Inspection Reports for
St Cabrini Nursing Home
115 Broadway, Dobbs Ferry, NY, 10522
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Inspection Report — Jan 29, 2026
Complaint Investigation State
Date: Jan 29, 2026
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 85 complaints about this facility; 9 led to on-site inspections. Complaint surveys were conducted on January 29, 2026; October 20, 2023; June 29, 2023; and other dates with citations issued.
Findings
Across 8 inspections, 43 citations were issued including 23 standard health and 20 Life Safety Code citations. Most deficiencies were minor potential harm and many were corrected; the facility had 85 complaints with 9 on-site inspections and 1 enforcement action recorded.
Citations (30)
Label/store Drugs And Biologicals: Failed to properly label and store drugs and biologicals as required.
Personal Privacy/confidentiality Of Records: Did not maintain adequate personal privacy and confidentiality of records.
Covid-19 Immunization: Deficiencies in Covid-19 immunization protocols were noted.
General Requirements: Some general requirements were not met as per quality of care standards.
Infection Prevention & Control: Infection prevention and control measures were inadequate.
Quality Of Care: Quality of care standards were not fully met.
Required In-service Training For Nurse Aides: Nurse aides did not receive required in-service training.
Residents Are Free Of Significant Med Errors: Residents were not free of significant medication errors.
Sufficient Nursing Staff: Nursing staff levels were insufficient.
Cooking Facilities: Cooking facilities did not meet Life Safety Code NFPA requirements.
Corridor - Doors: Corridor doors failed to comply with Life Safety Code NFPA requirements.
Electrical Equipment - Power Cords And Extens: Electrical equipment power cords and extensions were not compliant with NFPA requirements.
Electrical Systems - Essential Electric Systems: Essential electrical systems did not meet NFPA requirements.
Fire Alarm System - Testing And Maintenance: Fire alarm system testing and maintenance were inadequate per NFPA standards.
Gas Equipment - Cylinder And Container Storage: Gas equipment storage did not comply with NFPA requirements.
Standards Of Construction For New Existing Nh: Construction standards for new and existing nursing home areas were not fully met.
Bowel/bladder Incontinence, Catheter, Uti: Deficiencies in managing bowel/bladder incontinence, catheter use, and UTIs were found.
Develop/implement Comprehensive Care Plan: Failed to develop or implement a comprehensive care plan.
Resident's Care Supervised By A Physician: Resident care was not adequately supervised by a physician.
Accuracy Of Assessments: Assessments were not accurate or complete.
Food Procurement,store/prepare/serve-sanitary: Food procurement, storage, preparation, or serving was not sanitary.
Increase/prevent Decrease In Rom/mobility: Failed to increase or prevent decrease in range of motion or mobility.
Nutrition/hydration Status Maintenance: Nutrition and hydration status were not properly maintained.
Reporting Of Alleged Violations: Did not properly report alleged violations.
Resident Rights/exercise Of Rights: Resident rights and their exercise were not fully protected.
Portable Fire Extinguishers: Portable fire extinguishers did not meet NFPA requirements.
Sprinkler System - Installation: Sprinkler system installation was not compliant with NFPA standards.
Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were inadequate.
Subdivision Of Building Spaces - Smoke Barrier: Smoke barrier subdivision of building spaces did not meet NFPA requirements.
Reporting - National Health Safety Network: Failed to properly report to the National Health Safety Network.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 43
Inspections with violations: 7
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 2000
Number of enforcement actions: 1
Total complaints: 85
On-site inspections from complaints: 9
Citations issued from complaints: 9
Inspection Report — Jan 29, 2026
Abbreviated Survey CMS
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.
Citations (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 — May 20, 2025
Abbreviated Survey CMS
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.
Citations (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 — Oct 20, 2023
Abbreviated Survey CMS
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.
Citations (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 — Jun 29, 2023
Abbreviated Survey CMS
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.
Citations (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 — May 18, 2023
Annual Inspection CMS
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.
Citations (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 — Apr 18, 2019
Annual Inspection CMS
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.
Citations (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 — Aug 1, 2017
Annual Inspection CMS
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.
Citations (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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