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 Sutton Park Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that multiple resident rooms on two nursing units were stark, bare, and lacked personalization such as photos, decorations, or clocks, and many of these rooms did not contain chairs for resident or visitor use. One multi-occupancy room was also cluttered with a dirty floor and no seating. Staff interviews revealed that room personalization was largely dependent on family involvement, that some departments did not routinely address creating a homelike environment, and that managers were unaware of the extent of missing chairs. In addition, a tub room had windows with insulation coming out and a noticeable draft, and maintenance leadership reported being unaware of any issues or work orders related to that condition.
A resident with dementia, severe cognitive impairment, and a right hip replacement developed lethargy and right thigh tenderness, and an x-ray confirmed an acute posterior dislocation of the femoral head prosthesis. The resident was unable to explain what happened, staff reported no witnessed fall or incident, and the accident/incident report listed the date, time, and location of occurrence as unknown. Although the facility’s policy defined and required reporting of injuries of unknown source to the State Agency, there was no documentation that this event was reported, and the investigation form left the reporting section unchecked. The DON stated the event was not reported because there was no fracture and it was not considered an injury of unknown origin.
A resident with dementia, severe cognitive impairment, osteoarthritis, and a right hip replacement was found to have an acute posterior dislocation of the hip prosthesis after presenting with lethargy and right thigh tenderness. An X-ray confirmed the dislocation, and the injury was of unknown time, place, and cause, with the resident unable to explain the event. The facility’s investigation gathered multiple staff statements (from CNAs, LPNs, and therapy) that denied knowledge of any fall or incident but did not document what specific care was provided, when it was provided, or how many staff assisted with transfers, despite the resident requiring two-person assist. The investigative summary attributed the dislocation to the resident’s medical history and decline in ADLs and stated the care plan was followed, but there was no documented evidence detailing actual care activities to substantiate that conclusion or to fully rule out abuse, neglect, or mistreatment.
The facility failed to ensure resident dignity by not having staff seated while feeding a resident and by staff entering another resident's room without knocking. One resident required assistance with eating, and another resident, who was cognitively intact, expressed discomfort and concern for their privacy.
The facility failed to notify a resident and their representative in writing of the reasons for hospital transfers and did not inform the Ombudsman. The resident, with multiple diagnoses, was transferred to the hospital three times without proper documentation or notification, as confirmed by staff and the resident's representative.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, including one who self-administered medication against policy, one left unsupervised despite a fall risk, and one who refused to wear clothes without a documented care plan.
The facility failed to consistently administer long-acting insulin as prescribed for two residents with diabetes. Insulin was not given on multiple occasions due to blood sugar levels being within normal parameters or the residents being asleep, despite no documented parameters for holding the insulin. The deficiency was confirmed through interviews, record reviews, and observations during the recertification survey.
The facility did not ensure CNA performance reviews were completed at least once every 12 months or provide regular in-service based on such reviews for five CNAs. The ADON and Administrator confirmed that staff performance reviews had not been done and that the facility did not have a policy in place. A CNA stated they had been employed for many years without a performance review.
The facility failed to ensure proper food labeling and storage in kitchen freezers, with observations of unlabeled and undated perishable foods. Interviews with dietary staff revealed inconsistencies in the labeling process, contrary to the facility's food service policy.
Failure to Maintain Homelike Resident Rooms and Safe Tub Room Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment on multiple nursing units and in a tub room. On the 3rd floor, several four-bed rooms (including rooms 302 a-b, 307 a-d, 315 a-d, and 316 a-d) were observed with bare walls and lacking personalized items such as photos, pictures, clocks, or decorations. One four-resident room was also described as cluttered with a dirty floor containing debris and had no chairs available for residents or visitors. On the 6th floor, numerous rooms (602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 614, 616, 617, 619, and 620) were observed to be stark and bare without visible personalization, and many of these rooms did not contain a chair for resident or visitor use. These observations showed that many residents’ rooms were not personalized or furnished in a way that supported a homelike environment. Staff interviews confirmed awareness of these conditions and clarified how room personalization was typically handled. A RN Supervisor acknowledged that many resident rooms were not homelike or personalized and noted that residents with family visitors were more likely to have personalized rooms, while many residents without visitors did not. The RN Supervisor also stated they were unaware that many rooms lacked chairs. A social worker reported that families and friends frequently assisted with decorating rooms and that the Social Work Department did not usually address creating a homelike environment, viewing it instead as a Recreation Department activity. The Administrator stated that holiday decorations were generally limited to common areas and that resident rooms were usually personalized by families, and also stated that every resident room should have a chair. The Director of Recreation reported that staff rounded daily and would assist with personalization upon request but had not received requests to personalize rooms on the 6th floor and had not discussed room personalization with managers or administration. Additionally, in the 4th floor tub room, two windows had insulation coming out with a noticeable draft, and the Director of Building Services stated they were unaware of any concerns with the window insulation and that no work orders had been submitted.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by regulation and by its own abuse reporting policy. A resident with dementia, severe cognitive impairment, and a right hip replacement was dependent on staff for activities of daily living. A physician progress note documented that the resident was seen for lethargy and right thigh tenderness, and an x-ray of the right femur confirmed an acute posterior dislocation of the femoral head prosthesis with inward rotation of the femur. The resident could not explain what had happened, and staff statements indicated that no one had witnessed any fall or incident involving the resident. The facility’s accident/incident report documented the date, location, and time of occurrence as unknown, and the investigative summary later concluded there was no reasonable cause to believe abuse, mistreatment, or neglect had occurred. Despite the unknown cause of the dislocated hip prosthesis and the resident’s inability to provide an account, there was no documented evidence that this injury of unknown origin was reported to the State Agency. The facility’s abuse policy defined injuries of unknown source as those not observed, not explainable by the resident, or suspicious due to extent or location, and required investigation and reporting per New York State Department of Health and CMS regulations. However, on the investigative summary, the section indicating whether the incident was reported to the Department of Health was left unchecked. In an interview, the DON stated that because the resident did not have a fracture, the incident was not reported and was not considered an injury of unknown origin, and asserted that the facility followed its protocols, even though the cause, time, and location of the injury remained unknown and the resident was not cognitively intact to explain the event.
Failure to Thoroughly Investigate Dislocated Hip Injury of Unknown Source
Penalty
Summary
Surveyors found that the facility failed to conduct a thorough and complete investigation to rule out abuse, neglect, or mistreatment after a resident with a right hip replacement was discovered to have an acute posterior dislocation of the femoral head prosthesis. The resident had severe cognitive impairment, dementia, osteoarthritis, and required extensive assistance with activities of daily living, including two-person assistance for transfers. A physician note documented the resident was seen for lethargy and right thigh tenderness, and an X-ray confirmed the acute dislocation. The incident report classified the injury as having an unknown date, time, and location, and noted the resident was unable to explain what happened. The facility’s abuse policy required classification of injuries of unknown source when not observed, not explainable by the resident, or suspicious by extent or location. The investigation conducted by the facility consisted primarily of obtaining written statements from CNAs, LPNs, and therapy staff, all of whom reported no knowledge of any fall or incident and did not document the specific care they provided, including transfers or other activities. The investigative summary concluded that the dislocation was most likely related to the resident’s history of hip arthroplasty, osteoarthritis, and decline in ADLs, and stated there was no deviation from the care plan and no abuse, mistreatment, or neglect. However, there was no documented evidence in the investigation identifying who provided what care, when it was provided, or how many staff were involved in transfers or other care around the time of the injury to verify that the care plan, including two-person assist for transfers, was followed. The resident’s representative reported being informed only that the resident had a dislocated hip and not how it occurred. The Assistant DON later stated they relied on CNA interviews to determine the care plan was followed but could not explain why this was not documented in the written interviews or statements.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility did not ensure residents were treated with dignity for two residents reviewed for dignity. Specifically, staff were not seated when feeding one resident, and staff were observed entering another resident's room without knocking on the door. The facility's policy for the Feeding Assistance Program, dated March 2023, documented that staff should be seated when feeding a resident. However, during an observation, an LPN was seen standing while assisting a resident with their meal. The LPN acknowledged that they knew they should have been seated but did not sit while assisting the resident. This resident had diagnoses of metabolic encephalopathy, Alzheimer's disease, and abnormal weight loss and required assistance with eating according to their Minimum Data Set (MDS). Another resident, who was cognitively intact and had diagnoses of diabetes mellitus, cerebral vascular accident (CVA), and peripheral vascular disease, reported that some staff knocked before entering their room while others did not. This resident expressed discomfort and concern for their privacy, especially when on the phone. During an observation, an Activity Aide entered the resident's room without knocking or asking for permission. The Activity Aide admitted that they forgot to knock because it slipped their mind.
Failure to Notify Resident and Ombudsman of Hospital Transfers
Penalty
Summary
The facility did not ensure that a resident and their representative were notified in writing of the reason for the transfer or discharge to the hospital in a language they understood, nor did they notify the Ombudsman. Specifically, Resident #109, who had diagnoses including schizoaffective disorder, major depressive disorder, and hypertensive heart disease, was transferred to the hospital on three occasions. The facility failed to provide documented evidence that written notifications were given to the resident or their representative, and that the Ombudsman was informed of these transfers or discharges. During interviews, the resident's representative confirmed they had not received written notifications regarding the hospital transfers or discharges. The Director of Nursing and the Director of Social Work both acknowledged that they did not know if the required notifications were given to the resident or their representative, and admitted that the Ombudsman was not notified. This lack of compliance with the facility's policy and state regulations was identified during the recertification survey conducted from 11/7/2023 through 11/14/2023.
Deficiencies in Care Plan Implementation and Development
Penalty
Summary
The facility did not ensure the development and implementation of comprehensive person-centered care plans for three residents. Resident #120, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease (COPD), was observed with an albuterol inhaler in their possession for self-administration. This was against the facility's policy, which mandates that nurses administer all medications and do not leave medications at the bedside for residents to self-administer. The Assistant Director of Nursing confirmed that the resident should not have been carrying their own medication due to safety concerns. Resident #10, who had severely impaired cognition and a history of falls, was found unsupervised in their room with the door closed, the call bell out of reach, and the lights off. This was contrary to the care plan interventions, which included keeping the call bell within reach and providing adequate lighting. Staff members acknowledged that the resident should not have been left alone in the room with the door closed and that the call bell should always be within reach. Resident #46, who was cognitively intact and had a history of depressive disorder, was repeatedly observed lying in bed wearing only an adult brief and visible from the hallway. Despite staff awareness of the resident's refusal to wear clothes, there was no documented care plan addressing this behavior. Staff interviews revealed that the issue had not been discussed with the family or social worker, and no care plan meetings had been held to address the resident's refusal to wear clothing or the visibility issue from the hallway.
Failure to Administer Long-Acting Insulin as Prescribed
Penalty
Summary
The facility did not ensure that long-acting insulin was administered consistently as per physician orders for two residents. Resident #119, who has diagnoses including diabetes mellitus type II, cerebral vascular accident, and peripheral vascular disease, did not receive their prescribed insulin glargine on multiple occasions. Specifically, the insulin was not administered on 09/16/2023, 09/24/2023, 10/21/2023, and 10/30/2023 due to reasons such as blood sugar being within normal parameters or the resident being asleep. However, there were no documented parameters indicating when to hold the insulin. Resident #119 expressed uncertainty about receiving their insulin on time and mentioned sometimes only receiving pills instead of insulin. The Minimum Data Set Assessment indicated that Resident #119 was cognitively intact, and the care plan documented the need to provide medications as ordered. The facility's failure to administer insulin as prescribed was confirmed through interviews with the resident and staff, as well as a review of the medication administration records and physician orders. The Director of Nursing and the Pharmacy consultant both acknowledged that there were no parameters for holding long-acting insulin and that it should have been administered as a standing order. The Charge Nurse admitted to not conducting audits or checking medication administration records for completion, which contributed to the oversight in insulin administration for Resident #119 and Resident #116. Resident #116, who has diagnoses including diabetes type II, hypertension, and major depressive disorder, also did not receive their prescribed Levemir insulin on multiple occasions. The insulin was not administered on 9/4/2023, 10/10/2023, 10/15/2023, 10/19/2023, 10/27/2023, and 10/31/2023 due to blood sugar levels being within normal parameters. Similar to Resident #119, there were no documented parameters for holding the insulin, and the Charge Nurse and Pharmacy consultant confirmed that the insulin should have been administered as a standing order. The Director of Nursing stated that medication errors were part of quality assurance but had not been addressed because the facility did not have medication errors. The facility's failure to administer insulin as prescribed for both residents was identified during the recertification survey, highlighting a deficiency in medication administration practices.
Lack of CNA Performance Reviews and In-Service Training
Penalty
Summary
The facility did not ensure certified nurse aide (CNA) performance reviews were completed at least once every 12 months or that they provided regular in-service based on outcomes of such reviews for five CNAs. Specifically, there were no performance evaluations provided when requested. During interviews, the Assistant Director of Nursing (ADON) and the Administrator confirmed that staff performance reviews had not been done and that the facility did not have a policy in place. Additionally, one CNA stated that they had been employed at the facility for many years and had not had a performance review.
Improper Food Labeling and Storage in Kitchen Freezers
Penalty
Summary
The facility did not ensure that food was stored in accordance with acceptable standards for food safety practice. Specifically, during an initial tour of the kitchen, it was observed that perishable foods in kitchen freezer #1 and freezer #2 were not labeled and/or dated properly. Freezer #1 contained an opened and unsealed box of frozen manicotti without a use-by date. Freezer #2 contained an opened and unsealed box of frozen chicken wings with an illegible handwritten use-by date. The facility's food service policy required foods to be labeled with a best-by date and used by that date or discarded, and if no date was provided, the food should be labeled with the date received and discarded within six months. Interviews with the Dietary Supervisor, Dietary Director, and Dietary Aide #1 revealed inconsistencies in the labeling process. The Dietary Supervisor acknowledged that the box of manicotti should have had a use-by date and clarified that the use-by date on the chicken wings was 10/18/2025. The Dietary Director stated that if there was no manufacturer use-by date, they would use the food within three months and should have contacted the manufacturer for a use-by date. Dietary Aide #1 confirmed that frozen items should have a received/prepared date and a use-by date, and if not, the supervisor or director should contact the manufacturer to obtain the date. The aide also mentioned that all new frozen foods were supposed to be dated and rotated.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,374 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Schaffer Extended Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| United Hebrew Geriatric Center | 1.3 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 | 1.5 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.