Yonkers Gardens Center for Nursing and Rehab

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 2/5/2026 to 2/12/2026, the facility did not ensure that food was stored, prepared and distributed in accordance with professional standards for food safety practice. The facility also did not maintain essential kitchen equipment in a clean and sanitary condition. Specifically, observations revealed expired food items stored in the walk-in refrigerator. An opened and uncovered box of frozen vegetables was observed in the walk-in freezer. Sandwiches and cold cuts prepared for distribution were wrapped in plastic but lacked proper labeling. The glass doors of the countertop hot box food warmers were observed to be covered with large brown and black accumulations of burned grease. During tray line observation, the cook was not wearing a beard covering. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure the resident's right to a safe, clean, comfortable and homelike environment on (2) two of (5) five resident floors (floors 3 and 4). Specifically,1) resident room/s on floor 3 had bathroom fixtures in disrepair, bedroom furniture, doors/walls with stains/scratches, and a soiled stained mechanical lift, and 2) resident room/s on floor 4 had a clock hanging off the wall, a damaged radiator, patched and mismatched wall paint, stained and warped ceiling tiles, dried rust-colored stains on walls/radiators, and a resident hall bathroom on floor 4 had a soiled and stained privacy curtain.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure residents unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene for three (3) of six (6) residents (Resident #11, #7, and #78) reviewed for activities of daily living. Specifically, 1) Resident #11 was not provided with staff assistance to perform facial hair grooming, 2) Resident #7 was not provided with staff assistance to take showers, and 3) Resident #78 was not provided with staff assistance to shower or groom their facial hair.

Inspectors wroteBased on observation and interview conducted during the 02/05/2026 to 02/12/2026 Recertification Survey the facility did not ensure appropriate storage of medications in accordance with currently accepted professional standards of practice for one (1) of 10 medication carts and two (2) of six (6) medication rooms. Specifically, one (1) medication cart on the 6th floor was observed unlocked and unattended, and one (1) medication room on the 5th floor was observed unlocked/unattended and contained methadone for Resident #119 and #156 that was stored in the same locked cabinet with other narcotics.

Inspectors wroteBased on observation, and interview during recertification survey from 02/05/2026 to 02/12/2026, facility personnel did not ensure linens were handled and stored in a manner to prevent the spread of infection. Specifically, linens and towels were exposed and stored on top of hampers in resident rooms, and dirty linens were on the floor in the 4th and 5th floor shower rooms.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, 1) the designated smoking area had a substantial amount of cigarette butts and ice and snow covering on the ground, and 2) elevator #1 had damaged wall paneling and air vent grates.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated surveys (#2669870), from 02/05/2026-02/12/2026 the facility did not ensure an effective pest control program was maintained for 3 (three) of 5 (five) residential floors (4th, 5th, and 6th floor) in the facility. Specifically, a roach was observed in room [ROOM NUMBER], residents and staff voiced complaints regarding roaches and mice, and the pest control company logs for the past 6 (six) months documented the ongoing presence of roaches on the resident units.

Inspectors wroteBased on observation and interview during a recertification survey from 02/05/2026 through 02/12/2026, the facility did not ensure dignity was maintained for one (1) of four (4) residents (Residents #181) reviewed for dignity. Specifically, the phlebotomist drew blood from Resident #181 in the dining room area where residents were waiting for lunch.

Inspectors wroteBased on observations, record reviews and interviews during the recertification survey from 2/5/2026 to 2/12/2026 the facility did not promote and facilitate resident self determination through support of the resident's choices for one (1) of five (5) residents (Resident #7) reviewed for Choices. Specifically, Resident # 7 was not allowed to choose their bedtime.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure quarterly statements of the resident's financial record were made available for (1) one of (2) two residents (Resident #78) reviewed for Personal Funds. Specifically, there was no evidence quarterly statements of Resident #78's personal funds account was provided to the resident's Designated Representative.

Inspectors wroteBased on observation, record review and interview conducted during the recertification and abbreviated (2584489) survey from 02/05/2026 to 02/12/2026, the facility did not ensure that alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated for one (1) of five (5) residents. (Resident #140) reviewed for abuse. Specifically, for Resident #140 there was no documented evidence the facility conducted a complete and thorough investigation, including statements, after Resident #140's family member reported the resident was beaten in the shower by certified nurse aides.

Inspectors wroteBased on record review and interview conducted during the recertification survey 02/05/2026 - 0212/2026 the facility did not ensure a significant change Minimum Data Set assessment was completed within the 14-day requirement for one (1) of six (6) residents (Resident #2) reviewed for Nutrition. Specifically, a significant change Minimum Data Set was not initiated within 14 days for Resident #2 who had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, a decline in activities of daily living, a decline in cognition and a decline in urinary continence.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 2/05/2026 to 2/12/2026, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for two (2) of two (2) (Resident #83 and #96) residents reviewed for Minimum Data Set. Specifically, Resident #83 and #96's Minimum Data Set Assessments were completed on 10/07/2025, and were not transmitted until 02/09/2026.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 02/05/2026 to 02/12/2026, the facility did not ensure that the Minimum Data Set assessment accurately reflects the resident's status for (1) one of (3) three residents (Resident # 46) reviewed for Smoking. Specifically, the 12/10/2025 Minimum Data Set assessment was not accurately coded to reflect Resident #46's use of tobacco.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident for one (Resident #19) of three residents reviewed for smoking. Specifically, Resident #19 was not reassessed for their ability to smoke safely and care plan interventions to prevent future noncompliance were not developed and implemented following the resident's noncompliance with facility smoking rules.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for one (1) of one (1) residents reviewed for respiratory care. Specifically, Resident #92 had a physician order for oxygen via nasal canula at 4 liters per minute, and was observed receiving oxygen via nasal cannula at a rate of 2 liters per minute.

Inspectors wroteBased on record review, and interview conducted during the Recertification Survey and Abbreviated survey (2650146) from 02/05/2026 to 02/12/2026, the facility did not ensure medications were available to meet the needs of each resident for one (1) of three (3) residents reviewed for pain management. Specifically, when Resident #205 was re-admitted to the facility, Methadone was unavailable for timely administration.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (2669870), the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility was aware of ongoing sightings of roaches and mice (see F925) and there was no evidence a QAPI plan was in place to to address pest control.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 2/5/2026 to 2/12/2026, the facility did not ensure the Quality Assurance & Performance Improvement Committee consisted at a minimum of the Infection Control Practitioner, the Medical Director, the Administrator and the Director of Nursing. Specifically, the Infection Control Practitioner did not participate in Quality Assurance & Performance Improvement meetings for three (03) out of the three (03) quarterly meetings in 2025.

Inspectors wroteBased on record review and interviews during abbreviated surveys (NY00378486, NY00339264 and NY00343082), the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision for three (3) of three (3) residents (Residents #1 and #2 and #3) reviewed for elopement. [...]

Inspectors wrote[NAME] Gardens Center for Nursing and Rehab F600 J, Event ID: DSWK11 Exit Date 5/28/2025 Due Date 6/11/2025 [NAME] NR /[NAME] Based on record review and interviews conducted during an abbreviated survey (NY00367662), the facility failed to ensure residents were free from abuse for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, Resident #1 had a history of sexually inappropriate behaviors towards other residents on 9/20/2024 and 12/23/2024 and there was no documented evidence the facility revised care plans or implemented interventions and/or physician orders to prevent the resident from sexually abusing other residents. [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated survey (NY00367662), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 1/5/2025 at 1:30 PM, Resident #1 was found in bed with Resident #2 who was severely cognitively impaired Resident #1 was half naked on top of Resident #2 with their mouth on Resident #2's genital area. Administration was made aware of this event on 1/5/2025 at 1:43PM. The facility did not report the incident to the New York State Department of Health until 1/5/2025 at 4:10PM.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00367662) it was determined for 1 of 3 residents reviewed for abuse (Resident #1), the facility did not ensure a sexual abuse was thoroughly investigated and ensure residents safety during the investigation. Specifically, Resident #1 was found half naked on top of Resident #2 with their mouth on Resident #2's genital area. The facility did not conduct a thorough investigation, did not assess both residents and did not send both residents to the hospital for medical evaluation.

Inspectors wroteBased on record review and interview conducted during abbreviated survey (NY00367662), the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, Resident #1 had a history of sexually inappropriate behaviors towards other residents on 9/20/2024 and 12/23/2024 and there was no documented evidence the facility revised care plans or implemented interventions and/or physician orders to prevent the resident from abusing other residents.

Inspectors wroteBased on observations and interviews during an abbreviated survey (NY00337354), the facility did not ensure the resident's right to a dignified existence. This was evident for 5 out of 6 residents (Resident #4, #12, #13, #14, #15) reviewed for dignity. Specifically, (1) During an observation on 12/13/2024, the 6th floor unit hallway had 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns; (2) During an observation on 12/13/2024 on the 5th floor dining room, Registered Nurse #1 was standing over Resident #15 while assisting them with their meal.

Inspectors wroteBased on record review and interview during an abbreviated survey ((NY00337504, NY00353121), the facility did not ensure residents right to be free from abuse. This was evident for 6 out of 9 residents (Resident #3, #4, #5, #7, #8, #9). Specifically, (1) on 3/28/2024 Resident #2 hit Resident #5 with their walker after a verbal altercation in the hallway. Resident #5 sustained bruising to their left hand and chest area. (2) On 5/2/2024, Resident #2 and Resident #4 who resided in the same room engaged in a physical altercation. Resident #4 sustained a laceration to their chin and Resident #2 sustained a laceration to their left eyebrow. On 8/23/2024, Resident #2 was witnessed by staff hitting Resident #4 in the arm, while they were in the hallway without being provoked. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00337504, NY00353121) the facility did not ensure the report of the results of their investigation was submitted to the New York State Department of Health in accordance with State law within 5 working days of the incident for 2 of 3 residents (Resident #2, #6) reviewed for abuse. Specifically, (1) Resident # 2 was witnessed hitting Resident #5 on their left hand with their walker on 3/28/2024. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 4/11/2024. 2)On 5/2/2024 Resident #2 engaged in a physical altercation with Resident #4 and resulted in injury to both residents. There was no documented evidence that a 5-day investigative conclusion report was submitted to the New York State department of Health. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00334737) the facility did not ensure sufficient nursing staff to attain or maintain the well-being of each resident as determined by the facility staffing grid as necessary to meet the needs of the residents for 35-40 residents on the 3rd floor Dementia Unit. Specifically, review of the facility scheduled data sheets for January 2024, February 2024 and March 2024 revealed staffing was not adequate across various shifts based on the unit needs and Provider Average Ratio (PAR) levels documented on the staffing grid.

Inspectors wroteBased on observations and interviews during an abbreviated survey (NY00337354, NY00334737), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards chipped and coming off the wall, holes in the walls, chipped tiles, caving ceiling tiles and foul odors.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00337354) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 out of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 who was dependent on staff for all cares including rolling left to right acquired a Stage 3 pressure ulcer to their left hip during their stay at the facility. There was no documented physician order for turning and repositioning, and the certified nurse accountability form did not show that staff were consistently providing this care to the resident.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00337354, NY00337504, NY00353121, NY00334737), the facility did not ensure a facility-wide assessment was conducted to determine what resources are necessary to care for its residents competently. Specifically, the Facility Assessment did not identify individual staff assignments, systems for coordination, and continuity of care necessary to care for residents during both day-to-day operations including nights and weekends.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the resident's environment was free of accident hazards for one Resident (#5) of 9 residents reviewed for accidents. Specifically, Resident #5 with a known history of polysubstance abuse was not supervised to prevent the availability of non-prescribed drugs and their usage within the facility. Resident #5 had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/24,1/10/24, 1/18/24, 1/23/24, and 1/29/24 for which Narcan (an opioid reversal agent) had to be administered by facility staff. Resident #5 continued to obtain illicit drugs which required hospitalization. The facility failed to initiate an investigation into the drug overdoses or update the care plan for Resident #5. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00331536 and NY00330044), the facility did not ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated. This was evident for 4 of 4 residents (Residents #1, #2, #3, #4, #5) reviewed for Abuse. Specifically, (1) Resident #2 was accused of alleged inappropriate touching by Resident #1 on 1/13/2024 and the facility failed to call 911 or notify local law enforcement. Local law enforcement was notified of the sexual abuse allegation on 1/14/2024 by the hospital emergency room staff when Resident #1 reported the allegation to hospital staff; (2) Facility progress note documented Resident #2's aggressive physical/verbal/sexual behaviors towards staff and residents on 12/19/2023, 12/20/2023 and 1/12/2024. [...]

Inspectors wroteBased on interviews and record review conducted during an abbreviated survey(s) (NY00331536, NY00330044 and NY00332489) 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 and staff complained about short staffing, and how it delayed care to many of the residents 2) Observations of 1 CNA for an entire nursing unit who was also assigned provide continuous monitoring of Resident # (), and 3) analysis of the actual staffing schedule for 2/2/0224 showed the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on record review and interview during an abbreviated survey/s (#NY00331536, NY00330044, and NY00332489), the facility did not ensure each resident was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 3 of 3 residents (Resident #2, Resident #4, and Resident #5) reviewed for abuse . Specifically, 1 )Resident #2 displayed sexually aggressive behaviors beginning in December 2023 and a plan was not developed or implemented to prevent recurrence until after an alleged incident of sexual abuse of Resident #1 that occurred on 1/13/2023; [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey and extended survey (NY00332489), the facility did not ensure that all nursing staff were in-serviced in behavioral health care needs of residents. Specifically, the facility was unable to provide documented evidence that they provided nursing staff education on behavioral health between1/1/23 and 12/31/23.

Inspectors wroteBased on record review and interviews conducted during abbreviated survey (NY00331536, NY0033004, NY00332489), the facility did not ensure that residents were free from abuse, neglect, and exploitation for 2 of 4 (Residents #1 and #2) reviewed for abuse. Specifically, (1) Resident #2 had multiple documented incidents of sexual/physical and verbal aggression towards staff on 12/19/2023,12/20/2023,1/12/2024 and no new interventions were put in place to prevent further reoccurrence; (2) On 1/13/2024, Resident #1 reported to their assigned Certified Nursing Assistant (Staff # 21) that they were inappropriately touched by another resident (Resident #2). Resident #2's hat was found on Resident #1's bed and Resident #2's sweater was found on the ground next to the bed. Resident #1and #2 were assessed and transferred to the Emergency Room. [...]

Inspectors wroteBased on interview and record review conducted during an abbreviated survey (NY00332489) it was determined the facility did not ensure that the comprehensive person-centered care plan was implemented to meet the residents needs for safety for 1 of 9 residents reviewed for accidents (Resident #5). Specifically, Resident #5 with a known history of polysubstance abuse had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/2024,1/10/2024, 1/18/2024, 1/23/2024, 1/29/2024, and 2/2/2024 for which Narcan (an opioid reversal agent) had to be administered by facility staff; Resident #5's comprehensive care plan did not address the resident's known substance use disorder, was not updated to reflect the suspected overdoses. No new care plan interventions were put in place to ensure Resident #5's safety and prevent recurrent overdoses.

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (#NY00332489, NY00331536, NY00330044), the facility did not ensure that the resident's Primary Care Physician (PCP) comprehensively reviewed the resident's total program of care including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen for 1 of 9 residents (Resident #5) reviewed for accidents. Specifically, Resident #5 Resident #5 had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/24,1/10/24, 1/18/24, 1/23/24, and 1/29/24 for which Narcan (an opioid reversal agent) had to be administered by facility staff. Resident #5's comprehensive care plan was not updated after episodes of overdose or illicit substance. [...]

Inspectors wroteBased on interview and record review conducted during abbreviated surveys (NY00331536, NY00330044, and NY00332489) between 01/22/2024 and 02/07/2024, it was determined the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the 200 licensed bed facility did not operate with a full-time social worker from 8/12/2023 to 11/2/2023.

Inspectors wroteBased on record review and interviews conducted during abbreviated surveys (NY00331536, NY00330044, NY00332489), the facility with a licensed bed capacity of 200 beds was operating without a full-time social worker from 8/12/2023 to 11/2/2023.

Inspectors wroteBased on observation, interviews, and record reviews conducted during the Recertification Survey from 8/11/23 to 8/15/23, it was determined the facility did not ensure a resident's care plan was revised to reflect the resident's change in condition for one of one resident (Resident #102) reviewed for Incontinence of Bowel and Bladder. Specifically, when Resident #102 had a decline in continence of bowel and bladder, the care plan was not updated.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey and abbreviated survey conducted from 8/9/23-8/15/23(NY00315357) the facility did not provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for accidents. Specifically, Resident #237 left the facility undetected by staff on 4/23/23 and was not found until 4/24/23 when the facility found the resident had been admitted to a hospital.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 8/9/23 to 8/15/23. The facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 residents reviewed for Medication storage. Specifically, Resident #64 had a bottle of unlabeled Mucinex at his bedside.

Inspectors wroteBased on record review and interview conducted during a recertification survey from 8/9/23 to 8/15/23, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted annually to identify where waterborne pathogens could grow and spread in the facility water system and 2) the facility did not update the Water Management Plan since July 2017.

Inspectors wroteBased on record review and interviews during a recertification survey from 8/9/23 to 8/15/23, 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 who is the Director of Nursing Services (DON), did not have documented evidence of completed specialized training in infection prevention and control until 08/11/23.

Inspectors wroteBased on interview and record review conducted during a recertification survey from 8/9/23 to 8/15/23, the facility did not provide a COVID-19 vaccination for 1 (Resident #110) of 5 residents reviewed for COVID-19 vaccination after screening and consent was obtained. Specifically, Resident #110 had consent from 12/7/22 but had not received the vaccine when reviewed as of 8/14/23.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that 1 of 3 residents ( Resident #86) received care in a dignified manner. Specifically, during wound care and diaper change the resident's door was left ajar exposing the resident's private areas to public view.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that residents or their representatives and the ombudsman were provided with written notification of their transfer to the hospital. This was evident for 2 of 2 residents (Resident #45 and Resident #160) reviewed for hospitalizations.

Inspectors wroteBased on record review and interview conducted during the most recertification survey, the facility did not ensure that two quarterly assessments utilizing the State approved instrument were conducted for 1 of 11 residents (#59) reviewed for resident assessment.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure the comprehensive person-centered care plan was reviewed and revised with measurable objectives, time frames and appropriate interventions for 1 of 5 residents (Resident #86) reviewed for pressure ulcers. Specifically, the care plan 1. did not address the effectiveness of treatment to a left heel pressure injury identified on admission, 2. did not reflect the development and treatment of two new pressure ulcers, and 3. did not initiate new interventions to prevent further skin breakdown.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey the facility did not ensure that the environment was free of accident hazards and that each resident received adequate supervision and assistance to prevent accidents. This was evident for 1 resident reviewed for accident hazards. (Resident #153)