Westchester Center for Rehabilitation & Nursing

Inspectors wroteBased on record review, observations and interviews during the Abbreviated Survey (2633933) on 10/21/2025-10/22/2025, the facility did not ensure that the resident's representative was notified timely of an incident for (1) one (Resident #1) of (3) three residents reviewed for Abuse. Specifically, on 09/27/2025 Resident #1 had an episode of aggressive altercation with staff resulting in the need for Resident #1 to be sent out for psychiatric evaluation. The resident's representative was not informed of the incident until they visited and were informed by the resident who was visibly upset about the incident. The finding is:The facility's policy titled, Notification of Changes, last revised on 08/2024, documented it is the policy to notify the resident/designated representative when there is an accident/incident involving the resident. [...]

Inspectors wroteBased on observation and interview conducted during the recertification survey 1/22/25-1/29/25 the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, the trash compactor had food spilling out of it and the recycled boxes were not maintained within the dumpster.

Inspectors wroteBased on interview and record review during the recertification survey from 1/22/2025 to 1/29/2025, the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. This was evident for 106 residents with Personal Needs Accounts during review of Personal Funds. Specifically, the facility's Surety Bond for $250,000, was less than the sum total of 106 resident personal needs accounts maintained by the facility in the amount of $278,452.49.

Inspectors wroteBased on observations and interview conducted during the recertification survey 1/22/25 to 1/29/25, the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent New York State Department of Health (NYSDOH) survey. Specifically, the survey team did not observe survey results posted anywhere in the facility. In addition, members of the Resident Council were interviewed and reported that they did not know where the survey report was posted or accessible for residents to review.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey from 01/22/2025 to 01/27/2025, the facility did not ensure that 3(Residents #226, #333, and #96) of 3 Residents reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, 1. Resident #226 who had a Physicians order for Oxygen to be administered via nasal cannula at 2 liters per minute, was observed multiple times with the Oxygen rate not consistent with the Physicians' order, and with the tubing disconnected from the Oxygen concentrator. 2. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated surveys (NY00337247)) from 01/22/25 to 01/29/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1. Upon review of the nursing staffing schedule from 12/22/24-1/29/25, for multiple days, on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents, and as per their Facility Assessment, 2. On multiple dates during the night shift on the 2 South Unit, there were only two Certified Nurse Aides scheduled which was not consistent with the Facility assessment that documented that there should be a minimum of three certified nurse aides. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 1/22/25-1/29/25, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months for 4 (#'s 14, 25, 32, and 33) of 5 Certified Nurse Aides reviewed for certified nurse aide performance reviews.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly sealed and dated in the kitchen walk in refrigerator, freezer, dry storage, and unit panty refrigerator; outdated food was not disposed of when expired; and food was not served at appropriate temperature.

Inspectors wroteBased on record reviews and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure that the Certified Nurse Aides were provided the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide documented evidence that 5 (#'s 14, 25, 32, 33, and 34) of 5 Certified Nurse Aides reviewed for Nurse Aide training, were provided 12 hours of mandatory training.

Inspectors wroteBased on observation, interview, and record review during the Recertification survey from 01/22/2025 through 01/29/2025, the facility did not ensure residents had the right to a dignified dining experience for 2 of 35 residents (Residents #168, #14) reviewed for dignity while dining. Specifically, facility staff were observed standing over Residents #168 and #14 while assisting the residents with their meals.

Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated (NY#00336657) surveys from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's designated representative had the right to be informed in advance, by the physician or other practitioner or professional, of treatment options and to choose the alternative or option they preferred for 1 (Resident # 233) of 2 residents reviewed for resident rights. Specifically, the facility administered Donepezil (a medication for dementia) to Resident #233 and the resident representative had requested the medication to not be given.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to reside and receive services in the facility with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #167) of 7 residents reviewed for Environment. Specifically, Resident #167's wheelchair was unable to maneuver around their bed preventing Resident #167 from being able to access and use their own bathroom.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated (NY00352407) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to receive written notice, including the reason for the change, before the resident's room was changed. This was evident for 1 (Resident #10) of 7 residents reviewed for Choices. Specifically, Resident #10's Health Care Agent did not receive written notice of or explanation for the resident's room change on 10/11/2024.

Inspectors wroteBased on interview and record review conducted during the recertification and abbreviated (NY00344201) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to manage their financial affairs. This was evident for 1 (Resident #182) of 3 residents during Personal Funds review. Specifically, the facility diverted Resident #182's income to a personal needs account managed by the facility without informing the resident's court-appointed Legal Guardian.

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #333) reviewed for Respiratory Care. Specifically, Resident #333 was receiving continuous Oxygen, and the facility was unable to provided documented evidence that a Respiratory/Oxygen Care Plan was in place.

Inspectors wroteBased on interviews and record review during the recertification survey from 1/22-1/29/24 the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #92) reviewed for insulin. Specifically, Resident #92's insulin order had a dicrepency and the order was not being followed as written.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, including expiration dates when applicable for 2 of 2 medication storage rooms, and 1 of 4 med carts reviewed. This was evident for 2 (Medication Storage Rooms 3 South Unit and 2 North Unit) of 2 medication storage rooms and 1 of 4 medication carts observed. Specifically, the 3 South Unit and 2 North Unit Medication Storage Rooms had an expired box of hydrocolloid wound dressing and an expired box of safety needle, the 3 South Unit medication cart contained an open and undated 32 ounce bottle of supplement.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 1/22/25 through 1/29/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 1 of 3 residents reviewed for transmission-based precautions; and 2 of 10 staff reviewed for influenza vaccinations. Specifically, 1) Resident #483 was on Enhanced barrier Precautions and staff was observed providing care without wearing proper protective equipment. 2) Licensed Practical Nurse #17 and Certified Nurse Aide #15 did not receive the influenza vaccine and were observed not wearing a mask.

Inspectors wroteBased on interviews and record review during the recertification survey from 1/22-1/29/2025, the facility did not ensure that residents' financial records were available to the residents through quarterly statements for 1 of 4 residents reviewed for personal funds. Specifically, Resident #92 was not aware that they had any personal funds and the facility financial office was not able to provide proof that the resident received quarterly statements.

Inspectors wroteBased on observations, interviews and record review conducted during an abbreviated survey (NY00341327, NY00358946), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 6 residents (Resident #3 & #10) reviewed. Specifically, (1) Resident #3 who had a history of suicidal attempts and cut their left wrist sustaining a laceration that was unwitnessed by staff on 05/04/2024 was placed on 1:1 monitoring following the incident had no documented 1:1 monitoring. Resident #3 was found by Certified Nurse Aide with blood on his gown and on the floor on 5/5/2024 and was transferred to the hospital for further evaluation. The investigative summary concluded Resident #3 used a pointed pencil to harm self; [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the abbreviated survey (NY00351516) from 8/19/24 to 8/20/24, the facility did not ensure a resident's preferences were incorporated in developing care plan goals for 1 (Resident #1) of 3 residents reviewed for pain management. Specifically, when Resident #1 was placed on comfort care, the facility did not include the designated representative (family) in pain management care planning.

Inspectors wroteBased on observation, interviews, and record review conducted during the abbreviated survey (NY00351516) from 8/19/24 to 8/20/24, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents reviewed. Specifically, Resident #1 was placed on Comfort care without a plan for pain management. The family requested morphine for pain on 8/9/24 and 8/10/24 because the resident was in pain. There is no documentation that the facility staff consistently assessed the resident to determine their pain/comfort level and the need for alternate medication.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00311197) the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed for physical abuse. Specifically, Resident #1 reported they were shoved by Certified Nurse Assistant #1 that on 2/20/2023 at 12am. Resident #1 tried to show the Certified Nurse Aide how to operate the overhead light and Certified Nurse Assistant #1 shoved Resident #1 with their shoulder onto the bed in the resident's room.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00311197, NY00332234) the facility did not ensure an allegation of abuse was thoroughly investigated and the results of the investigation reported to the New York State Department of Health, in accordance with State law within 5 working days of the incident for 2 (Resident #1, #4) of 6 residents reviewed for abuse. Specifically, Resident #1 reported that they were shoved by a Certified Nurse Aide on 2/20/23 at approximately 12 AM in their room, when trying to show them how to work the overbed lighting of their roommate. The facility did not provide documentation of the completed investigation and no report was submitted to the New York State Department of Health. 2) Resident #4 reported to Certified Nurse Assistant #5 that on 1/25/2024, Licensed Practical Nurse #2 pinched them on the left lower leg. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00311197), the facility did not ensure the comprehensive care plan was reviewed and revised for 1 (Resident #1) out of 3 residents reviewed for care planning. Specifically, Resident #1's abuse care plan was not updated to reflect an allegation of abuse on 2/20/2023.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00303362) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #2) of 3 residents reviewed for accident. Specifically, Resident #1 upon admission was scored as a mild fall risk and there was no documented evidence of any safety measures or assistive devices in place for use to prevent an accident. Resident #1 subsequently had a fall on 10/12/2022 and sustained a left wrist fracture and a laceration to the left eye.

Inspectors wroteBased on record review and interviews during a Recertification and Abbreviated survey (Case #NY00276712) conducted from 3/14/22-3/21/22, the facility failed to protect each resident's right to be free from abuse, neglect, exploitation and misappropriation of resident property for 1 (Resident #119) of 5 residents reviewed. Specifically, Resident #58 exhibited abusive behaviors toward staff and Resident #119. The facility did not ensure adequate supervision for each resident knowing Resident#58 had a history unpredictable recurring aggression and resident to resident altercations. As a result, Resident #58 pushed Resident #119, causing Resident #119 to fall and sustain a fracture of the wrist. This resulted in actual harm to Resident #119 that was not immediate jeopardy. .

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity. Specifically, a urine filled catheter bag was observed with no covering and visible from the unit hallway for 1 of 2 residents reviewed for dignity (resident #155) .

Inspectors wroteBased on Record review Observation and Interview conducted during a Recertification Survey and Abbreviated Survey (#292469) the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental and psychosocial needs for 1 of 1 residents reviewed for positioning/mobility (#82) and 1 of 1 residents reviewed for respiratory care (#102. Specifically, 1) no CCP was developed and implemented to address the resident's range of motion and contractures (Resident #82), and 2) no CCP was developed and implemented for the nebulizer treatment ordered by the Physician to address the resident's Chronic Obstructive Pulmonary Disease (COPD)/Shortness of Breath (SOB) (Resident #102). [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification/complaints survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident with contractures on both upper extremities was not provided with the splint device as per order, this was evident for 1 out of 2 residents reviewed for Limited ROM, (Resident #82)

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification / Complaint survey (NY00292469)), the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, 1) nebulizer tubing was observed in the resident's room not properly protected from infection, with no label, and there was no documented evidence that the tubing was changed, this was evident for 1 resident reviewed for respiratory care, (Resident #102). [...]

Inspectors wroteBased on observation, interviews and record review conducted during the most recent recertification survey, the facility did not ensure that care was provided in accordance with the written Plans of Care addressing pain management and nutrition for 2 of 40 sampled residents (Residents #9 and #131) reviewed. Furthermore, the facility did not ensure that interventions for catheter care and maintaining skin integrity were identified in the Plans of Care for 2 of 40 sampled residents (Residents #205 and #407). Specifically, Resident #9 was not being monitored for the presence of pain in terms of location and intensity as directed in the Plan of Care; Resident #131 was not provided the dietary supplements or additional water as directed in the Plan of Care. [...]

Inspectors wroteBased on observations, interviews and record review during a recertification survey, the facility did not implement effective monitoring procedures to ensure the resident assistive equipment remain free from a repeat accident hazard. Specifically, the corrective action plan did not provide a consistent monitoring action by the laundry staff to effectively test and track Hoyer lift pads after they have been washed and dried. These are the findings Resident #169 is a [AGE] year-old female admitted to the facility 06/19/2018 with diagnoses of Hypertension, chronic pain, anemia, Parkinson's disease. MDS (minimum data sheet, an assessment tool) annual assessment 06/05/2019 indicates the resident is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #169 requires a two-person assist with transfers to wheelchair. [...]

Inspectors wroteBased on observation and interview during the recent recertification survey, the facility did not ensure proper sanitation and food handling procedures were implemented to prevent the potential for foodborne illness. Specifically, potentially hazardous food items delivered to the facility were not put away in a timely manner; the walk-in freezer was packed up to the door and leaving no space for air to circulate around the items and the dishwasher was not sanitizing dishes or utensils during the final rinse cycle.

Inspectors wroteBased on record review, observation and interview conducted during a Recertification Survey the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, Physician's Orders and facility's policy. This was evident for 1 of 1 residents reviewed for accidents (Resident #169), 1 of 3 residents (Resident #406) reviewed for pain management, 1 of 6 residents (Resident #407) reviewed for Skin Impairment and 1 of 5 residents (Resident #179) reviewed for the administration of medications. Specifically, Resident #169 sustained a fall from a Hoyer lift and did not receive timely treatment and care for complaints of pain. Resident #407 did not receive timely treatment and care for a left heel ulcer or monitoring and treatment for left upper leg staples; [...]

Inspectors wroteBased on record review observation and record review conducted during the most recent recertification survey, the facility did not ensure that 1 of 1 resident (Resident #205) reviewed for indwelling catheter (tube inserted into the bladder to drain urine) received the appropriate care and services. Specifically, there was no documented evidence that the resident who was admitted to the facility with a Foley catheter received catheter cares and urine output monitoring in accordance with the Care Plan.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that medications were available when needed to meet the needs of each resident. Specifically, two doses of Kayexalate, a medicine used to lower high serum potassium levels, was not given to a resident for eleven hours after it was first ordered by the physician which put the resident at risk for complications associated with hyperkalemia and caused the resident to be transferred to the emergency room for evaluation and treatment.

Inspectors wroteBased on record review and interview, during the recent recertification survey, the facility did not ensure the results from diagnostic monitoring for a resident receiving an antipsychotic medication were available for review by the primary care physician (PCP). Specifically, electrocardiogram (EKG or ECG) monitoring every 2 weeks was ordered, initiated on 1/29/19. The EKG results were not available for review until surveyor intervention. This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #66).

Inspectors wroteBased on observations, interview and record review the facility did not ensure that medications were secured in a locked storage area. Specifically, prescription eye drops were found in resident's top drawer of night table during a medication pass.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that each time a resident was transferred to a hospital, the resident's representative was notified of the transfer in writing. This was evident for 3 of 3 residents (Residents # 123, #165 and #167 reviewed for hospitalization.