Inspection Reports for
Cedar Manor Nursing and Rehabilitation Center
Cedar Lane, P.o. Box 928, Ossining, NY, 10562
Back to Facility Profile6 Reports
Inspection Report — Nov 4, 2025
Complaint Investigation State
Date: Nov 4, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 69 complaints about this facility; 13 led to on-site inspections.
Findings
Across 11 inspections, 7 resulted in citations totaling 50 deficiencies primarily related to standard health and life safety code issues. The facility had one enforcement action with fines and multiple citations indicating minor potential harm.
Citations (47)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient in isolated instances.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient in isolated instances.
Standard Health Citation — quality of care: Activities Daily Living (adls)/mntn Abilities was deficient in isolated instances.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents showed a pattern of deficiencies.
Standard Health Citation — quality of care: Antibiotic Stewardship Program was deficient in isolated instances.
Standard Health Citation — quality of care: Covid-19 Immunization showed a pattern of deficiencies.
Standard Health Citation — quality of care: Dialysis was deficient in isolated instances.
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly was deficient in isolated instances.
Standard Health Citation — quality of care: Drug Regimen Is Free From Unnecessary Drugs was deficient in isolated instances.
Standard Health Citation — quality of care: Free From Misappropriation/exploitation was deficient in isolated instances.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility was deficient in isolated instances.
Standard Health Citation — quality of care: Infection Control was deficient in isolated instances.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals was deficient in isolated instances.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient in isolated instances.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning was deficient in isolated instances.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif had no harm potential.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment showed a pattern of deficiencies.
Standard Health Citation — quality of care: Sufficient Nursing Staff showed a pattern of deficiencies.
Life Safety Code Citation — NFPA requirements: Cooking Facilities showed widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Egress Doors showed widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Hvac showed widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors showed widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Rubbish Chutes, Incinerators, And Laundry Chu was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing showed a pattern of deficiencies.
Life Safety Code Citation — NFPA requirements: Standards Of Construction For New Existing Nh had no harm potential.
Standard Health Citation — quality of care: Free From Abuse And Neglect was deficient in isolated instances.
Standard Health Citation — quality of care: Reporting Of Alleged Violations showed a pattern of deficiencies.
Standard Health Citation — quality of care: Reporting - National Health Safety Network showed widespread deficiencies and was not yet corrected.
Standard Health Citation — quality of care: Baseline Care Plan was deficient in isolated instances.
Standard Health Citation — quality of care: Drug Regimen Review, Report Irregular, Act On was deficient in isolated instances.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient in isolated instances.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility was deficient in isolated instances.
Standard Health Citation — quality of care: Infection Prevention & Control showed a pattern of deficiencies.
Standard Health Citation — quality of care: License/comply W/ Fed/state/locl Law/prof Std was deficient in isolated instances.
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc. ) was deficient in isolated instances.
Standard Health Citation — quality of care: Quality Of Care was deficient in isolated instances.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Corridor - Doors was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste showed a pattern of deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Emergency Lighting was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure showed a pattern of deficiencies.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors showed a pattern of deficiencies.
Life Safety Code Citation — NFPA requirements: Organization And Administration was deficient in isolated instances.
Life Safety Code Citation — NFPA requirements: Physical Environment showed a pattern of deficiencies.
Standard Health Citation — quality of care: Reporting - National Health Safety Network showed widespread deficiencies and was not yet corrected.
Report Facts
Inspections on page: 11
Total violations/deficiencies cited: 50
Inspections with violations: 7
Inspections without violations: 4
Total complaints: 69
On-site complaint inspections: 13
Complaint citations issued: 15
Enforcement actions: 1
Total fines: 10000
Inspection Report — Nov 4, 2025
Abbreviated Survey CMS
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.
Citations (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 — Apr 11, 2025
Annual Inspection CMS
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.
Citations (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 — Jun 12, 2024
Abbreviated Survey CMS
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.
Citations (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 — Jan 25, 2024
Annual Inspection CMS
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.
Citations (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 — Nov 20, 2020
Annual Inspection CMS
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.
Citations (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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