Inspection Reports for
Cedar Manor Nursing and Rehabilitation Center
Cedar Lane, P.o. Box 928, Ossining, NY, 10562
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
17.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
249% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
80
60
40
20
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Nov 4, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with care planning and activities of daily living requirements for residents, specifically focusing on behaviors and care provision for Resident #1.
Findings
The facility failed to develop and implement a comprehensive behavior care plan for Resident #1 who exhibited care refusal and behavioral disturbances. Additionally, the facility did not ensure adequate assistance with activities of daily living, resulting in hygiene and care deficiencies, including multiple documentation omissions by certified nurse aides.
Deficiencies (2)
F 0656: The facility did not develop or implement a comprehensive behavior care plan for Resident #1 who refused care and exhibited behavioral disturbances.
F 0677: The facility failed to provide necessary care and assistance with activities of daily living for Resident #1, resulting in poor hygiene and multiple grievances related to care neglect.
Report Facts
Residents reviewed for behaviors: 3
Residents reviewed for activities of daily living: 3
Grievances on file: 2
Certified Nurse Aide documentation omissions: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Documented nursing progress notes and described oversight of certified nurse aides |
| Certified Nurse Aide #4 | Certified Nurse Aide | Reported behaviors and refusals of care by Resident #1 |
| Certified Nurse Aide #6 | Certified Nurse Aide | Reported challenges with documentation and workload |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, documentation issues, and staff oversight |
| Unit Manager #2 | Unit Manager | Responsible for reviewing documentation and initiating behavior care plan |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Apr 11, 2025
Visit Reason
The survey was a recertification and abbreviated survey conducted from 4/6/2025 to 4/11/2025 to assess compliance with regulatory requirements for Cedar Manor Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, inadequate linen supply, environmental maintenance issues, misappropriation of resident property, insufficient assistance with activities of daily living, improper respiratory and dialysis care, medication management errors, staffing shortages, improper medication storage, inadequate antibiotic stewardship, improper waste disposal, and incomplete COVID-19 vaccination documentation for staff.
Deficiencies (14)
F 0550: The facility did not ensure residents were treated with respect and dignity during meals, with staff observed standing over residents while feeding them instead of sitting.
F 0584: The facility did not provide adequate bath linens for all residents and had displaced baseboard moldings in resident rooms.
F 0602: The facility did not safeguard resident property, resulting in a missing package for Resident #102 that was reimbursed after a delay of several months.
F 0676: Resident #81 was not showered twice weekly as per schedule and had not received a shower in a week despite care plans.
F 0677: The facility did not ensure dependent residents received necessary care for grooming and hygiene, including inconsistent incontinence care, long dirty fingernails, and lack of showers.
F 0688: Resident #18 with contracture of the right hand was observed without the prescribed gauze roll on multiple occasions.
F 0695: Resident #92 received oxygen at higher flow rates than ordered and was observed with an empty portable oxygen tank while sleeping.
F 0698: Resident #439 receiving hemodialysis lacked consistent assessment and documentation of pre- and post-dialysis vital signs and treatment monitoring.
F 0725: The facility was repeatedly short staffed below minimum certified nurse aide levels on multiple dates, impacting resident care.
F 0757: Resident #49 received unnecessary hydromorphone doses outside physician orders, including simultaneous administration of different dosages without order.
F 0761: Medication carts were left unlocked and unattended, medications were left unattended on carts, and expired medications and biologicals were found in the medication storage room.
F 0814: Garbage debris was observed around the dumpster perimeter, and the dumpster area was not maintained in a clean condition.
F 0881: The facility did not maintain an effective antibiotic stewardship program, lacking documentation and monitoring of antibiotic use for residents #78 and #190.
F 0887: The facility did not provide documentation of COVID-19 vaccination screening, administration, declination, or education for 10 staff members reviewed.
Report Facts
Certified Nurse Aides staffing: 9
Certified Nurse Aides staffing: 10
Certified Nurse Aides staffing: 11
Certified Nurse Aides staffing: 12
Certified Nurse Aides staffing: 6
Certified Nurse Aides staffing: 12
Certified Nurse Aides staffing: 11
Certified Nurse Aides staffing: 11
Certified Nurse Aides staffing: 5
Expired medications: 4
Antibiotic doses: 9
Antibiotic doses: 14
Antibiotic doses: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Commented on hydromorphone administration and documentation |
| Director of Nursing | Director of Nursing | Commented on hydromorphone administration and antibiotic stewardship |
| Registered Nurse #31 | Registered Nurse Unit Manager | Responsible for monitoring medication room and dialysis communication book |
| Registered Nurse #19 | Registered Nurse | Observed oxygen administration and corrected oxygen flow rate |
| Certified Nurse Aide #8 | Certified Nurse Aide | Observed feeding residents standing and unaware of gauze roll order |
| Certified Nurse Aide #24 | Licensed Practical Nurse | Left medication unattended on cart |
| Medical Director | Medical Director | Commented on hydromorphone administration and antibiotic stewardship |
| Staffing Coordinator | Staffing Coordinator | Discussed staffing shortages and agency staff issues |
| Food Service Director | Food Service Director | Commented on dumpster area cleanliness |
| Assistant Director of Nursing | Assistant Director of Nursing | Commented on medication room monitoring and dialysis documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 30
Date: Apr 11, 2025
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies mostly Level 2 severity, many corrected by May 2025.
Findings
Inspection identified multiple standard health and life safety code deficiencies mostly Level 2 severity, many corrected by May 2025.
Deficiencies (30)
Activities daily living (adls)/mntn abilities
ADL care provided for dependent residents
Antibiotic stewardship program
Covid-19 immunization
Dialysis
Dispose garbage and refuse properly
Drug regimen is free from unnecessary drugs
Free from misappropriation/exploitation
Increase/prevent decrease in rom/mobility
Infection control
Label/store drugs and biologicals
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Responsibilities of providers; required notif
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Cooking facilities
Egress doors
Hvac
Rubbish chutes, incinerators, and laundry chu
Sprinkler system - maintenance and testing
Corridor - doors
Electrical systems - essential electric syste
Emergency lighting
Hazardous areas - enclosure
Illumination of means of egress
Maintenance, inspection & testing - doors
Organization and administration
Physical environment
Standards of construction for new existing nh
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 11, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey of Cedar Manor Nursing & Rehabilitation Center to assess compliance with regulatory requirements related to resident care, environment, staffing, and activities of daily living.
Findings
The facility was found deficient in providing adequate bath linens, maintaining safe and comfortable living environments, ensuring residents received necessary assistance with activities of daily living including showering and hygiene, and maintaining sufficient nursing staff levels to meet resident needs.
Deficiencies (4)
F 0584: The facility did not provide an adequate supply of bath towels for residents and had displaced baseboard moldings in resident rooms.
F 0676: Resident #81 was not showered twice weekly as per the unit shower schedule, resulting in inadequate assistance with activities of daily living.
F 0677: The facility failed to provide consistent care for grooming and personal hygiene for three dependent residents, including inadequate incontinence care, long dirty fingernails, and lack of showers or hair washing.
F 0725: The facility did not maintain sufficient nursing staff levels on multiple dates, resulting in staffing below the facility's assessed minimum requirements.
Report Facts
Resident census on South unit: 52
Certified Nurse Aides minimum staffing requirement: 14
Certified Nurse Aides actual staffing: 9
Certified Nurse Aides actual staffing: 10
Certified Nurse Aides actual staffing: 11
Certified Nurse Aides actual staffing: 12
Certified Nurse Aides actual staffing: 6
Certified Nurse Aides actual staffing: 12
Certified Nurse Aides actual staffing: 11
Certified Nurse Aides actual staffing: 11
Certified Nurse Aides actual staffing: 5
Towels on linen cart: 0
Towels in linen closet: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | Certified Nurse Aide | Reported towel shortage and towel distribution on South unit |
| Certified Nurse Aide #6 | Certified Nurse Aide | Reported towel shortage on South unit |
| Certified Nurse Aide #28 | Certified Nurse Aide | Reported use of sheets and blankets for drying residents due to towel shortage |
| Administrator | Acknowledged ongoing towel shortage and ordering issues | |
| Maintenance Director | Director of Maintenance | Reported lack of awareness of displaced baseboard tiles |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported lack of awareness of environmental concerns and work order process |
| Certified Nurse Aide #33 | Certified Nurse Aide | Reported Resident #81 refusal of shower and hygiene care |
| Licensed Practical Nurse #23 | Licensed Practical Nurse | Reported awareness of Resident #81 care refusals and lack of documentation |
| Unit Manager Registered Nurse #31 | Registered Nurse Unit Manager | Reported no notification of Resident #81 care refusals |
| Certified Nurse Aide #17 | Certified Nurse Aide | Reported documentation practices for resident care |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported follow-up responsibilities for care documentation |
| Certified Nurse Aide #8 | Certified Nurse Aide | Reported fingernail grooming responsibilities and observations |
| Registered Nurse Manager #2 | Registered Nurse Manager | Reported observations of resident fingernail condition |
| Registered Nurse Manager #31 | Registered Nurse Manager | Reported shower schedule and awareness for Resident #56 |
| Certified Nurse Aide #32 | Certified Nurse Aide | Reported concerns about bariatric shower chair and showering Resident #56 |
| Certified Nurse Aide #34 | Certified Nurse Aide | Reported short staffing and impact on resident showers |
| Staffing Coordinator | Reported staffing minimums and challenges with agency staff | |
| Director of Nursing | Director of Nursing | Reported staffing levels and use of nursing supervisors to cover shortages |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
Complaint survey with two standard health citations related to abuse and reporting violations, corrected by July 2024.
Findings
Complaint survey with two standard health citations related to abuse and reporting violations, corrected by July 2024.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, and failure to timely report suspected abuse incidents involving multiple residents at Cedar Manor Nursing & Rehabilitation Center.
Complaint Details
The survey was complaint-related, triggered by reports of abuse including a resident being bopped on the head by staff and being left in the shower for a long time. The complaint was substantiated for physical abuse by a Certified Nurse Assistant. Other abuse allegations were investigated but not corroborated. The facility failed to report incidents timely to authorities.
Findings
The facility failed to protect residents from abuse, including physical abuse by staff, and did not timely report suspected abuse incidents to the proper authorities as required by federal and state law. Investigations found that a Certified Nurse Assistant bopped a resident on the head, and multiple incidents of alleged abuse were not reported within required timeframes.
Deficiencies (2)
F 0600: The facility did not ensure residents' right to be free from abuse, neglect, and mistreatment. A Certified Nurse Assistant was witnessed bopping a resident on the head, and the incident was not reported timely by staff.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not submit investigation results to the New York State Department of Health within required timeframes for 3 residents.
Report Facts
Suspension duration: 5
Number of residents reviewed for abuse: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #5 | Named in abuse finding for bopping Resident #3 on the head; received a 5-day suspension. | |
| Certified Nurse Assistant #7 | Witnessed abuse incident involving Resident #3 and Certified Nurse Assistant #5. | |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting and investigation procedures. |
| Registered Nurse #3 | Conducted assessments and reported Resident #3's abuse allegations. | |
| Licensed Practical Nurse #1 | Reported hearing sounds related to abuse incident involving Resident #1. | |
| Certified Nurse Assistant #3 | Involved in an incident with Resident #2; failed to report abuse concerns timely. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 17
Date: Jan 25, 2024
Visit Reason
Complaint survey with multiple standard health and life safety code citations mostly Level 2 severity, many corrected by March 2024.
Findings
Complaint survey with multiple standard health and life safety code citations mostly Level 2 severity, many corrected by March 2024.
Deficiencies (17)
Baseline care plan
Drug regimen review, report irregular, act on
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Infection prevention & control
License/comply w/ fed/state/locl law/prof std
Notify of changes (injury/decline/room, etc. )
Quality of care
Resident rights/exercise of rights
Corridor - doors
Electrical systems - essential electric syste
Emergency lighting
Hazardous areas - enclosure
Illumination of means of egress
Maintenance, inspection & testing - doors
Organization and administration
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and evaluate the facility's care and operational standards.
Findings
The facility was found deficient in timely notification of resident representatives after incidents, ensuring appropriate follow-up care, providing adequate supervision to prevent accidents, compliance with sharps disposal regulations, and infection prevention and control practices including accurate infection tracking and proper PPE use.
Deficiencies (5)
F 0580: The facility failed to notify a resident's representative timely after a fall, notifying them two hours later instead of immediately as required.
F 0684: The facility did not ensure appropriate treatment and follow-up care for two residents, including delayed orthopedic follow-up and failure to update the doctor on fracture reassessment.
F 0689: The facility failed to provide adequate supervision and accident hazard prevention, allowing a resident to exit the facility undetected and sustain injury.
F 0836: The facility did not operate in compliance with state law by not accepting sharps for disposal from the community since the COVID-19 pandemic ended.
F 0880: The facility failed to maintain an effective infection prevention and control program, including inaccurate infection tracking and improper PPE use in isolation rooms.
Report Facts
Residents reviewed for notification of change: 9
Residents reviewed for accidents: 9
Residents reviewed for accidents: 1
COVID-19 positive cases: 18
Sharps drop-off last date: Nov 12, 2020
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a recertification survey from January 17 to January 25, 2024, to assess compliance with regulatory requirements for Cedar Manor Nursing & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified care, timely notification of changes in condition, baseline care planning, provision of ordered medical devices, environmental safety, and medication regimen review. Deficiencies were noted for failure to ensure dignified feeding assistance, delayed family notification after a fall, missing baseline care plans, inadequate use of splints and boots, insufficient supervision leading to resident elopement, and failure to discontinue unnecessary medication as recommended by the pharmacist.
Deficiencies (6)
F 0550: The facility did not ensure residents had the right to a dignified existence; staff were observed standing over Resident #73 while feeding and other residents did not receive lunch in a timely manner.
F 0580: The facility failed to notify Resident #181's representative timely after a fall; notification occurred two hours later when the representative arrived for an appointment.
F 0655: The facility did not develop a baseline care plan within 48 hours of admission addressing the use of a Foley catheter for Resident #129.
F 0688: The facility did not provide ordered devices to maintain or improve range of motion for Residents #11 and #32; splints and boots were not applied as prescribed.
F 0689: The facility failed to provide adequate supervision and environmental safety; Resident #184 exited the facility undetected, fell, and sustained injury.
F 0756: The facility did not ensure that irregularities identified by the pharmacist were acted upon; Resident #82's aspirin was not discontinued as recommended.
Report Facts
Residents reviewed for notification of change: 9
Residents reviewed for hospitalization: 3
Residents reviewed for range of motion: 6
Residents reviewed for accidents: 9
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #15 | Registered Nurse | Observed feeding Resident #73 and interviewed regarding feeding practices. |
| Staff #24 | Certified Nurse Aide | Interviewed about tray delivery timing and fall incident notification. |
| Staff #25 | Nursing Supervisor | Interviewed about fall incident notification responsibilities. |
| Director of Nursing | Interviewed regarding expectations for family notification and supervision. | |
| Staff #18 | Registered Nurse | Interviewed about missing baseline care plan for Foley catheter. |
| Minimum Data Set Coordinator | Interviewed about baseline care plan completion. | |
| Director of Rehabilitation | Interviewed about use of splints and boots for residents. | |
| Staff #14 | Certified Nurse Aide | Interviewed about application of splints and boots. |
| Staff #16 | Certified Nurse Aide | Interviewed about splint application. |
| Staff #1 | Nursing Supervisor | Interviewed about front door locking and alarm activation during elopement incident. |
| Staff #10 | Nurse Practitioner | Interviewed about medication discontinuation responsibility. |
| Staff #3 | Pharmacist Consultant | Interviewed about drug regimen review and communication with facility. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2023
Visit Reason
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 survey with one standard health citation for reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 20, 2020
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for Cedar Manor Nursing & Rehabilitation Center.
Findings
The survey identified deficiencies related to resident dignity with urinary catheter care, management of residents' personal funds, failure to revise care plans for unplanned weight loss, and lack of timely medical supervision for significant weight loss in a resident.
Deficiencies (4)
F 0550: The facility failed to maintain dignity for Resident #56 by not concealing the urinary catheter tubing and drainage bag as required by policy.
F 0567: The facility did not honor Resident #58's request to access personal funds due to lack of available petty cash for 7-10 days.
F 0657: The facility failed to review and revise the care plan for Resident #30 to address ongoing unplanned weight loss and did not initiate new interventions.
F 0710: The facility did not provide timely medical supervision for Resident #30's significant weight loss as the physician and nurse practitioner were unaware and labs were not obtained.
Report Facts
Weight loss: 15.8
Petty cash shortage duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding catheter care and Resident #30's weight loss. |
| SW #1 | Social Worker | Confirmed Resident #58's requests for personal funds and communication issues. |
| Administrator | Facility Administrator | Confirmed petty cash shortage at reception desk. |
| RD | Registered Dietitian | Documented Resident #30's weight loss and noted lack of interventions. |
| NP | Nurse Practitioner | Unaware of Resident #30's significant weight loss and lack of labs. |
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