Inspection Reports for
St Cabrini Nursing Home
115 Broadway, Dobbs Ferry, NY, 10522
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
32
24
16
8
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jan 29, 2026
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with privacy protections for residents' personal and medical records and the secure storage of medications and biologicals.
Findings
The facility failed to ensure medication carts were locked and computers had privacy screens applied, leaving residents' personal and medical information exposed. Medication carts were observed unlocked and unattended on multiple units, violating facility policies and regulatory requirements.
Deficiencies (2)
F 0583: The facility did not ensure medication carts were locked and privacy screens applied, exposing residents' personal and medical information on multiple units during the survey.
F 0761: The facility failed to store medications and biologicals securely, with medication carts left unlocked and unattended on multiple units during the survey.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager # 2 | Noticed and locked an unlocked medication cart and computer screen during observation. | |
| Licensed Practical Nurse # 5 | Interviewed about not applying privacy screen and leaving medication cart unlocked. | |
| Licensed Practical Nurse # 4 | Observed administering medication and acknowledged failure to apply privacy screen and lock cart. | |
| Licensed Practical Nurse # 3 | Interviewed about forgetting to lock medication cart and apply privacy screen. | |
| Licensed Practical Nurse # 2 | Interviewed about not locking medication cart and not applying privacy screen. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: May 20, 2025
Visit Reason
Complaint Survey with 8 health and 7 life safety citations, mostly Level 2 severity, all corrected by July 15, 2025.
Findings
Complaint Survey with 8 health and 7 life safety citations, mostly Level 2 severity, all corrected by July 15, 2025.
Deficiencies (15)
Covid-19 immunization
General requirements
Infection prevention & control
Label/store drugs and biologicals
Quality of care
Required in-service training for nurse aides
Residents are free of significant med errors
Sufficient nursing staff
Cooking facilities
Corridor - doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Standards of construction for new existing nh
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with professional standards of care and regulatory requirements.
Findings
The facility failed to ensure timely notification of a cardiologist's recommendation to reduce a resident's medication dosage, resulting in continued administration of the higher dose for several days. Interviews confirmed the physician was not notified until days later, though no harm occurred to the resident.
Deficiencies (1)
F 0684: The facility did not notify the physician timely of a cardiologist's recommendation to reduce Carvedilol dosage for Resident #489, resulting in continued administration of the higher dose from 8/9/24 to 8/13/24.
Report Facts
Medication administration dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Registered Nurse | Stated standard procedure included reviewing recommendations, calling the physician, and documenting; no documentation found of notification. |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Stated nurse should have read recommendations and called physician; had no recollection of receiving cardiologist's paperwork. |
| Physician #7 | Physician | Stated no call was received from nursing staff regarding cardiologist's recommendations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
Complaint Survey with 1 health citation for bowel/bladder incontinence, catheter, uti; Level 2 severity, corrected by November 30, 2023.
Findings
Complaint Survey with 1 health citation for bowel/bladder incontinence, catheter, uti; Level 2 severity, corrected by November 30, 2023.
Deficiencies (1)
Bowel/bladder incontinence, catheter, uti
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with care standards related to bowel and bladder care for residents, specifically focusing on appropriate care for residents who are continent or incontinent of bowel/bladder and prevention of urinary tract infections.
Findings
The facility failed to ensure appropriate bowel care for one resident who was incontinent of bowel, as the resident's constipation care plan and facility bowel protocol were not followed. There was no documented evidence that the physician was notified of the resident's lack of bowel movements from 08/01/2023 to 08/05/2023, despite multiple shifts without bowel movements and no new physician orders or treatments.
Deficiencies (1)
F 0690: The facility did not follow the bowel protocol for Resident #1 who had no documented bowel movements from 08/01/2023 to 08/05/2023. There was no evidence that the physician was notified or that new orders were obtained during this period.
Report Facts
Residents affected: 3
Residents affected: 1
Dates without bowel movement: 6
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
Complaint Survey with 2 health citations related to care plan development and physician supervision; Level 2 severity, corrected by August 15, 2023.
Findings
Complaint Survey with 2 health citations related to care plan development and physician supervision; Level 2 severity, corrected by August 15, 2023.
Deficiencies (2)
Develop/implement comprehensive care plan
Resident's care supervised by a physician
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 29, 2023
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with care plan implementation and physician orders related to nutrition and aspiration precautions for residents.
Findings
The facility failed to consistently weigh a resident with significant weight loss and did not consistently monitor meal intake. Additionally, the facility did not ensure a physician's order for aspiration precautions was in place for a resident with dysphagia and a history of aspiration pneumonia.
Deficiencies (2)
F 0656: The facility did not implement interventions in accordance with the care plan for Resident #1, who experienced significant weight loss and inconsistent weekly weighing and meal intake monitoring.
F 0710: The facility failed to obtain a physician's order for aspiration precautions for Resident #1, who had dysphagia and a history of aspiration pneumonia, resulting in inadequate supervision and care.
Report Facts
Weight loss: 15
Meal intake documentation: 35
Meal intake documentation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Interviewed regarding Resident #1's meal intake and weighing. |
| RNUM #1 | Registered Nurse Unit Manager | Interviewed about weekly weight procedures and missed weights. |
| Dietician #1 | Dietician | Interviewed about meal intake monitoring and missed weights. |
| CNA #2 | Certified Nursing Assistant | Interviewed about Resident #1's feeding and coughing before hospitalization. |
| Physician | Interviewed regarding lack of order for aspiration precautions. | |
| Director of Nursing | DON | Interviewed about absence of aspiration precaution order and care plan. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 18
Date: May 18, 2023
Visit Reason
Complaint Survey with 8 health and 13 life safety citations, mostly Level 2 severity, corrected by July 2023.
Findings
Complaint Survey with 8 health and 13 life safety citations, mostly Level 2 severity, corrected by July 2023.
Deficiencies (18)
Accuracy of assessments
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Infection prevention & control
Nutrition/hydration status maintenance
Quality of care
Reporting of alleged violations
Resident rights/exercise of rights
Cooking facilities
Corridor - doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Subdivision of building spaces - smoke barrie
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Gas equipment - cylinder and container storag
Standards of construction for new existing nh
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 18, 2023
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards including abuse reporting, treatment of infections, and food safety.
Findings
The facility failed to timely report alleged abuse incidents to the New York State Department of Health and local law enforcement for multiple residents. Additionally, the facility did not ensure timely treatment and follow-up of lab results for a resident with a urinary tract infection. Food safety violations were also identified, including unlabeled food, lack of cooling logs, inadequate sanitizer concentration, and unsanitary kitchenware conditions.
Deficiencies (3)
F 0609: The facility did not timely report suspected abuse incidents involving four residents to the New York State Department of Health and local law enforcement, violating immediate reporting requirements.
F 0684: The facility failed to provide appropriate treatment and care by not performing timely follow-up of lab results for a urinary tract infection, resulting in delayed treatment for one resident by twenty-one days.
F 0812: The facility did not ensure food was prepared, stored, and served in accordance with professional standards, including unlabeled food, lack of cooling logs, sanitizer concentration below required levels, and unsanitary food contact equipment.
Report Facts
Days delayed in reporting abuse: 7
Days delayed in reporting abuse: 5
Days delayed in reporting abuse: 7
Urinary tract infection treatment delay: 21
Sanitizer concentration: 150
Sanitizer concentration: 200
Skin tear size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD#1 | Medical Doctor | Commented on delayed treatment for Resident #380's urinary tract infection |
| RNUM #2 | Registered Nurse Unit Manager | Described specimen collection and lab follow-up process related to UTI treatment delay |
| Director of Nursing | Director of Nursing (DON) | Involved in abuse investigations and reporting; commented on lab and infection monitoring |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Described abuse reporting procedures and timelines |
| Food Service Director | Food Service Director (FSD) | Reported on food labeling, sanitizer issues, and kitchen sanitation |
| Food Service Manager | Food Service Manager (FSM) | Reported on sanitizer concentration and cooling logs |
| Pot Washer | Pot Washer | Reported on cleaning and drying procedures for food service equipment |
| Administrator | Administrator | Interviewed regarding abuse incident reporting and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 18, 2023
Visit Reason
The inspection was a recertification survey conducted from May 10 to May 18, 2023, to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, accurate resident assessments, appropriate range of motion care, nutritional supplementation, and infection prevention and control practices. Deficiencies were generally assessed as minimal harm with few residents affected.
Deficiencies (5)
F 0550: The facility failed to ensure residents' dignity by allowing a nurse to remove an IV in the dining room and leaving a urinary drainage bag uncovered and visible to others.
F 0641: The Minimum Data Set assessments did not accurately reflect Resident #224's diagnosis of Psychosis across multiple assessment dates.
F 0688: Resident #127 with limited range of motion was not provided the prescribed left-hand resting splint consistently, and staff did not refer for therapy reassessment despite resident pain.
F 0692: Resident #135 did not consistently receive ordered nutritional supplements, and dietary and nursing staff failed to ensure supplements were provided or properly documented refusals.
F 0880: The infection prevention program failed to document infections at onset and did not track or monitor infections effectively, limiting infection control efforts.
Report Facts
Weight loss: 8.5
Supplement doses missed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed removing IV from Resident #153 in dining room and interviewed about the incident. |
| RNUM #4 | Registered Nurse Unit Manager | Interviewed regarding uncovered urinary drainage bag for Resident #43. |
| CNA #2 | Certified Nurse Assistant | Reported Resident #127 cried in pain when splint was applied and did not apply splint. |
| LPN #2 | Licensed Practical Nurse | Signed TAR indicating Resident #127 could not tolerate splint due to pain. |
| OT #1 | Occupational Therapist | Interviewed about lack of referral for Resident #127's splint pain. |
| IP/DON | Infection Preventionist/Director of Nursing | Interviewed about deficiencies in infection surveillance and documentation. |
| RD #2 | Registered Dietician | Interviewed about missing nutritional supplements for Resident #135. |
| FSD | Food Service Director | Interviewed about dietary procedures for supplement delivery and refusal. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; Level 2 severity; correction status unclear.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; Level 2 severity; correction status unclear.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
Covid-19 Survey with 1 health citation for reporting to national health safety network; Level 2 severity; correction status unclear.
Findings
Covid-19 Survey with 1 health citation for reporting to national health safety network; Level 2 severity; correction status unclear.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Apr 18, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for St Cabrini Nursing Home.
Complaint Details
Complaint #NY00236060 involved Resident #276 alleging physical abuse by a CNA during a confrontation. The CNA denied the allegations. The CNA demonstrated lack of competency in managing the situation appropriately.
Findings
The facility was found deficient in multiple areas including employee screening for abuse history, inaccurate resident assessments, incomplete care plans, inadequate management of bladder and bowel incontinence, improper use of splints, failure to maintain appropriate feeding tube care, lack of competency in staff handling resident behavior, and failure to adjust medication regimens appropriately.
Deficiencies (9)
F 0607: The facility did not ensure all employees were screened via the Nurse Aide Registry to rule out a history of abuse and neglect, specifically one housekeeper was not screened.
F 0641: The facility did not ensure accurate bladder continence assessment for Resident #276, resulting in a care plan that did not address actual incontinence.
F 0656: The facility failed to develop and implement complete care plans addressing hospitalization, weight loss, and ongoing loose bowel movements for multiple residents.
F 0657: Care plan interventions were not evaluated or updated for effectiveness regarding weight loss, urinary incontinence, and loose stools for several residents.
F 0688: Resident #166 did not have a left-hand splint applied as ordered, and staff failed to follow up on the splint use.
F 0690: Resident #276's bladder incontinence was not properly assessed or managed, and care plans did not reflect the resident's incontinence status or provide appropriate interventions.
F 0693: Resident #63's feeding tube care was inadequate as the head of bed was not kept elevated during feeding as ordered.
F 0726: A Certified Nurse Aide failed to appropriately manage a confrontational situation with Resident #276, escalating a conflict and not communicating effectively.
F 0757: Resident #63 remained on three laxatives despite ongoing loose bowel movements, with no documented physician notification or medication adjustment until surveyor intervention.
Report Facts
Incontinence episodes: 14
Incontinence episodes: 32
Incontinence episodes: 59
Incontinence episodes: 26
Incontinence episodes: 5
Incontinence episodes: 18
Incontinence episodes: 8
Incontinence episodes: 7
Incontinence episodes: 6
Weight loss percentage: 6.1
Medication orders: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in abuse allegation and competency finding related to confrontation with Resident #276 |
| RN #3 | Unit Nurse Manager/Registered Nurse | Interviewed regarding care of Resident #63 and bowel management |
| RN #2 | Registered Nurse | Interviewed regarding bladder incontinence care for Resident #31 |
| DHR | Director of Human Resources | Interviewed regarding employee screening for abuse history |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding care of Resident #63 and bowel management |
| DTR | Dietetic Technician Registered | Interviewed regarding nutrition and feeding care for Resident #63 and Resident #199 |
| RN #1 | Registered Nurse | Interviewed regarding Resident #166 splint use |
| Unit Manager #1 | Unit Manager | Interviewed regarding Resident #166 splint use |
| CNA #6 | Certified Nurse Aide | Interviewed regarding care of Resident #276 and incontinence episodes |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 1, 2017
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility failed to ensure that one resident (#379) was given the choice between a bed bath and a shower as per her preferences. Additionally, the facility did not consistently apply bilateral heel boots to the resident to promote healing and prevent pressure ulcers.
Deficiencies (3)
F 0242: The facility did not ensure that resident #379 was given the choice between a bed bath and a shower, contrary to her care plan and preferences.
F 0282: The facility failed to provide care by qualified persons according to the resident's written plan of care, as bilateral heel boots were not consistently applied to resident #379 to offload heels and prevent pressure ulcers.
F 0314: The facility did not provide proper treatment to prevent new or heal existing pressure sores for resident #379, as bilateral heel boots were not consistently used despite physician orders.
Report Facts
Showers received: 1
Showers received: 1
Showers received: 3
Showers received: 0
Showers received: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assigned Social Worker | Interviewed regarding resident's refusal of showers. | |
| Director of Social Work | Interviewed regarding resident's refusal of showers. | |
| Assigned Certified Nursing Aide (CNA) | Interviewed about resident's bathing and showering care. | |
| MDS Coordinator / Unit Charge Nurse | Interviewed about care documentation and use of heel boots. | |
| Director of Nursing (DON) | Interviewed about facility policy and resident care. | |
| Licensed Practical Nurse (LPN) | Interviewed regarding wound care and use of heel boots. |
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