Inspection Reports for
Nyack Ridge Rehabilitation and Nursing Center
476 Christian Herald Road, Valley Cottage, NY, 10989
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
20.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
304% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 4, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with safety protocols following an incident involving a mechanical lift that caused injury to a resident.
Findings
The facility failed to ensure a safe environment free from accident hazards during a mechanical lift transfer, resulting in a resident sustaining a head laceration requiring hospital treatment. Staff involved had not received training on the new mechanical lift prior to the incident.
Deficiencies (1)
F 0689: The facility did not ensure the residents' environment was free from accident hazards during mechanical lift transfers. Resident #1 was injured when a new mechanical lift tilted and struck their head, causing a laceration requiring hospital care.
Report Facts
Staff trained on mechanical lift: 34
Staples required: 3
Date of incident: Aug 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Involved in the mechanical lift transfer incident causing resident injury | |
| Certified Nurse Aide #2 | Involved in the mechanical lift transfer incident causing resident injury | |
| Registered Nurse #7 | Registered Nurse Supervisor | Documented and assessed Resident #1 after the incident |
| Director of Maintenance | Oversaw mechanical lift assembly and inspection after incident | |
| Nurse Educator | Provided training on the mechanical lift after the incident | |
| Administrator | Administrator | Reported on incident and staff training following the event |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: Jan 14, 2025
Visit Reason
Multiple standard health and life safety code deficiencies identified, all corrected by March 13, 2025.
Findings
Multiple standard health and life safety code deficiencies identified, all corrected by March 13, 2025.
Deficiencies (22)
Antibiotic stewardship program
Criminal history record check process
Discharge summary
Encoding/transmitting resident assessments
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Grievances
Infection prevention & control
Label/store drugs and biologicals
Maintains effective pest control program
Medicaid/medicare coverage/liability notice
Nurse aide peform review-12 hr/yr in-service
Nutrition/hydration status maintenance
Pasarr screening for md & id
Quality of care
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Right to be free from physical restraints
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Treatment/service for dementia
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as part of the Recertification and abbreviated survey to assess compliance with regulatory requirements for Nyack Ridge Rehabilitation and Nursing Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring proper discharge planning and communication, providing appropriate treatment and care according to physician orders, and maintaining adequate nursing staff levels. Multiple environmental issues were observed on the 3rd floor, discharge summaries were incomplete or missing for several residents, one resident did not receive prescribed eye drops as ordered, and staffing shortages were reported and documented.
Deficiencies (4)
F 0584: The facility failed to maintain a safe, clean, and homelike environment on the 3rd floor, evidenced by pervasive foul odors, stained and soiled furniture and bathrooms, damaged walls, and broken fixtures.
F 0661: The facility did not ensure completion of discharge summaries and adequate discharge planning for 3 residents, including incomplete communication of medication instructions and lack of documentation of discharge summaries.
F 0684: Resident #107 did not receive prescribed eye drops as ordered after cataract surgeries, with documented refusals and delays in administration.
F 0725: The facility did not provide sufficient nursing staff consistently to meet resident needs, with documented understaffing on all shifts and reports of delayed care and overtime work by staff.
Report Facts
Days understaffed: 30
Residents reviewed for discharge: 3
Residents reviewed for quality of care: 30
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Jan 14, 2025
Visit Reason
Recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, notification of Medicare coverage changes, environmental cleanliness and maintenance, grievance process awareness, use of physical restraints, timely submission of resident assessments, PASARR screening, discharge planning and summaries, pressure ulcer care, accident hazard prevention, nursing staff sufficiency, nurse aide performance evaluations, dementia care, medication storage, food safety, infection control, antibiotic stewardship, and pest control.
Deficiencies (19)
F 0550: Facility staff did not ensure residents had a dignified dining experience; staff were observed standing over residents while assisting with meals.
F 0582: Facility failed to provide proper notice of changes in Medicare coverage to a cognitively impaired resident and their family, and did not use certified mail to confirm delivery of notices.
F 0584: The 3rd Floor was observed with pervasive foul odors, stained and damaged fixtures, soiled resident rooms and common areas, and maintenance issues impacting a homelike environment.
F 0585: Facility did not ensure residents were aware of the grievance process; signage and information were lacking and residents and staff were unaware of grievance forms and procedures.
F 0604: Resident #25 was restrained with a concave mattress to prevent falls without documented physician order; restraint use was not justified as medically necessary.
F 0640: Eleven resident Minimum Data Set assessments were not submitted to CMS within 14 days of completion as required.
F 0645: Resident #245 was discharged without complete discharge summary or instructions; family was not provided notice or opportunity to appeal discharge; discharge planning was inadequate.
F 0686: Resident #25 did not receive pressure relieving devices as ordered; wound care nurse failed to follow proper hand hygiene and barrier precautions during wound care.
F 0689: Resident #44 was fed a mechanically altered diet by unqualified and unsupervised staff; feeding assistance was provided by a transporter without required training or supervision.
F 0692: Residents #80 and #25 had significant weight loss; interventions to address weight loss were not adequately identified, implemented, or monitored.
F 0695: Residents #46 and #107 received oxygen therapy at 3 liters per nasal cannula despite physician orders for 2 liters; tubing and humidifier bottles were not dated or changed as required.
F 0725: Facility was understaffed on all shifts from December 6, 2024 through January 6, 2025; residents and family reported insufficient staff and delayed responses; staff reported frequent overtime.
F 0730: Six Certified Nurse Aides had not received performance evaluations at least once every 12 months.
F 0744: Resident #30 with dementia did not receive person-centered dementia care or meaningful activities; gradual dose reduction of antipsychotic medication was not implemented per psychiatry recommendations; Resident #122 lacked meaningful activities to enhance wellbeing.
F 0761: Medication storage room contained expired, undated, and open food and medications; refrigerator temperature was above acceptable range.
F 0812: Food storage and preparation practices were unsafe; undated and expired food items found; hot food held below required temperature; cold food held above required temperature.
F 0880: Wound care nurse failed to perform proper hand hygiene and barrier precautions during wound care on Resident #25; Certified Nurse Aide failed to follow enhanced barrier precautions for Resident #69; Resident #121's catheter bag was on the floor.
F 0881: Facility did not implement an antibiotic stewardship program with protocols and monitoring; documentation of antibiotic use was incomplete and not up to date.
F 0925: Facility kitchen had live and dead roaches; pest control program was ineffective; pest control service was unable to service kitchen on one occasion.
Report Facts
Deficiencies cited: 19
Weight loss percentage: 15.68
Weight loss percentage: 14.11
Staffing understaffed days: 30
Temperature: 114
Temperature: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #22 | Named in dignity during dining deficiency and feeding assistance observation | |
| Certified Nurse Aide #28 | Named in dignity during dining deficiency | |
| Nurse Educator/Infection Control Preventionist | Nurse Educator/Infection Control Preventionist | Interviewed regarding feeding assistance and infection control |
| Director of Social Work | Director of Social Work | Interviewed regarding grievance process, discharge planning, psychiatry consult communication, and dementia care |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, antibiotic stewardship, psychiatry consult communication, and dementia care |
| Certified Nurse Aide #15 | Named in infection control deficiency for failure to follow enhanced barrier precautions | |
| Wound Care Nurse | Wound Care Nurse | Observed and interviewed regarding wound care hand hygiene and barrier precautions |
| Food Service Director | Food Service Director | Interviewed regarding food storage and safety |
| Licensed Practical Nurse #9 | Interviewed regarding medication storage and oxygen therapy | |
| Licensed Practical Nurse #21 | Interviewed regarding dementia care and feeding assistance | |
| Transporter #23 | Observed and interviewed regarding feeding assistance and dementia activities | |
| Dietician | Dietician | Interviewed regarding nutritional care and weight loss |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection control and antibiotic stewardship |
| Human Resources/Staffing Coordinator | Human Resources/Staffing Coordinator | Interviewed regarding staffing and nurse aide performance evaluations |
| Nurse Educator | Nurse Educator | Interviewed regarding nurse aide performance evaluations and feeding assistance |
| Psychiatry Nurse Practitioner | Psychiatry Nurse Practitioner | Interviewed regarding psychiatry consult and medication recommendations |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding psychiatry consult communication and medication management |
| Director of Maintenance | Director of Maintenance | Interviewed regarding pest control services |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding environmental cleanliness and odor |
| Administrator | Administrator | Interviewed regarding environmental concerns, discharge planning, and antibiotic stewardship |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Apr 25, 2024
Visit Reason
Standard health citations related to investigation and reporting of alleged violations and resident records; all corrected by June 18, 2024.
Findings
Standard health citations related to investigation and reporting of alleged violations and resident records; all corrected by June 18, 2024.
Deficiencies (3)
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Apr 25, 2024
Visit Reason
The visit was an abbreviated survey conducted to evaluate compliance with regulations related to abuse reporting, investigation, and medical record accuracy following an alleged abuse incident involving Resident #1 and the facility podiatrist on 3/28/2024.
Findings
The facility failed to timely report an alleged abuse incident to the State Survey Agency and other required authorities. The investigation of the alleged abuse was incomplete, lacking proper incident reports, timely interviews, and documented assessments. Resident #1's medical record did not contain a documented skin assessment post-incident. The facility concluded no abuse was substantiated, but failed to meet regulatory requirements for reporting and documentation.
Deficiencies (3)
F 0609: The facility did not ensure timely reporting of suspected abuse involving Resident #1 and the podiatrist to the State Survey Agency and other authorities as required by regulation.
F 0610: The facility did not thoroughly investigate the alleged abuse incident involving Resident #1, failing to complete an accident/incident report, conduct timely interviews, or document skin assessments.
F 0842: The facility failed to maintain accurate medical records for Resident #1, lacking documentation of a skin assessment following the alleged abuse incident on 3/28/2024.
Report Facts
Residents reviewed: 3
Resident #1 BIMS score: 0
Date of alleged incident: Mar 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Registered Nurse Wound Care Nurse | Provided statement about witnessing the incident and reporting concerns |
| Staff #3 | Registered Nurse Unit Manager | Completed skin assessment post-incident but did not document it |
| Director of Nursing | Conducted investigation and obtained verbal statements regarding the incident | |
| Administrator | Informed of the incident and involved in investigation and decision not to report to State | |
| Wound Care Doctor | Witnessed incident and reported concerns to administration |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
One standard health citation for reporting to national health safety network with no correction noted.
Findings
One standard health citation for reporting to national health safety network with no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Sep 28, 2023
Visit Reason
Multiple standard health and life safety code citations including a Level 4 immediate jeopardy for accident hazards; all corrected by November 1, 2023.
Findings
Multiple standard health and life safety code citations including a Level 4 immediate jeopardy for accident hazards; all corrected by November 1, 2023.
Deficiencies (19)
Discharge summary
Entering into binding arbitration agreements
Facility assessment
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Infection prevention & control
Infection preventionist qualifications/role
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Menus meet resident nds/prep in adv/followed
Quality of care
Resident rights/exercise of rights
Treatment/srvcs mental/psychoscial concerns
Develop ep plan, review and update annually
Electrical systems - maintenance and testing
Electrical systems - other
Fire drills
Hazardous areas - enclosure
Ramps and other exits
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 25, 2023
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with professional standards of practice and regulatory requirements.
Findings
The facility failed to ensure appropriate treatment and care for residents, including timely orthopedic follow-up, proper medication administration, and adequate wheelchair positioning. Additionally, pharmaceutical services were deficient with expired, discontinued, and unsecured medications found on medication carts and in medication rooms.
Deficiencies (3)
F 0684: The facility did not ensure timely orthopedic follow-up for Resident #129 after x-ray revealed a healing right humeral neck fracture. Resident #150 was administered discontinued Lorazepam without a physician order. Resident #119 was not referred for a rehabilitation screen despite multiple observations of legs hanging off wheelchair footrests.
F 0758: The facility did not ensure that Resident #150's drug regimen was free of unnecessary medications, as Lorazepam was administered without a valid physician order after discontinuation.
F 0761: The facility failed to ensure drugs and biologicals were labeled and stored properly; expired, undated, and discontinued medications were found on medication carts and in medication rooms, and medications were left unattended and unsecured.
Report Facts
Medication administrations: 6
Dates of survey: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor #3 | Medical Doctor | Commented on Lorazepam medication error for Resident #150 |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Administered Lorazepam to Resident #150 after order discontinuation |
| Registered Nurse Manager #1 | Registered Nurse Manager | Discussed physiatrist consult and medication cart observations |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed orthopedic consult order delay and medication errors |
| Physical Therapist #1 | Physical Therapist | Explained wheelchair positioning and referral process |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Observed medication cart issues and handling of discontinued narcotics |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Observed leaving medication blister pack unattended |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Sep 25, 2023
Visit Reason
The survey was conducted as a recertification and extended survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, investigation of accidents, treatment and care according to orders, fall prevention and supervision, medication management, infection control, and facility-wide assessments. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (14)
F 0550: The facility failed to ensure residents had the right to a dignified dining experience; Resident #146 was served late and Residents #88 and #89 were referred to as 'feeders' by the ADON in the presence of residents.
F 0610: The facility did not conduct a thorough investigation for Resident #129's healing humeral neck fracture to determine the root cause.
F 0661: The facility failed to develop discharge summaries for 2 of 3 residents reviewed, including Residents #156 and #157, compromising safe transitions of care.
F 0684: The facility did not ensure appropriate treatment and care for Residents #129, #150, and #119, including failure to ensure timely orthopedic follow-up, administration of discontinued medication, and lack of rehabilitation screening for wheelchair positioning.
F 0689: The facility failed to provide adequate supervision and assistance to prevent falls for Residents #129 and #145, resulting in actual harm and immediate jeopardy.
F 0689 (follow-up): The facility implemented corrective actions including staff training, monitoring, and updated care plans for fall prevention.
F 0742: The facility failed to ensure Resident #9 received appropriate treatment and psychiatric follow-up for mental health conditions, including a delayed psychological evaluation.
F 0758: The facility administered Lorazepam to Resident #150 after the medication was discontinued and without a valid physician order.
F 0761: The facility failed to ensure medications were properly labeled, stored, and secured; expired, undated, and discontinued medications were found on medication carts and in medication rooms, and medications were left unattended.
F 0803: The facility did not ensure Resident #77 received menu items and preferences as listed on meal tray tickets, including failure to serve the tray early as requested.
F 0838: The facility did not update the facility-wide assessment annually to determine resources necessary for competent resident care during day-to-day operations and emergencies.
F 0847: The facility did not provide residents or their representatives the right to rescind binding arbitration agreements within 30 days of signing for 3 residents reviewed.
F 0880: The facility failed to maintain infection control interventions for Resident #408; the foley catheter tubing and drainage bag were observed touching the floor.
F 0882: The facility's designated Infection Preventionist did not complete specialized infection prevention training prior to assuming the role.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Staff training coverage: 88
Fall risk assessment scores: 24
Fall risk assessment scores: 20
Fall risk assessment scores: 16
Fall risk assessment scores: 20
Fall risk assessment scores: 21
Fall risk assessment scores: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor #3 | Medical Doctor | Named in medication error finding related to Lorazepam administration to Resident #150 |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in dignified dining and medication error findings |
| Registered Nurse Manager #1 | Registered Nurse Manager | Named in orthopedic follow-up and fall prevention findings |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in medication administration error for Lorazepam |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Named in mental health treatment deficiency for Resident #9 |
| Director of Nursing | Director of Nursing | Named in infection preventionist training and dignified dining findings |
| Certified Nurse Aide #2 | Certified Nurse Aide | Named in fall prevention findings |
| Physical Therapist Director | Director of Physical Therapy | Named in fall prevention findings |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Jun 12, 2023
Visit Reason
Standard health citations related to bowel/bladder incontinence, nurse aide registry, staffing info, quality of care, and environment; all corrected by September 1, 2023.
Findings
Standard health citations related to bowel/bladder incontinence, nurse aide registry, staffing info, quality of care, and environment; all corrected by September 1, 2023.
Deficiencies (5)
Bowel/bladder incontinence, catheter, uti
Nurse aide registry verification, retraining
Posted nurse staffing information
Quality of care
Safe/clean/comfortable/homelike environment
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Jun 12, 2023
Visit Reason
The facility underwent an abbreviated survey to assess compliance with regulatory standards related to resident care, environment safety, staffing, and certification.
Findings
The survey identified multiple deficiencies including disrepair of resident room air conditioners, failure to perform timely pacemaker checks, inadequate catheter care documentation, employment of a CNA with an expired certification, and failure to post daily nurse staffing and census information.
Deficiencies (5)
F 0584: The facility failed to maintain a safe, clean, and homelike environment as 7 resident room air conditioners were in disrepair with duct tape used to seal gaps, causing drafts.
F 0684: The facility failed to ensure Resident #2's pacemaker was checked every 3 months as ordered, lacking consistent documentation of required monitoring.
F 0690: The facility failed to provide adequate evidence that Residents #1, #3, and #4 received Foley catheter care per professional standards and physician orders.
F 0729: The facility allowed CNA #1 to work with an expired New York State Department of Health certification for 602 days.
F 0732: The facility failed to post current census and actual nursing staff hours daily in a prominent, accessible location as required by regulation.
Report Facts
Resident room air conditioners in disrepair: 7
Residents reviewed for pacemaker care: 3
Residents reviewed for Foley catheter care: 4
Residents affected by Foley catheter care deficiency: 3
Days CNA worked with expired certification: 602
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Worked with expired New York State Department of Health certification |
| Director of Nursing | Director of Nursing | Interviewed regarding pacemaker checks, catheter care, staffing postings, and CNA certification issues |
| Human Resources Director | Human Resources Director | Interviewed regarding CNA #1 certification oversight |
| Certified Nursing Assistant (CNA #2) | Certified Nursing Assistant | Interviewed regarding air conditioner drafts and duct tape use |
| Certified Nursing Assistant (CNA #4) | Certified Nursing Assistant | Interviewed regarding documentation of Foley catheter care |
| Administrator | Administrator | Interviewed regarding maintenance director resignation and facility maintenance issues |
| Facility Maintenance Employee | Facility Maintenance Employee | Interviewed regarding air conditioner repairs and duct tape use |
| Front Desk Attendant | Front Desk Attendant | Interviewed regarding staffing posting responsibilities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
One standard health citation for accident hazards corrected by April 11, 2023.
Findings
One standard health citation for accident hazards corrected by April 11, 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 8, 2022
Visit Reason
Standard health citations for notification of changes and pressure ulcer treatment corrected by August 25, 2022.
Findings
Standard health citations for notification of changes and pressure ulcer treatment corrected by August 25, 2022.
Deficiencies (2)
Notify of changes (injury/decline/room, etc. )
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 14, 2022
Visit Reason
One standard health citation for quality of care corrected by April 25, 2022.
Findings
One standard health citation for quality of care corrected by April 25, 2022.
Deficiencies (1)
Quality of care
Inspection Report
Deficiencies: 0
Date: Feb 19, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Nyack Ridge Rehabilitation and Nursing Center following a survey completed on February 19, 2020.
Findings
No health deficiencies were found during the survey.
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