Inspection Reports for
Northeast Center for Rehabilitation and Brain Injury
300 Grant Ave, Lake Katrine, NY, 12449
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jul 25, 2025
Visit Reason
The facility underwent an abbreviated survey to assess compliance with resident rights, nursing staffing adequacy, and facility-wide assessment requirements.
Findings
The survey found the facility failed to ensure resident dignity and privacy during insulin administration, did not provide sufficient nursing staff to meet resident needs consistently, and lacked a complete and approved facility-wide assessment including staffing for weekends and behavioral health services.
Deficiencies (3)
F 0550: The facility did not ensure Resident #22 was treated with respect and dignity during insulin administration, as the resident self-administered insulin publicly without a prior order for self-administration.
F 0725: The facility did not provide sufficient nursing staff daily to meet resident needs, with staffing frequently below required levels and inadequate coverage on weekends and nights.
F 0838: The facility failed to conduct and document a complete facility-wide assessment including necessary staffing levels for weekends, behavioral health services, and lacked signatures and review dates.
Report Facts
Certified Nurse Aides needed: 26
Certified Nurse Aides needed: 25
Certified Nurse Aides needed: 16
Licensed Practical Nurses needed: 12
Licensed Practical Nurses needed: 10
Residents on unit: 40
Call bell wait time: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Floor Nurse | Observed handing insulin syringe to Resident #22 and allowing self-administration without prior order |
| Unit Manager #2 | Unit Manager | Reported no prior order for Resident #22 to self-administer insulin before 6/24/2025 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about staffing shortages and care delays |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about staffing shortages and care delays |
| Staffing Coordinator | Staffing Coordinator | Provided staffing needs and described staffing challenges |
| Director of Nursing | Director of Nursing | Interviewed about staffing awareness and facility challenges |
| Administrator | Administrator | Interviewed about staffing crisis, incentives, and facility assessment deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Jan 16, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse and to assess staff competency and training related to behavioral health care for residents with complex diagnoses.
Complaint Details
The investigation was complaint-driven, triggered by reports on 1/12/25 that Resident #1 was being physically restrained and abused by a Certified Nursing Assistant. The complaint was substantiated based on interviews, observations, and record reviews.
Findings
The facility failed to ensure that Resident #1 was free from abuse when a Certified Nursing Assistant physically restrained the resident against their will. The facility also failed to provide adequate behavioral health training to agency staff, particularly the Certified Nursing Assistant involved in the incident, who lacked training in de-escalation and behavior management techniques.
Deficiencies (3)
F 0600: The facility did not protect Resident #1 from abuse when a Certified Nursing Assistant held the resident's arms down and prevented them from leaving their room despite multiple staff interventions.
F 0741: The facility failed to ensure staff competency in behavioral health care as agency staff were not trained in managing residents with severe behaviors, including the use of Mandt training.
F 0949: The facility did not provide behavior health training to all staff as determined by facility assessment, excluding agency staff from mandatory behavioral crisis intervention training.
Report Facts
Residents reviewed for abuse: 3
Date of incident: Jan 12, 2025
Date of survey: Jan 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Agency Staff | Involved in physically restraining Resident #1 and lacked behavioral health training |
| Licensed Practical Nurse #1 | Intervened to stop the restraint of Resident #1 | |
| Assistant Director of Nursing | Provided information on staff training and agency staff Mandt training policies | |
| Staff Educator | Reported that agency staff do not receive Mandt training | |
| Director of Nursing | Explained Mandt training requirements and exclusions for agency staff | |
| Administrator | Discussed zero-tolerance policy and agency staff training limitations |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Nov 21, 2024
Visit Reason
The survey was a recertification and abbreviated annual inspection conducted from 11/13/24 to 11/21/24 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, notification of Medicare non-coverage, housekeeping and maintenance, transfer/discharge notifications, baseline care plans, quality of care, nutrition monitoring, staffing levels, nurse aide performance reviews, medication storage, and infection prevention and control.
Deficiencies (11)
F 0550: The facility did not ensure residents were provided a dignified dining experience; a Certified Nurse Aide was observed standing while feeding residents.
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage to residents or their representatives for two residents.
F 0584: The facility did not maintain a safe, clean, and homelike environment; rooms had soiled walls, stained curtains, and feeding tube pumps with dried formula.
F 0623: The facility failed to provide timely written notification of hospital transfers and failed to notify the Ombudsman for multiple residents.
F 0655: Baseline care plans were not developed within 48 hours of admission for three residents.
F 0684: The facility did not provide appropriate treatment and care; a neurology consult was not ordered as recommended and residents had positioning and follow-up care issues.
F 0692: Weight measurements were not obtained timely as per physician order for a resident with significant weight loss.
F 0725: The facility did not ensure sufficient nursing staff on all shifts; staffing was consistently below projected levels affecting resident care.
F 0730: Certified Nurse Aide performance reviews were not completed at least once every 12 months for two aides.
F 0761: Expired medications and an insulin pen beyond 28 days of opening were found; a medication refrigerator containing controlled substances was not secured.
F 0880: The facility did not maintain an infection prevention and control program; symptom tracking of infection was not implemented prior to antibiotic start for two residents.
Report Facts
Residents reviewed: 41
Staffing days reviewed: 32
Weight loss percentage: 9.29
Certified Nurse Aides missing performance reviews: 2
Expired medications found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #18 | Observed standing while feeding residents, related to dignity deficiency. | |
| Rehabilitation Assistant #14 | Responsible for notifying residents/representatives of Medicare Non-Coverage. | |
| Director of Nursing | Interviewed regarding staffing, baseline care plans, and medication storage. | |
| Assistant Director of Nursing #2 | Interviewed regarding baseline care plans, neurology consults, and infection prevention. | |
| Registered Nurse Unit Manager | Interviewed regarding baseline care plans and shower documentation. | |
| Nurse Practitioner #1 | Interviewed regarding admission orders and neurology consults. | |
| Physician #1 | Interviewed regarding follow-up care and weight monitoring. | |
| Director of Human Resources | Interviewed regarding Certified Nurse Aide performance reviews. | |
| Pharmacy Consultant | Interviewed regarding medication cart checks and expired medication monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Nov 21, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 11/13/24 to 11/21/24 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, grievance resolution, abuse prevention, transfer/discharge notification, baseline care plan development, activities of daily living assistance, treatment and care according to orders, fall prevention, nursing staff sufficiency, nurse aide performance reviews, behavioral health services, infection prevention, and pressure ulcer care.
Deficiencies (14)
F 0584: The facility failed to maintain a safe, clean, and homelike environment, with soiled walls, stained privacy curtains, and dried formula on feeding tube pumps for several residents.
F 0585: The facility did not make prompt efforts to resolve grievances or inform complainants of investigation outcomes for two residents.
F 0600: The facility failed to protect residents from abuse; a resident with a history of aggression punched another resident, and staff failed to implement care plans and report verbal aggression.
F 0623: The facility did not provide timely notification to residents, representatives, and the Ombudsman before transfers or discharges to the hospital for multiple residents.
F 0655: Baseline care plans were not developed and implemented within 48 hours of admission for three residents.
F 0677: The facility failed to provide scheduled showers for two residents dependent on assistance, with documentation showing multiple missed showers over several months.
F 0684: The facility did not provide appropriate treatment and care according to orders; a resident did not receive a neurology consultation as ordered, and another resident was improperly positioned in a wheelchair.
F 0686: The facility failed to prevent pressure ulcers; a resident was admitted with redness to the buttocks but did not receive timely skin assessments and developed a stage 3 sacral pressure ulcer.
F 0689: The facility failed to ensure adequate supervision and assistance to prevent accidents; a resident requiring two-person assist was transferred by one staff member, resulting in a fall and head laceration requiring staples.
F 0711: The facility did not ensure the resident's doctor reviewed and verified medication orders accurately at admission; a resident's medication orders were incorrectly transcribed and not reviewed by the Nurse Practitioner.
F 0725: The facility did not provide sufficient nursing staff consistently to meet resident needs; staffing was below projected levels on multiple occasions, impacting resident care.
F 0730: The facility failed to complete annual performance reviews for two Certified Nurse Aides as required.
F 0740: The facility did not ensure a resident received necessary behavioral health services; a resident diagnosed with bipolar disorder was not evaluated by a psychiatrist as ordered.
F 0880: The facility did not maintain an infection prevention and control program to track infection symptoms prior to antibiotic initiation for two residents.
Report Facts
Days of missed showers: 30
Number of grievances not documented: 6
Number of residents reviewed: 41
Staffing shortfalls: 32
Staples required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Nurse Practitioner | Responsible for medication reconciliation and ordering consults for Resident #677. |
| Certified Nurse Aide #25 | Certified Nurse Aide | Attempted transfer alone of Resident #234 resulting in fall and head injury. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Regularly provided care to Resident #212 and admitted to missing scheduled showers. |
| Director of Nursing | Director of Nursing | Oversaw staffing and care plan compliance; acknowledged issues with shower documentation. |
| Assistant Director of Nursing #2 | Assistant Director of Nursing / Infection Preventionist / Wound Care Nurse | Responsible for wound care assessments and infection prevention program. |
| Physician #1 | Physician | Interviewed regarding follow-up consultations and care plan oversight. |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Managed shower schedules and addressed complaints for Resident #212. |
| Administrator | Administrator | Suspended and terminated CNA #25 for failure to follow care plan. |
| Director of Human Resources | Director of Human Resources | Responsible for tracking Certified Nurse Aide performance reviews. |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Mar 22, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of physical abuse involving Resident #1 and to assess compliance with abuse prevention, reporting, and care planning regulations.
Findings
The facility failed to protect Resident #1 from physical abuse by a Community Support Specialist who hit the resident after being struck with food. The facility also failed to timely report the abuse investigation results to the state and did not develop a comprehensive care plan to prevent abuse for Resident #1.
Deficiencies (3)
F 0600: The facility did not ensure residents' rights to be free from physical abuse. Resident #1 was hit in the face by a Community Support Specialist after throwing food on them. The abuse was unsubstantiated due to reactive nature, lack of injury, and lack of willful intent.
F 0609: The facility did not timely report the results of the abuse investigation to the New York State Department of Health within 5 working days. The 5-day report was submitted 2 days late.
F 0656: The facility did not develop or implement a comprehensive person-centered care plan for Resident #1, who was at risk for abuse and exhibited physical and verbal aggression. The potential victim of abuse care plan was not initiated until the day of the incident.
Report Facts
Residents reviewed for abuse: 3
5-day report submission delay: 2
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Witnessed the abuse incident involving Resident #1 | |
| Licensed Practical Nurse | Witnessed the abuse incident involving Resident #1 | |
| Community Support Specialist | Perpetrator who hit Resident #1 in the face | |
| Administrator | Provided statements about the incident and reporting | |
| Director of Nursing | Oversaw response to the incident and care plan initiation | |
| Director of Community Support Specialists | Commented on staff responsibilities and behavior management | |
| Registered Nurse Unit Manager | Provided information on care plan initiation and staff roles | |
| Assistant Director of Nursing | Described care plan initiation responsibilities |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Dec 27, 2023
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with medication administration, nutrition, and food safety regulations at the nursing home.
Findings
The facility failed to ensure timely and complete medication administration for two residents, including missed doses of Dronabinol and Bupropion without proper documentation or notification. Additionally, the facility did not provide a resident with double portions as ordered and failed to properly label and date refrigerated food items.
Deficiencies (4)
F 0755: The facility did not ensure pharmaceutical services met residents' needs, resulting in Resident #2 missing 46 doses of Dronabinol and Resident #5 missing 8 doses of Bupropion without documentation of reasons or physician notification.
F 0760: The facility did not ensure residents were free from significant medication errors, with missed doses of prescribed medications for Residents #2 and #5 and lack of documentation for missed doses.
F 0800: Resident #5 did not receive double portions as per dietary recommendations, physician order, and meal ticket during observed meals.
F 0812: The facility did not ensure proper storage of refrigerated food; food items in the walk-in refrigerator were unlabeled and undated, violating food safety standards.
Report Facts
Missed doses of Dronabinol: 46
Missed doses of Bupropion: 8
Residents reviewed for medication administration: 3
Residents reviewed for food and meals: 5
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Nov 2, 2023
Visit Reason
The abbreviated survey was conducted to review compliance with regulations related to resident abuse, neglect, timely reporting of abuse, and appropriate treatment and care.
Findings
The facility failed to ensure residents were free from abuse and neglect during a resident-to-resident altercation resulting in injury. The facility also failed to timely report the alleged abuse to the State Survey Agency and did not perform required monthly weights for a resident as ordered by the physician.
Deficiencies (3)
F 0600: The facility did not ensure 2 of 4 residents were free from abuse and neglect after a resident-to-resident altercation resulted in injury to one resident.
F 0609: The facility failed to timely report suspected abuse and the results of the investigation to proper authorities for 1 resident involved in a resident-to-resident altercation.
F 0684: The facility did not ensure necessary monitoring was performed to maintain weight and prevent loss for 1 resident, as monthly weights ordered by the physician were not consistently carried out.
Report Facts
Weights documented: 6
Residents reviewed for abuse and neglect: 4
Residents reviewed for nutrition: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #3 | Unit Manager | Interviewed regarding resident altercation and behavior. |
| Nurse Practitioner #2 | Nurse Practitioner | Interviewed regarding assessment and reporting of incident. |
| Director of Nursing | Director of Nursing | Interviewed regarding behavior monitoring and incident investigation. |
| Administrator | Administrator | Interviewed regarding abuse investigation and reporting decisions. |
| Assistant Administrator | Assistant Administrator | Interviewed regarding behavior care plans and monitoring. |
| Dietician Tech | Dietician Technician | Interviewed regarding weight monitoring and documentation. |
| Certified Nurses Assistant #1 | Certified Nurses Assistant | Interviewed regarding resident incident and weight monitoring. |
| Certified Nurses Assistant #2 | Certified Nurses Assistant | Interviewed regarding resident weight monitoring procedures. |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding awareness of resident weight monitoring. |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Aug 25, 2023
Visit Reason
The visit was an abbreviated survey to evaluate compliance with regulatory requirements related to resident care, restraint use, pressure ulcer prevention and treatment, and environmental safety.
Findings
The facility failed to ensure proper use and assessment of physical restraints for residents, resulting in inappropriate restraint use without physician orders or proper care plans. Resident #4 developed multiple pressure ulcers due to inadequate pressure relieving interventions and inconsistent implementation of care plans. The facility also failed to maintain a safe, clean, and comfortable environment in bathing/shower rooms, with issues such as missing tiles, stained shower curtains, and debris on floors.
Deficiencies (3)
F 0604: The facility did not ensure restraints were the least restrictive and reassessed regularly for 2 of 5 residents. Resident #4 and #5 had restraints without consistent assessments or physician orders.
F 0686: Resident #4 was not provided adequate pressure ulcer care, resulting in multiple pressure ulcers. Pressure relieving devices were inconsistently used and care plans were not re-evaluated for effectiveness.
F 0921: The facility did not maintain bathing/shower rooms in a safe, clean, and comfortable condition. Rooms had missing and cracked tiles, stained shower curtains, and debris on floors.
Report Facts
Residents reviewed for restraint use: 5
Residents reviewed for pressure ulcers: 5
Bathing/shower rooms observed: 3
Date of survey completion: Aug 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #15 | Unit Manager | Provided information on restraint assessments and wound care. |
| LPN #13 | Licensed Practical Nurse | Documented restraint use and family interactions regarding Resident #4. |
| RN #2 | Registered Nurse | Participated in wound care rounds and provided wound assessments. |
| NP #18 | Nurse Practitioner | Conducted weekly wound rounds and made treatment recommendations. |
| Housekeeping Manager #8 | Housekeeping Manager | Discussed cleaning and maintenance of bathing/shower rooms. |
| Director of Maintenance #9 | Director of Maintenance | Responsible for repairs in bathing/shower rooms. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 25, 2022
Visit Reason
The inspection was a Recertification survey conducted from 5/16/2022 to 5/25/2022 to assess compliance with regulatory standards for the nursing home.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing and implementing comprehensive person-centered care plans, providing appropriate treatment and care according to orders and resident preferences, and ensuring a nursing home area free from accident hazards including proper maintenance of an electric wheelchair.
Deficiencies (4)
F 0584: The facility failed to maintain a safe, clean, and homelike environment on the Vent unit, with sticky floors and dried tube feeding residue on the floor, tube feeding pole, and machine in one resident's room.
F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives for two residents, including a plan for cleaning a resident's room with refusal of care and a plan addressing the use of a long call bell for a resident with aggressive behaviors.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for one resident, who was discharged with a bowel obstruction after inconsistent documentation of bowel movements and delayed physician notification.
F 0689: The facility did not ensure an environment free from accident hazards by failing to provide maintenance to a resident's electric wheelchair as per the manufacturer's specifications, contributing to a fire incident.
Report Facts
Dates of bowel status documentation missing: 15
Dates of Recertification Survey: Survey conducted from 5/16/2022 to 5/25/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Responsible for cleaning resident rooms and equipment including tube feeding poles; interviewed regarding cleaning deficiencies | |
| Housekeeper #2 | Floats throughout facility; responsible for cleaning floors and tube feeding poles; interviewed about cleaning oversight | |
| Housekeeper #3 | Assigned to clean Resident #108's room; reported difficulties due to resident's verbal aggression | |
| Registered Nurse (RN #2) | Registered Nurse | Interviewed regarding lack of behavior care plan and cleaning issues for Resident #108 |
| Director of Social Work | Director of Social Work | Interviewed about behavior care plan absence and resident's verbal abuse |
| Activity Aide #1 | Activity Aide | Interviewed about use of long call bell by Resident #403 |
| RN #3 | Registered Nurse | Interviewed about call bell safety for residents |
| RN #4 | Registered Nurse | Interviewed about safety assessments for call bells |
| Director of Nursing (DON) | Director of Nursing | Interviewed about management of unit and care plan issues |
| Brain Injury Director | Brain Injury Director | Interviewed about call bell use and room audits |
| Licensed Practical Nurse (LPN #1) | Licensed Practical Nurse | Documented nursing progress notes regarding Resident #253's bowel status |
| Licensed Practical Nurse (LPN #2) | Licensed Practical Nurse | Documented nursing progress notes and interviewed about Resident #253's condition and hospital transfer |
| Licensed Practical Nurse (LPN #3) | Licensed Practical Nurse | Documented nursing progress notes regarding Resident #253's symptoms |
| Licensed Practical Nurse (LPN #4) | Licensed Practical Nurse/Unit Manager | Documented nursing progress notes and involved in care of Resident #253 |
| Certified Nursing Assistant (CNA #1) | Certified Nursing Assistant | Interviewed about Resident #253's care and bowel movement documentation |
| Assistive Technology Practitioner (ATP) | Assistive Technology Practitioner | Interviewed about wheelchair repairs and inspections |
| Rehab Tech (RT) | Rehab Technician | Interviewed about wheelchair repairs and fire incident |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Feb 7, 2019
Visit Reason
The inspection was conducted as part of the most recent recertification (annual) survey of the Northeast Center for Rehabilitation and Brain Injury.
Findings
The facility was found deficient in multiple areas including failure to protect resident property, untimely reporting of alleged sexual abuse, failure to notify residents and representatives in writing about hospital transfers and bed hold policies, inadequate pressure ulcer prevention care, and improper food handling practices in the kitchen.
Deficiencies (6)
F 0584: The facility did not exercise reasonable care to protect Resident #36's clothing, which was lost after admission and not reimbursed timely.
F 0609: The facility failed to timely report an alleged sexual abuse incident involving Residents #219 and #43 within the required two-hour timeframe.
F 0623: The facility did not provide timely written notification to residents, representatives, and the Ombudsman for hospital transfers for 4 residents (#149, #181, #212, #265).
F 0625: The facility failed to notify residents or representatives in writing about the bed hold policy prior to discharge or transfer for 4 residents (#149, #181, #212, #265).
F 0686: The facility did not ensure pressure ulcer prevention care was provided as ordered; Resident #194 was not provided off-loading booties as prescribed.
F 0812: Dietary staff failed to perform proper hand hygiene while preparing food, repeatedly donning gloves without washing hands.
Report Facts
Residents reviewed for hospitalization/discharge notification: 4
Residents reviewed for pressure ulcer care: 3
Residents affected by clothing loss: 1
Residents affected by sexual abuse reporting deficiency: 2
Inspection Report
Capacity: 60
Deficiencies: 0
Date: Inspection Report
Visit Reason
Summary of inspection history and citations for Northeast Center for Rehabilitation and Brain Injury
Findings
No citations or enforcement actions reported from October 1, 2021 through September 30, 2025
Report Facts
Total inspections: 0
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