. The resident was incontinent of bladder and frequently incontinent of bowel, yet the care plan did not address incontinence management, and staff failed to document or implement necessary interventions. Physician wound assessments repeatedly noted the need for pressure offloading and incontinence management, but these recommendations were not consistently acted upon or documented by nursing staff. The resident continued to use a standard foam wheelchair cushion, which was not appropriate for a Stage 3 or unstageable pressure ulcer, and a pressure-relieving cushion was not provided until much later. Interviews with staff revealed a lack of communication and follow-through regarding the need for specialized equipment and interventions, with the rehabilitation department not being notified in a timely manner and nursing staff not updating care plans or implementing recommended protocols. Observations and interviews confirmed that the resident's wound worsened over time, with increasing necrotic tissue and delayed healing, and that appropriate interventions were not put in place until after significant deterioration had occurred. The facility's own policies required regular monitoring, pressure relief, and incontinence management for residents at risk, but these were not followed or documented for this resident, resulting in actual harm.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months, as required by both facility policy and state regulation. During the recertification survey, it was found that five CNAs did not have documented performance reviews within the past year. The facility's policy, revised in April 2023, specifies that administrative, managerial, or supervisory staff are responsible for conducting annual performance appraisals and forwarding completion information to the human resources department, with each department maintaining the actual appraisal files. However, there was no evidence that these reviews had been completed for the identified CNAs, some of whom had been employed for several years. Interviews with facility leadership revealed a lack of compliance and awareness regarding the required frequency of performance appraisals. The DON acknowledged being behind on completing the appraisals, while the Director of Human Resources confirmed awareness of the annual requirement but admitted the reviews were not being completed on time. The Assistant Administrator was under the impression that appraisals were required every two years and was unaware that the annual requirement was not being met. This lack of adherence to policy and regulatory requirements resulted in the cited deficiency.
Deficient Food Labeling, Storage, and Hand Hygiene Practices
Penalty
Summary
Surveyors identified multiple failures in food service safety and hygiene practices. Unlabeled and undated food items were found in both the kitchen and unit pantry, including a bag of sundried tomatoes and containers of mayonnaise in the salad refrigerator, as well as blueberries and fruit salad in the unit pantry. Expired food items, such as protein meal bars, canned tuna, apple juice, and nutritional supplements, were discovered in the emergency food supply and kitchen storage. Staff interviews confirmed that all food items should be labeled, dated, and discarded according to policy, but these procedures were not consistently followed. Additionally, a plastic bag of cake was found in the unit pantry with a date indicating it should have been discarded, and staff acknowledged it was their responsibility to ensure proper labeling and timely disposal. Further deficiencies were observed in hand hygiene practices. A dietary staff member was seen preparing a sandwich without washing hands after coughing and before donning gloves, contrary to facility policy. The Food Service Director and DON both confirmed that staff are required to wash hands before putting on gloves and that education on this policy had been provided. The environmental department was noted as responsible for general pantry cleaning, but expired and improperly stored food items were still present during the survey.
Failure to Implement Effective Infection Surveillance and Documentation
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. The policy required the Infection Control Committee to investigate, control, and prevent infections, including performing surveillance and investigation to prevent the onset and spread of infection. However, review of the Antibiotic list for March and April 2025 showed that while residents were documented as being on antibiotic therapy for various infections, there was no documentation available for infection onset dates, signs and symptoms, laboratory or radiology results, isolation status, or outbreak potential. During interviews, the DON/Infection Preventionist confirmed responsibility for infection tracking and surveillance, and stated that the Antibiotic list served as the surveillance report. Upon further review, the DON/Infection Preventionist acknowledged that the list lacked critical documentation elements necessary for effective infection surveillance, such as infection onset date, clinical signs and symptoms, lab and radiology results, type of precaution, and assessment of outbreak potential.
Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents. One resident with schizophrenia, depression, and severe obesity, who was incontinent of bladder and at risk for pressure ulcers, did not have a documented care plan addressing incontinence care or an incontinence schedule, despite frequent episodes of incontinence recorded across all shifts. The Director of Nursing was unable to provide documentation of any interventions or care plan for this resident's incontinence. Another resident with cancer, peripheral vascular disease, and asthma, who required substantial to maximal assistance for activities of daily living (ADLs), did not have an ADL care plan in place until after the survey period, even though the resident was dependent in bed mobility, transfers, and wheelchair mobility. Additionally, a resident with stiff-man syndrome, type 1 diabetes, dysphagia requiring G-tube feedings, and stomach cancer had an incomplete care plan for tube feeding, lacking measurable goals and interventions. Staff interviews revealed gaps in care plan initiation and completion, as well as a lack of documented in-service education for nurse managers and supervisors.
Failure to Maintain Functional Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. On the 5th floor, the call bell system was not audible and did not have a centralized location to alert staff in all twenty-nine rooms. Additionally, the visual indicator light above the door did not function in five of these rooms. In ten rooms, alternative manual tap or hand bells, which were part of the facility's interim plan, were not provided or readily available. Observations by surveyors confirmed that residents were unable to reliably summon assistance, with several residents reporting long wait times of one to three hours after using the hand bell, and concerns that staff could not hear the bells. Staff interviews corroborated that the call bell system had been nonfunctional for approximately a year, and that manual bells and 15-minute rounding were implemented as temporary measures. However, these measures were inconsistently applied, as not all rooms had the required manual bells. Facility records and staff interviews revealed that the call bell system was deemed irreparable, and efforts to replace it were delayed due to a lengthy approval process involving multiple departments. Despite ongoing complaints from residents and families, and acknowledgment from facility leadership that the call bell system was critical for resident safety, the system remained nonfunctional for an extended period, leaving residents without a reliable means to request assistance.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an injury of unknown origin, later determined to be a fracture, to the state survey agency within the required two-hour timeframe. A resident with severe cognitive impairment, hemiplegia, hemiparesis, and total dependence on staff was observed by a CNA during morning care to have a swollen, warm, and tender right arm with limited range of motion and facial grimacing. The CNA promptly notified the nurse, and subsequent documentation by nursing staff confirmed the findings. An x-ray later revealed a fracture of the right humeral shaft. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, especially those resulting in serious bodily injury, the incident was not reported to the state agency until the following day. Interviews with facility staff, including the DON, RN Unit Manager, and Administrator, revealed a lack of clarity and timely action regarding the reporting process. The DON and RN Unit Manager acknowledged that the injury should have been reported within two hours, and the Medical Director confirmed the fracture was of unknown origin and not pathological. The delay in reporting was attributed to uncertainty about the cause of the injury and miscommunication among staff regarding responsibility for notification. The incident was ultimately reported more than 24 hours after initial discovery, in violation of regulatory requirements.
Failure to Timely Repair Resident Wheelchair and Document Requests
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who required a manual wheelchair for mobility. The resident, who had diagnoses including cancer, peripheral vascular disease, and asthma, was cognitively intact and dependent on staff for wheelchair mobility. Despite informing the Director of Social Work that their wheelchair was too small and in need of repair at least three months prior, no documented assessment or action was taken by the rehabilitation or nursing departments to address the issue. There was no evidence in the electronic medical record, social work notes, or work orders that the wheelchair had been reported for repair or that the resident's concerns were documented. Observations revealed that the wheelchair had a shredded left wheel and a non-functioning left wheel lock, making it unsafe and difficult to use. Staff interviews confirmed that the condition of the wheelchair had been reported multiple times to nursing supervisors and that the Director of Rehabilitation was only informed the night before the surveyor's observation. The Director of Social Work acknowledged being told about the issue but did not document the resident's request or follow up with progress notes or grievances. This lack of timely response and documentation resulted in the resident continuing to use a wheelchair in disrepair for an extended period.
Delayed Significant Change MDS Assessment After Decline in Swallowing Ability
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who experienced a notable decline in swallowing ability. The resident, admitted with dementia, was initially assessed as having no swallowing disorders and was tolerating a modified diet. However, following a physician's order for aspiration precautions and a diet change to nothing by mouth, as well as a speech therapy evaluation indicating high risk for aspiration and the need for NPO status, the facility did not initiate the required significant change MDS assessment promptly. Instead, the assessment was delayed and completed at the time of the next scheduled quarterly assessment, rather than within 14 days of the significant change in the resident's condition. Interviews with facility staff confirmed that the assessment was postponed despite the resident's worsening dysphagia and inability to take oral feedings. This delay resulted in noncompliance with regulatory requirements for timely assessment following a significant change in a resident's status.
Failure to Provide Ordered Edema Care and Leg Elevation
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hemiplegia following cerebral infarction, morbid obesity, and heart failure did not receive care in accordance with physician orders and professional standards. The resident's care plan and physician orders required the left foot to be wrapped with an ace bandage for 12 hours daily, applied in the morning and removed at bedtime, and for the legs to be elevated as much as possible during the day. However, observations on multiple days showed the resident sitting in a chair with both lower legs exhibiting 2-3 plus edema, without the left foot ace wrap in place and without leg elevation. Documentation confirmed inconsistent application of the ace wrap, and there was no evidence in the Certified Nurse Aide Tasks addressing leg elevation. Interviews with the resident revealed that they were aware of the need for leg elevation and the ace wrap, but reported that staff often delayed or failed to apply the wrap in the morning and did not provide a means to elevate their legs when out of bed. The resident stated they had requested assistance multiple times without resolution. Staff interviews confirmed a lack of awareness regarding the need for leg elevation and acknowledged delays in applying the ace wrap, with some staff unaware that the resident lacked equipment to elevate their legs. These actions and omissions resulted in the resident not receiving care as ordered and as per professional standards.
Failure to Act on Pharmacist-Identified Medication Irregularity and Laboratory Monitoring
Penalty
Summary
A deficiency was identified when the facility failed to ensure that irregularities identified by the consultant pharmacist during a monthly medication regimen review were acted upon for a resident with dementia, psychotic disturbance, anxiety, and a history of falls. The medication regimen review on 4/4/25 noted that laboratory monitoring was required for the resident's Seroquel use, and there were no recent labs on file. The physician signed the review, indicating agreement to order the labs, but there was no documented evidence in the physician orders that the requested laboratory tests were actually ordered or obtained. Interviews with facility staff revealed that the LPN was aware of the pharmacist's recommendation and the physician's signature but confirmed that labs were not ordered and no results were available. The unit manager RN was unfamiliar with the medication regimen review documentation and confirmed there was no lab order or physician note regarding the labs. The DON reported contacting the physician, who stated the resident must have refused the labs, but there was no documentation of any refusal. This sequence of events resulted in the facility not following through on the pharmacist's identified irregularity and the agreed-upon physician action.
Failure to Provide Food and Liquids in Prescribed Form for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to provide food and liquids in the prescribed form for two residents with specific dietary needs. One resident, with a history of hypertension, heart failure, and chronic kidney disease, had physician orders and care plans specifying a minced and moist texture diet with thin liquids due to aspiration risk. Despite this, the resident was observed receiving a regular tropical fruit cup instead of the required minced fruit cup. The Registered Dietitian confirmed that the regular fruit cup did not meet the required texture, and the Food Service Director acknowledged that dietary staff had not received documented in-service training on the new diet textures, nor was there a policy in place regarding diet textures and consistencies. Another resident, diagnosed with chronic obstructive pulmonary disease, schizoaffective disorder, and heart disease, had orders for a regular diet with nectar-thick liquids due to swallowing difficulties. This resident was observed with a lunch tray containing thickened liquids but also had access to a pitcher of non-thickened ice water, which was provided by a Certified Nurse Aide (CNA) who was unaware of the resident's dietary restrictions. Interviews revealed that CNAs did not have clear access to or knowledge of residents' diet orders, and the LPN and Director of Nursing confirmed that the resident should not have received regular water. The dietician also stated that the resident should not have received regular water.
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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 New Rochelle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sutton Park Center For Nursing And Rehabilitation | 0.1 mi | ★★★★★ | 3 | 0 |
| United Hebrew Geriatric Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Glen Island Center For Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 11 | 0 |
| The Wartburg Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Bayberry Nursing Home | 1.4 mi | ★★★★★ | 0 | 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.