Inspection Reports for
Sarah Neuman Center for Rehabilitation and Nursing
845 Palmer Avenue, Mamaroneck, NY, 10543
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Inspection Report — Oct 23, 2025
Abbreviated Survey CMS
Date: Oct 23, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and care standards, specifically focusing on accident hazards and supervision during resident transfers.
Findings
The facility failed to ensure a safe environment free from accident hazards and adequate supervision during resident transfers, resulting in actual harm to two residents due to improper use of mechanical lifts and unauthorized staff involvement. Additionally, the facility did not convene timely quality assurance meetings or fully implement corrective plans.
Citations (2)
F 0689: The facility failed to ensure accident-free environment and adequate supervision during resident transfers, resulting in a hematoma for Resident #1 due to improper use of a Hoyer lift by unapproved staff and a swollen knee for Resident #2 due to transfer without required equipment and staff.
F 0867: The facility failed to establish an ongoing quality assessment and assurance group to review deficiencies and develop corrective plans, missing required meetings and failing to implement the directed Plan of Correction by the deadline.
Report Facts
Residents on unit during shift: 43
Certified Nurse Aides on shift: 4
Hematoma size: 0.5
Hematoma size: 0.5
Plan of Correction compliance date: Dec 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Involved in improper transfer of Resident #1 resulting in hematoma | |
| Private Aide #1 | Assisted Certified Nurse Aide #1 in transfer of Resident #1 without authorization | |
| Certified Nurse Aide #2 | Transferred Resident #2 alone without required equipment and staff assistance | |
| Registered Nurse Supervisor #1 | Documented incident reports and nursing progress notes related to Resident #1 | |
| Assistant Director of Nursing #1 | Provided interview statements regarding unauthorized staff involvement | |
| Licensed Practical Nurse #12 | Provided interview statements about staffing and rounding practices | |
| Registered Nurse Unit Manager #1 | Oversaw unit staff and provided interview statements on supervision and rounding | |
| Medical Doctor #1 | Provided medical assessment and interview statements regarding injuries and care expectations | |
| Registered Nurse #13 | Documented incident report for Resident #2 injury |
Inspection Report — Oct 23, 2025
Complaint Investigation State
Date: Oct 23, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from 2022 to 2025 with detailed deficiency and enforcement history.
Complaint Details
The state logged 239 complaints about this facility; 12 led to on-site inspections.
Findings
Across 11 inspections, 46 citations were issued including 34 standard health and 12 Life Safety Code citations. The facility had 2 enforcement actions totaling $6,000 in fines and a high volume of complaints with 239 reported and 12 on-site inspections.
Citations (32)
Free Of Accident Hazards/supervision/devices: Multiple citations for failure to maintain a safe environment to prevent accidents.
Qapi/qaa Improvement Activities: Deficiencies in quality assurance and performance improvement activities.
Develop/implement Comprehensive Care Plan: Failure to develop or implement a comprehensive care plan for residents.
Free From Abuse And Neglect: Instances of failure to prevent abuse and neglect of residents.
Encoding/transmitting Resident Assessments: Inadequate encoding or transmission of resident assessments.
Dialysis: Deficiencies related to dialysis care quality.
Infection Prevention & Control: Failure to maintain adequate infection prevention and control measures.
Notice Of Bed Hold Policy Before/upon Trnsfr: Failure to properly notify residents about bed hold policies before or upon transfer.
Notice Requirements Before Transfer/discharge: Failure to meet notice requirements before resident transfer or discharge.
Nurse Aide Peform Review-12 Hr/yr In-service: Failure to provide required nurse aide performance reviews and in-service training.
Nutrition/hydration Status Maintenance: Deficiencies in maintaining residents' nutrition and hydration status.
Personal Privacy/confidentiality Of Records: Failure to protect resident privacy and confidentiality of records.
Posted Nurse Staffing Information: Failure to post required nurse staffing information.
Quality Of Care: General deficiencies in quality of care provided to residents.
Reporting Of Alleged Violations: Failure to properly report alleged violations.
Required In-service Training For Nurse Aides: Failure to provide required in-service training for nurse aides.
Resident Rights/exercise Of Rights: Deficiencies in protecting and exercising resident rights.
Sufficient Nursing Staff: Failure to maintain sufficient nursing staff levels.
Cooking Facilities: Life Safety Code violation related to cooking facilities not meeting NFPA requirements.
Discharge From Exits: Life Safety Code violation regarding discharge from exits.
Electrical Equipment - Power Cords And Extens: Life Safety Code violation concerning electrical equipment power cords and extensions.
Electrical Systems - Essential Electric Syste: Life Safety Code violation related to essential electrical systems.
Exit Signage: Life Safety Code violation for inadequate exit signage.
Fire Alarm System - Testing And Maintenance: Life Safety Code violation for fire alarm system testing and maintenance.
Fundamentals - Building System Categories: Life Safety Code violation regarding building system categories.
Hazardous Areas - Enclosure: Life Safety Code violation for enclosure of hazardous areas.
Illumination Of Means Of Egress: Life Safety Code violation for illumination of means of egress.
Rubbish Chutes, Incinerators, And Laundry Chu: Life Safety Code violation related to rubbish chutes, incinerators, and laundry chutes.
Sprinkler System - Maintenance And Testing: Life Safety Code violation for sprinkler system maintenance and testing.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code violation regarding subdivision of building spaces and smoke barriers.
Reporting - National Health Safety Network: Failure to properly report to the National Health Safety Network.
Investigate/prevent/correct Alleged Violation: Failure to investigate, prevent, or correct alleged violations.
Report Facts
Total citations: 46
Standard Health citations: 34
Life Safety Code citations: 12
Total inspections: 11
Total complaints: 239
On-site inspections from complaints: 12
Complaints citations issued: 22
Enforcement actions: 2
Total fines: 6000
Inspection Report — Jun 4, 2025
Abbreviated Survey CMS
Date: Jun 4, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with care planning and accident prevention regulations for residents, specifically focusing on Resident #1's behavioral care plan and fall prevention.
Findings
The facility failed to develop and implement a comprehensive behavior/resistive to care plan for Resident #1 prior to 3/25/25 and did not ensure adequate supervision to prevent falls, resulting in Resident #1 sustaining a fall with head injury on 3/20/25.
Citations (2)
F 0656: The facility did not ensure development and implementation of a comprehensive person-centered behavior care plan for Resident #1 prior to 3/25/25 despite a history of resistive behaviors.
F 0689: The facility failed to provide adequate supervision and effective use of monitoring to prevent falls for Resident #1, who fell in the bathroom on 3/20/25 causing a head abrasion with bleeding.
Report Facts
Residents reviewed for behaviors: 3
Residents reviewed for accidents: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Responsible for initiating and updating care plans; stated they are new and reviewing quarterly care plans |
| Director of Nursing | Director of Nursing | Provided statements regarding Resident #1's behavior, care plan initiation, and fall risk |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Reported on fall incident investigation and resident supervision requirements |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed Resident #1 fall in bathroom and described resident's resistive behaviors |
Inspection Report — Mar 14, 2025
Abbreviated Survey CMS
Date: Mar 14, 2025
Visit Reason
The abbreviated survey was conducted to investigate an allegation of abuse involving a Certified Nurse Aide pushing a resident, Resident #1, who is severely cognitively impaired.
Complaint Details
The complaint was substantiated based on the internal investigation and direct observation by Registered Nurse Supervisor #1. Certified Nurse Aide #1 admitted to pushing the resident and was suspended pending termination.
Findings
The facility substantiated the abuse allegation after an internal investigation confirmed that Certified Nurse Aide #1 pushed Resident #1 causing the resident to stumble backwards without falling. The Certified Nurse Aide was suspended and is expected to be terminated. The facility is educating staff on abuse and rough handling of residents.
Citations (1)
10NYCRR 415.4(b) Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to ensure residents were free from abuse when Certified Nurse Aide #1 pushed Resident #1 causing the resident to stumble backwards.
Report Facts
Residents Affected: 1
Date of incident: Mar 5, 2025
Date of internal investigation: Mar 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in abuse finding for pushing Resident #1. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Witnessed the abuse incident and conducted initial assessment. |
| Director of Nursing | Director of Nursing | Oversaw investigation and planned termination of Certified Nurse Aide #1. |
| Administrator | Administrator | Provided administrative oversight and confirmed lack of video footage. |
Inspection Report — Jan 30, 2025
Annual Inspection CMS
Date: Jan 30, 2025
Visit Reason
The visit was a recertification survey conducted from 01/22/2025 through 01/30/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, timely submission of Minimum Data Set assessments, comprehensive care planning for hospice residents, accident prevention and supervision, nutrition and hydration management, dialysis care oversight, staffing adequacy, nurse aide performance evaluations, nurse staffing information posting, infection prevention and control, and nurse aide training.
Citations (11)
F 0550: The facility failed to ensure residents had the right to a dignified dining experience, with staff observed standing over residents while feeding and referring to a resident as a feeder.
F 0640: The facility did not submit Minimum Data Set assessments within 14 days for 2 residents, delaying required reporting.
F 0656: The facility failed to develop and implement a comprehensive care plan for a hospice resident, with no documented care plan after hospice admission.
F 0689: The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in actual harm including fractures and bruises for multiple residents due to improper transfers and falls.
F 0692: The facility did not ensure a resident on fluid restriction had documented evidence of fluid intake monitoring and the fluid restriction was not reflected on meal tickets.
F 0698: The facility failed to provide consistent assessment and oversight before, during, and after dialysis treatment for a resident, with inconsistent documentation and missing pre/post dialysis notes.
F 0725: The facility did not consistently provide adequate nursing staff to meet resident needs, with multiple documented shifts failing to meet minimum staffing requirements across units and shifts.
F 0730: The facility failed to complete annual performance reviews for nursing staff, missing reviews for 2 of 5 certified nurse aides.
F 0732: The facility did not post daily resident census and nurse staffing information in a prominent, readily accessible place for residents and visitors on multiple days.
F 0880: The facility failed to implement infection prevention and control practices, including lack of a current water management plan for Legionella and failure of environmental services staff to follow contact precautions for a resident with Clostridium difficile.
F 0947: The facility did not ensure certified nurse aides received the required 12 hours of annual in-service training, with 3 of 5 aides not meeting this requirement.
Report Facts
Falls: 7
Deficiencies cited: 11
Staffing shortages: 50
Fluid restriction: 960
Dialysis treatments: 15
In-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #36 | Observed feeding Resident #165 while standing. | |
| Certified Nurse Aide #37 | Observed feeding Resident #72 while standing. | |
| Certified Nurse Assistant #17 | Referred to Resident #585 as a feeder during lunch. | |
| Certified Nurse Assistant #21 | Referred to Resident #585 as a feeder during lunch. | |
| Director of Nursing | Provided multiple interviews regarding deficiencies and staffing. | |
| Registered Nurse Supervisor #3 | Interviewed regarding hospice care plan and supervision. | |
| Certified Nurse Aide #24 | Used sit to stand device instead of mechanical lift causing injury to Resident #70. | |
| Certified Nurse Aide #31 | Provided care alone to Resident #207 requiring two-person assist. | |
| Certified Nurse Aide #32 | Assisted with mechanical lift transfer for Resident #207. | |
| Registered Dietician #1 | Interviewed regarding fluid restriction for Resident #163. | |
| Nurse Educator | Provided in-service training hours for certified nurse aides. | |
| Director of Human Resources | Interviewed regarding annual performance appraisals. | |
| Nurse Manager #27 | Interviewed regarding posting of daily staffing information. | |
| Environmental Service Worker #28 | Observed not following contact precautions for Resident #588. | |
| Director of Facilities and Lead Engineer | Interviewed regarding water management plan for Legionella. |
Inspection Report — Jan 6, 2025
Abbreviated Survey CMS
Date: Jan 6, 2025
Visit Reason
The inspection was conducted as an abbreviated survey focusing on allegations of abuse and failure to timely report suspected abuse at the Sarah Neuman Center for Rehabilitation and Nursing.
Findings
The facility failed to protect residents from abuse, specifically an incident where a Certified Nursing Assistant threw towels at a resident and yelled at them. Additionally, the facility did not timely report suspected abuse incidents to the New York State Department of Health as required.
Citations (2)
F 0600: The facility did not ensure residents' rights to be free from abuse. Certified Nursing Assistant #4 threw towels at Resident #7 and yelled at them. The assistant was removed from caring for Resident #7 but continued caring for others during the shift. The Licensed Practical Nurse did not report the incident to their supervisor.
F 0609: The facility failed to timely report suspected abuse to proper authorities. Incidents involving Resident #1 and Resident #7 were not reported within 2 hours as required, with delays of up to two days.
Report Facts
Residents reviewed for abuse: 8
Residents affected: 2
Incident report submission delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in abuse incident involving throwing towels at Resident #7. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Did not immediately report alleged abuse by Certified Nursing Assistant #4 and finished their shift. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Failed to check injury and notify supervisor regarding Resident #1's skin injury. |
| Director of Nursing | Director of Nursing | Conducted investigation and suspended Certified Nursing Assistant #4. |
Inspection Report — Jul 12, 2024
Abbreviated Survey CMS
Date: Jul 12, 2024
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of abuse involving a Certified Nurse Aide and a resident at the Sarah Neuman Center for Rehabilitation and Nursing.
Findings
The facility failed to ensure a resident's right to be free from abuse when a Certified Nurse Aide was observed aggressively grabbing a resident's arm. The Certified Nurse Aide was suspended pending investigation. The Director of Nursing found that the incident should have been reported immediately and that the Certified Nurse Aide should have been removed from the assignment pending investigation.
Citations (1)
F 0600: Protect each resident from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to prevent abuse when a Certified Nurse Aide aggressively grabbed Resident #1's arm during transport in the dayroom.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in abuse allegation for aggressively grabbing Resident #1. | |
| Therapeutic Recreational Specialist | Witnessed the abuse incident and reported it. | |
| Registered Nurse Supervisor #1 | Received reports about the incident and did not immediately report to Director of Nursing. | |
| Director of Nursing | Reviewed incident and stated Certified Nurse Aide #2 should have been removed pending investigation. |
Inspection Report — May 9, 2024
Abbreviated Survey CMS
Date: May 9, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with safety and supervision requirements related to resident transfers using mechanical lifts.
Findings
The facility failed to ensure adequate supervision and assistance during resident transfers, resulting in Resident #4 being transferred alone by a Certified Nurse Assistant despite care plans requiring two-person assistance. Resident #4 hit their head on the Hoyer lift bar but sustained no injury. The staff member was retrained and suspended from working with the resident.
Citations (1)
F 0689: The facility did not ensure residents received adequate supervision and assistance to prevent accidents. Resident #4 was transferred alone using a Hoyer lift requiring two-person assistance and hit their head on the lift bar.
Report Facts
Date of incident: Oct 18, 2023
Date of MDS assessment: Sep 27, 2023
Date of care plan initiation: Nov 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Transferred Resident #4 alone using Hoyer lift against care plan; suspended and retrained |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations and retraining after incident |
| Administrator | Administrator | Interviewed regarding policy enforcement and zero tolerance for abuse and neglect |
Inspection Report — Jun 6, 2022
CMS
Date: Jun 6, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home survey conducted by the Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the survey.
Inspection Report — Dec 19, 2018
Annual Inspection CMS
Date: Dec 19, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The survey identified multiple deficiencies including inadequate housekeeping and maintenance, incomplete care planning and resident participation, inappropriate pressure ulcer care, medication administration errors including a 5-day missed dose of Hydrocortisone for a resident with Addison's disease, and inaccurate medical record documentation.
Citations (6)
F 0584: The facility did not provide housekeeping and maintenance services necessary to maintain a clean, comfortable, and homelike environment, including peeling paint, missing floorboards, holes in walls, exposed wires, soiled floors, and unsealed ceiling openings.
F 0657: The facility failed to ensure one resident was given the opportunity to participate in care plan development and did not revise care plans with measurable objectives and appropriate interventions for pain and accident prevention.
F 0686: Medication was administered for excessive duration without adequate indication for ongoing use to one resident during pressure ulcer treatment; topical antibacterial cream was applied to intact skin.
F 0755: The facility did not ensure medication orders were processed consistently and accurately; a medication for Addison's disease was unavailable and not administered for 5 consecutive days.
F 0760: Medication was administered with significant error for one resident; Hydrocortisone was not administered as ordered for 5 days due to failed order transmission and communication breakdowns.
F 0842: Medical records were not accurately documented; pressure ulcer treatments that were not performed were documented as done.
Report Facts
Days medication unavailable: 5
Pressure ulcer size: 2.5
Pressure ulcer size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding pain management and medication administration errors for Resident #153 and #312 |
| RN #3 | Clinical Care Coordinator | Reviewed Medication Administration Record for May 2018 and confirmed missed Hydrocortisone doses |
| MD #1 | Attending Physician | Interviewed regarding medication administration procedures and adverse effects for Resident #312 |
| MD #2 | Medical Director | Interviewed regarding medication incident and actions to be taken when medication is unavailable |
| Pharmacy Director | Pharmacy Director | Interviewed regarding medication availability and order transmission issues |
| Unit Nurse Manager | Unit Nurse Manager | Observed wound care and noted inaccurate documentation of pressure ulcer treatments |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Involved in medication incident where Hydrocortisone was unavailable and did not notify MD or Nursing Supervisor timely |
| Nurse Practitioner (NP) | Nurse Practitioner | Clarified medication order during Hydrocortisone availability incident |
| Social Worker | Social Worker | Interviewed regarding care plan meeting attendance documentation |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan meeting attendance documentation |
| Plant Operations Director (POD) | Plant Operations Director | Interviewed regarding maintenance and repair issues in the facility |
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