Nyack Ridge Rehabilitation and Nursing Center

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure the resident environment remained as free from accident hazards as possible and did not ensure residents received adequate supervision to prevent accidents for 4 (Residents #1, #3, #5, and #6) of 6 residents reviewed for accidents. Specifically, 1. Resident #1, who had a history of behavioral symptoms including refusal of care and agitation during care, sustained a 4 centimeter by 1 centimeter laceration to the head when Certified Nurse Aide #6 shaved the resident's head while providing care. Resident #1 was transferred to the emergency room and required four staples. This resulted in actual harm to Resident #1 that was not immediate jeopardyThe

Inspectors wroteBased on observations, record review, and interviews conducted during Abbreviated Surveys, the facility failed to provide necessary care and services to attain or maintain residents' highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice for two (Residents #3 and #7) of six residents reviewed for quality of care. Specifically, 1. Resident #3, who had impaired cognition and poor safety awareness was identified as a high risk for falls and required 30-minute monitoring and visual checks. On 04/23/2026 at 1:19PM, Resident #3's 30-minute monitoring form documented monitoring observations through 2:30 PM prior to the required observation times occurring. 2. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated Survey (#2583624), the facility did not ensure that the residents' environment remained as free of accident hazards as possible for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was transferred by Certified Nurse Aides #1 and #2 with a new mechanical lift they had not received training on. The lift tilted during the transfer, hitting Resident #1 on the head. Resident #1 sustained a laceration to the head and was transferred to the hospital for emergency care and received staples for the laceration. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and abbreviated (NY00343179) survey from 1/6/2025 to 1/14/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 of 2 resident floors (3rd Floor) during observation of the environment. Specifically, the 3rd Floor was observed with foul, pervasive, and strong odor of urine and feces on multiple occasions; shower rooms with hanging ceiling tiles, stained wall and floor tiles, and stained worn shower chairs; there were multiple resident rooms with soiled and stained bathrooms, broken light fixtures, and dirty, spackled walls with mismatched paint; and, there was a floor dayroom with soiled bins of dolls and stuffed animals, marked floors, and scratched damaged walls.

Inspectors wroteBased on interviews and record review conducted during the Recertification and abbreviated surveys (NY00335588, NY00358884) from 1/6/2025 to 1/14/2025, the facility did not ensure the completion of discharge summaries for 3 out of 3 residents (Resident #124, #247 and #245) reviewed for discharge. Specifically, 1) Resident #124's electronic medical record did not contain a discharge summary. 2) Resident #247 was severely cognitively impaired and discharge did not include adequate communication with the resident's family regarding injectable medications. 3) Resident #245's discharge summary and instructions were incomplete and did not included a recapitulation of the residents' stay. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status. This was evident for 2 (Resident #80 and #25) of 8 residents reviewed for Nutrition. Specifically, 1) interventions were not identified, implemented, monitored, and modified to prevent and address Resident #80's significant weight loss, and 2) interventions were not identified, implemented, monitored, and modified to prevent and address Resident #25's significant weight loss.

Inspectors wroteBased on interview and record review conducted during the Recertification and abbreviated surveys (NY00348193) from 01/06/25 to 01/14/25, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during the Resident Council Group meeting that the facility was short staffed and did not have sufficient nursing staff to care for the residents, there was a lack of timely staff response to call bells, 2) several nursing staff members reported working double shifts on the weekends; and 3) analysis of the actual staffing schedule showed that on multiple occasions from December 6, 2024 through January 6 2025, the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 1/6/25 to 1/14/25, the facility did not ensure that food was stored and prepared in accordance with professional standards for food safety practice. Specifically, 1) Opened and undated food was stored in refrigerators, freezer, and the dry storage room. 2) Employee stored personal food in the freezer and kitchen reach-in refrigerator that was not designated for employee food storage. 3) Expired food items were observed in the emergency food supply and reach in refrigerator. 4) Hot food was held below 135 degrees Fahrenheit the steam table and cold turkey was at 51 degrees Fahrenheit.

Inspectors wroteBased on observation, interview, and record review during the Recertification survey from 01/06/2025 through 01/14/2025, the facility did not ensure residents had the right to a dignified dining experience for 3 of 30 residents (Residents #48, #345, and # 30) reviewed for dignity while dining. Specifically, facility staff were observed standing over Residents #48, #345 and #30 while assisting the residents with their meals.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 11/6/2025 to 1/14/2025, the facility did not ensure a resident was provided with notice of changes in Medicare coverage of items and services. This was evident for 1 (Resident #118) of 3 residents reviewed for skilled nursing facility beneficiary notification. Specifically, Resident #118 was provided a written Notice of Medicare Non-coverage and Advanced Beneficiary Notice of Non-coverage despite the resident's inability to understand the content of the notices.

Inspectors wroteBased on interviews and record review during the Recertification Survey from 1/6-1/14/2025, the facility did not ensure that residents were aware of the grievance process or that they were notified of their right to, and process of, filing a grievance with the facility or independent entities through postings in prominent locations throughout the facility. Specifically, 16 of 16 residents in attendance at the Resident Council meeting were not aware of the grievance filing process. In addition, signage for the grievance process, ombudsman contact information, and Complaint hotline was not found throughout the facility for resident view. The Facility Grievance Policy last reviewed 10/2021 documented that the facility will provide a mechanism for filing a grievance. Residents will be informed orally and in writing of their right to make complaints. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure a resident was free from physical restraints imposed for convenience and not required to treat the resident's medical symptoms. This was evident for 1 (Resident #25) of 3 residents reviewed for falls. Specifically, Resident #25 was observed with a concave mattress in place to reduce the resident's fall risk by preventing the resident from getting out of bed.

Inspectors wroteBased on record review and interviews during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. This was evident for 1 of 30 residents (Resident #86) reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. Answers to items 27, 28, 29 and 30 were not documented.

Inspectors wroteBased on observation, interview and record review conducted during a Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 1 of 5 residents (Resident #25) reviewed for Pressure Ulcers. Specifically, Resident #25 did not receive pressure relieving devices to promote pressure ulcer healing in accordance with the Physician Order.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure a resident remained free of accident hazards. This was evident for 1 (Resident #44) of 5 residents reviewed for accidents. Specifically, Resident #44 was fed a mechanically altered diet by unqualified and unsupervised staff.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 1/6-1/14/2025, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 3 residents (Resident #46 and Resident #107) reviewed for Respiratory Care. Specifically, 1) Resident #46 was provided oxygen 3 liters via nasal cannula with a physician order for 2 liters; and 2) Resident #107 was provided oxygen 3 liters via nasal cannula with a physician order for oxygen 2 liters. In addition, the nasal cannula and humidified water bottle for Resident #107 was not dated.

Inspectors wroteBased on interviews and review of the facility's records during the Recertification survey from 1/6/2025 through 1/14/2025, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, six of six randomly selected Certified Nurse Aides (#29, #30, #31, #32, #33, and #34) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on observation, interview, and record review conduced during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #30) of 2 residents reviewed for Dementia Care and 1 (Resident #122) of 1 resident(s) reviewed for Activities. Specifically, 1) treatment of Resident #30's dementia and related behaviors did not include a person-centered individualized approach or meaningful activities to address the resident's customary routines and preferences, and 2) there was no evidence Resident #122's plan of care included meaningful activities that enhanced the resident's wellbeing.

Inspectors wroteBased on observations and interviews conducted during a Recertification survey from 1/6-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards, labeling, expiration date, and storage of medication at proper temperatures. Specifically, expired feedings, supplies, and test kits, open unlabeled medications, and a medication storage refrigerator temperature above the acceptable range, were found in one of one medication storage rooms (Second Floor Unit) examined for medication storage.

Inspectors wroteBased on observation, record review and interviews conducted during a Recertification survey on 1/6/2025 to 1/14/2025 the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. This was evident for 2 (Resident #69 and #25) of 5 residents reviewed for pressure injuries and 1 of 2 residents (Resident #121) reviewed for urinary tract infections. Specifically, 1) Resident #69 was on enhanced barrier precautions and a certified nurse aide was observed providing care without proper personal protective equipment; 2) Resident #121 had a history of urinary tract infections and their catheter bag was observed lying directly on the floor; and 3) the Wound Care Nurse did not perform handwashing or don a gown while performing wound care on Resident #25.

Inspectors wroteBased on record review and interviews conducted during a Recertification survey from 1/6/2025 to 1/14/2025, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide documentation as requested on 1/10/2025 of tracking antibiotic use which included appropriate use of antibiotics, results of laboratory tests and duration of antibiotic treatment for November 2024, December 2024, and January 2025.

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification survey 1/6/25 to 1/14/25 the facility did not maintain an effective pest control program so that the facility was free of pasts. Specifically, the facility kitchen was observed to have live and dead roaches.

Inspectors wroteBased on record reviews and interviews conducted during the Recertification Survey from 1/6/25 to 1/14/25, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 11 (Resident #43, Resident #51, Resident #88, Resident #90, Resident #104, Resident #108, Resident #120, Resident #124, Resident #129 and Resident# 131) of 30 Minimum Data Set assessments submissions, reviewed were not submitted to the Centers for Medicaid and Medicare Services within 14 days of completion.

Inspectors wroteBased on interviews and record review during the Recertification and abbreviated (NY00339429) surveys from 1/6-1/14/2025, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 30 residents reviewed for quality of care (Resident #107). Specifically, Resident #107 did not receive their eye drops as ordered by the physician after and prior to their cataract surgeries.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00339416), the facility did not ensure that for 1 (Resident #1) of 3 residents reviewed, all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury, to the Administrator of the facility and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction. Specifically, on 3/28/2024, the Director of Nursing and the Administrator were informed of an alleged abuse incidence that occurred between Resident #1 and the facility Podiatrist. [...]

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00339416), the facility did not ensure that an allegation of abuse was thoroughly investigated for 1 (Resident #1) out of 3 residents reviewed for abuse. Specifically, on 3/28/2024 the Director of Nursing and the Administrator were informed of an alleged abuse incidence that occurred between Resident #1 and the facility Podiatrist. There was no documented evidence that an accident/incident report was completed, there was no documented skin assessment from the Registered Nurse, there was documented interviews of other residents seen by the Podiatrist on the day of the incident, and the complainant was not interviewed until the next day.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00339416), the facility did not ensure in accordance with accepted professional standards and practices that a resident's medical records was accurately completed and contained a record of the assessment performed for 1(Resident #1) of 3 residents reviewed. Specifically, on 3/28/2024, Resident #1 had an incident of alleged abuse during a podiatry toenail trimming consult overheard by staff (the Wound Doctor and the Registered Nurse Wound Care Nurse-Staff #4 and the Certified Nurse Aide-Staff #1). There was no documented assessment in the electronic medical record of Resident #1.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility failed to ensure that each resident received adequate supervision and assistance to prevent falls. for 2 of 6 residents (Resident #129 and #145) reviewed for accidents. Specifically, Resident #129 sustained injuries related to falls between 8/19/2023 and 8/22/2023 : one injury required staples to the back of the head and one injury resulted in left arm proximal (nearer to the trunk of the body) and left arm distal (further from the trunk of the body) wounds (injuries that break the skin or other body tissue). Subsequently, Resident #145 had 5 falls between 7/4/2023 and 9/21/2023; one of which resulted in a right hip fracture on 8/13/2023. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility provided pharmaceutical services to assure accurate acquiring, receiving and administration of medications to meet the needs of each resident. Specifically, 1. expired and undated and/or discontinued medications were found on 2 of 3 medication carts and in 1 of 1 medication rooms 2. 1 of 3 medication carts were not kept locked or under direct observation of authorized staff in an area where residents could access them and 3. A blister pack of medications for Resident #81 was left on the medication cart unattended in the hallway on the A unit.

Inspectors wroteBased on observations, interview and record review during the Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure each resident had the right to a dignified dining experience for 3 of 11 residents (Residents # 146, # 88, and # 89 ) Specifically, 1. Resident # 146 was served their meal 15 minutes after their tablemate's had received their meals, 2. Residents #88 and #89 were referred to as 'feeders' by the Assistant Director of Nursing (ADON) in the 3rd floor dining room in the presence of residents.

Inspectors wroteBased on record review and interview conducted during a recertification survey the facility did not ensure a thorough and complete investigation was conducted for 1 of 6 residents (Residents #129) reviewed for accidents. Specifically an 8/26/2023 and 9/3/2023 xray reports revealed Resident # 129 had a healing humeral neck fracture and the facility did not ensure that an investigation into the fracture was completed to determine root cause.

Inspectors wroteBased on interview and record review conducted during a recertification survey (9/13/2023-9/25/2023), the facility did not ensure it developed a discharge summary for 2 of 3 (Resident #156, #157) residents reviewed for discharge. Specifically, there was no evidence that discharge summaries which included a recapitulation of the residents' stay detailing the resident's clinical status, course of treatment, reconciliation of the residents' post discharge medications and post discharge needs, were completed to ensure a safe and effective transition of care.

Inspectors wroteBased on observations, interviews, and record reviews conducted during recertification and abbreviated surveys (NY 00323895) from 09/13/2023 through 09/25/2023 it was determined the facility did not ensure that the residents received treatment and care in accordance with professional standards of practice in order to meet the resident's physical, mental and psychosocial needs for one (Resident #129) of six residents reviewed for accidents, one (Resident #150) reviewed for medication error and/or storage, and one (Resident #119) of two residents reviewed for positioning and mobility. Specifically, 1. the facility did not ensure timely orthopedic follow-up for Resident # 129 after xray reports revealed a healing right humeral neck fracture and as per physiatrist recommendation, 2. Resident #150 was administered discontinued Lorazepam without a physician order, and 3. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 9/13/2023-9/25/2023, the facility did not ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychological well-being for 1 of 7 residents (R) #9. Specifically, Resident #9 exhibited periods of worsening irritability and agitation, and had a physician order for a psychological evaluation that was not completed timely.

Inspectors wroteBased on record review, and interview conducted during the recertification survey and abbreviated survey (NY00323895) the facility did not ensure that each resident (Resident #150) reviewed for medication error and/or storage had a drug regime that was free of unnecessary medications. Specifically the issue involved the administration of and lack of a documented indication for the continued use of an as needed (PRN) antipsychotic medication without a physician order.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey completed on 9/25/2023 the facility did not ensure for 1 of 5 residents reviewed for food, (Resident # 77) received menu items and preferences listed on the meal tray tickets. Specifically, the preference to receive their meal tray early was not honored. Additionally, food and drink items listed on the meal tray ticket for Resident # 77 were not provided according to the resident's personal preference.

Inspectors wroteBased on interviews and record review Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure that the facility wide assessment was updated annually to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.

Inspectors wroteBased on record review, and interviews conducted during the Recertification and Extended survey from 09/13/2023 through 09/25/2023, the facility did not ensure the they explicitly granted the resident or the residents representative the right to rescind the arbitration agreement within 30 calendar days of signing it for 3 (Resident #1, #211, and #212) of 3 sampled residents. Specifically, Resident #1, #211, and #212's Binding Arbitration Agreements were reviewed, and there was no documented evidence the agreements gave the resident and/or representative the right to rescind the agreement within 30 calendar days of signing the agreement.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey, it was determined that for one resident (# 408) of two reviewed for urinary catheters, the facility did not ensure staff maintained and complied with infection control interventions to prevent the transmission and development of infection and disease. Specifically, the foley catheter tubing and foley catheter drainage bag for Resident #408 were observed touching the floor.

Inspectors wroteBased on record review and interviews during the Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control prior to assuming the role. Specifically, the facility's designated IP, did not have documented evidence of having completed specialized training in infection prevention and control prior to 09/22/2023.