Inspection Reports for
Salem Hills Rehabilitation and Healthcare
539 NY-22, Purdys, NY 10578, NY, 10578
Back to Facility Profile5 Reports
Inspection Report — Apr 28, 2026
Complaint Investigation State
Date: Apr 28, 2026
Visit Reason
State-compiled facility profile showing 4 inspections from 2023 to 2026 with deficiency and enforcement history.
Complaint Details
The state logged 17 complaints about this facility; 4 led to on-site inspections.
Findings
Across 4 inspections, 22 citations were issued including 15 standard health and 7 life safety code citations. One inspection found no citations; 17 complaints were logged with 4 on-site inspections and 1 enforcement action recorded.
Citations (22)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Bedrails were cited for deficiencies.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was deficient.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient.
Life Safety Code Citation — NFPA requirements: Discharge From Exits was deficient.
Life Safety Code Citation — NFPA requirements: Physical Environment was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie was deficient.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient.
Standard Health Citation — quality of care: Increase/prevent Decrease In Rom/mobility was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Standard Health Citation — quality of care: Reasonable Accommodations Needs/preferences was deficient.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer was deficient.
Life Safety Code Citation — NFPA requirements: Discharge From Exits was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste was deficient.
Life Safety Code Citation — NFPA requirements: Fire Drills was deficient.
Life Safety Code Citation — NFPA requirements: Smoking Regulations was deficient.
Standard Health Citation — quality of care: Free From Abuse And Neglect was deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was deficient.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 22
Inspections with violations: 3
Inspections without violations: 1
Plan of correction counts: 22
Total fines: 2000
Number of enforcement actions: 1
Total complaints: 17
On-site complaint inspections: 4
Citations issued from complaints: 4
Inspection Report — May 16, 2024
Annual Inspection CMS
Date: May 16, 2024
Visit Reason
The inspection was a recertification survey conducted from 5/9/2024 to 5/16/2024 to assess compliance with regulatory requirements for Salem Hills Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident dignity, call bell accessibility, care planning, treatment and care, pressure ulcer prevention, range of motion maintenance, accident prevention, medication administration safety, and infection prevention and control. Several residents were observed with unmet needs or unsafe conditions, and staff interviews confirmed lapses in policy adherence and supervision.
Citations (8)
Residents #33 and #105 were not treated with respect and dignity; Resident #33 wore socks with visible name labels and Resident #105 had photographs depicting positioning devices visible from the door.
Resident #123's call bell was not within reach on multiple occasions.
Resident #3 did not have a comprehensive care plan for self-medication administration.
Resident #57 was observed multiple times without a footrest extender on their wheelchair as ordered.
Residents #33 and #105 did not receive appropriate pressure ulcer prevention care; Resident #33's right heel rested on metal footrest and Resident #105 lacked prescribed cushions.
Resident #89 did not receive 1:1 supervision as required, resulting in a fall; Residents #72 and #3 had medications and creams left unattended in their rooms on a dementia unit.
Resident #89 was observed on multiple occasions without the ordered right resting hand splint.
Staff failed to perform proper hand hygiene during dining assistance for Resident #21; infection surveillance and water management plan were inadequate or outdated.
Report Facts
Residents reviewed for dignity: 3
Residents reviewed for environment: 5
Residents reviewed for accidents: 7
Residents reviewed for pressure ulcers: 8
Residents reviewed for positioning: 3
Residents reviewed for range of motion: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Licensed Practical Nurse | Stated policy on clothing labels and dignity issue with visible name labels on socks |
| Staff #6 | Certified Nurse Aide | Reported socks labeled on outside and did not report to nursing |
| Staff #7 | Licensed Practical Nurse Charge Nurse | Acknowledged dignity issue with socks labeling |
| Staff #23 | Physical Therapist | Explained use of photographs for positioning devices |
| Director of Rehabilitation | Stated photographs should be placed inside closet door and discussed wheelchair footrest positioning | |
| Staff #24 | Registered Nurse | Described use of photographs for positioning devices |
| Staff #14 | Certified Nurse Aide | Stated call bells should be within reach |
| Staff #22 | Registered Charge Nurse | Stated call bells must be within reach and care plans updated timely |
| Assistant Director of Nursing | Discussed creams left in resident rooms and infection preventionist duties | |
| Staff #5 | Certified Nurse Aide | Forgot to apply footrest extender |
| Staff #11 | Certified Nurse Aide | Unaware of footrest extender requirement |
| Staff #10 | Physical Therapist | Observed not washing hands before meal assistance |
| Staff #12 | Licensed Practical Nurse | Left medications unattended in resident room |
| Staff #21 | Registered Nurse | Reported certified nurse aide left 1:1 supervision resident unattended |
| Staff #13 | Licensed Practical Nurse Supervisor | Educated certified nurse aide on 1:1 supervision requirements |
| Staff #17 | Certified Nurse Aide | Admitted leaving 1:1 supervision resident unattended |
| Staff #25 | Certified Nurse Aide | Reported offloading heels and positioning devices |
| Staff #3 | Certified Nurse Aide | Did not apply resident's right hand splint because it was dirty |
| Staff #4 | Registered Nurse | Unaware resident was not wearing right hand splint |
| Nurse Practitioner | Discussed medication safety and self-medication assessment | |
| Director of Nursing | Discussed call bell accessibility, medication safety, infection control, and supervision issues |
Inspection Report — Feb 10, 2023
Abbreviated Survey CMS
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and mistreatment of a resident by a housekeeper at Salem Hills Rehabilitation and Nursing Center.
Complaint Details
The complaint involved allegations that Housekeeper #1 cursed at Resident #1 and aggressively repositioned the resident's wheelchair on 01/24/2023. The incident was witnessed by Housekeeper #2 and confirmed by video footage. The facility investigation found the abuse substantiated. The housekeeper was terminated, but the facility failed to report the abuse to the NYSDOH within the required 2-hour timeframe, reporting it instead nearly two days later.
Findings
The facility failed to ensure that one resident was free from abuse and mistreatment by a housekeeper who was observed cursing at and aggressively repositioning the resident. The facility also failed to report the abuse to the New York State Department of Health within the required 2-hour timeframe. The housekeeper was terminated, and the facility revised its abuse prevention and reporting policies.
Citations (2)
Failure to protect a resident from abuse and mistreatment by a housekeeper who was observed cursing at and aggressively repositioning the resident.
Failure to timely report suspected abuse to the New York State Department of Health within 2 hours of occurrence.
Report Facts
Residents sampled: 12
Residents affected: 1
Date of abuse incident: Jan 24, 2023
Date of survey completion: Feb 10, 2023
Date abuse reported to NYSDOH: Jan 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Named in abuse and mistreatment finding; terminated for cursing at and aggressively repositioning resident |
| Housekeeper #2 | Housekeeper | Witnessed abuse incident and reported it to supervisor |
| Housekeeper Lead | Housekeeper Lead | Received report from Housekeeper #2 and reported incident to Director of Housekeeping |
| Director of Nursing | Director of Nursing (DON) | Conducted physical assessment of resident after incident |
| Director of Housekeeping and Laundry | Director of Housekeeping and Laundry (DHL) | Oversaw abuse prevention training and confirmed termination of Housekeeper #1 |
| Administrator | Administrator | Oversaw investigation and policy revision following delayed abuse reporting |
Inspection Report — Aug 5, 2021
CMS
Date: Aug 5, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Salem Hills Rehabilitation and Nursing Center, summarizing the findings of a facility survey completed on 08/05/2021.
Findings
No health deficiencies were found during the survey.
Inspection Report — May 31, 2019
Complaint Investigation CMS
Date: May 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#NY00218018) and recertification survey to evaluate compliance with care plan implementation, medication use, and treatment standards.
Complaint Details
Complaint #NY00218018 involved concerns about care plan implementation, medication use, and injury of unknown origin to Resident #374. The investigation found failure to use mechanical lift as per care plan, resulting in injury. The facility self-reported and corrected the noncompliance prior to survey.
Findings
The facility was found deficient in developing and implementing complete care plans for residents, including failure to address medication use and positioning devices. One resident was transferred without the required mechanical lift assistance, resulting in injury. The facility corrected this issue prior to survey. Additionally, the facility failed to ensure physician follow-up on pharmacy consultant recommendations for lab tests.
Citations (4)
Failure to develop and implement a complete care plan meeting all resident needs, including use of mechanical lifts and medication management.
Failure to revise comprehensive care plan within 7 days of assessment, specifically not updating for use of left leg skil care relief boot.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, including improper use of positioning devices.
Failure to ensure attending physician acted upon pharmacy consultant's recommendations regarding medications and lab tests.
Report Facts
Deficiencies cited: 4
Medication dosage: 3000
Medication dosage: 9500
Medication dosage: 15000
Medication dosage: 25
Medication dosage: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in investigation for transferring Resident #374 unassisted without mechanical lift |
| Director of Nursing | Director of Nursing | Completed investigation of injury to Resident #374 |
| RN #1 | Registered Nurse Manager | Interviewed regarding care issues and physician follow-up on pharmacy recommendations |
| CNA #1 | Certified Nursing Assistant | Reported resident refusal to use positioning devices |
| Physical Therapist | Physical Therapist | Provided information on purpose of left leg skil care relief boot and hip abductor pillow |
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