Inspection Reports for
Sutton Park Center for Nursing and Rehabilitation
31 Lockwood Avenue, New Rochelle, NY, 10801
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 28, 2026
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and investigate allegations of abuse and environmental concerns.
Findings
The facility failed to maintain a homelike environment in multiple resident rooms and a tub room, did not report an injury of unknown origin to the State Agency, and did not conduct a thorough investigation into the dislocation of a resident's hip prosthesis.
Deficiencies (3)
F 0584: The facility did not maintain a homelike environment in multiple resident rooms and a tub room, including lack of personalization and visitor seating, and window insulation issues causing drafts.
F 0609: The facility failed to timely report an injury of unknown origin involving a resident's dislocated right hip prosthesis to the State Agency.
F 0610: The facility did not ensure a thorough and complete investigation was conducted to rule out abuse, neglect, or mistreatment related to the resident's dislocated hip prosthesis.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Resident rooms without personalization: 15
Resident rooms without chairs: 15
Residents reviewed for abuse: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #6 | Registered Nurse Supervisor | Interviewed regarding awareness of resident room personalization and visitor seating |
| Social Worker #2 | Social Worker | Interviewed regarding family/friend involvement in room personalization |
| Administrator | Administrator | Interviewed regarding facility decoration practices and resident room personalization |
| Director of Recreation | Director of Recreation | Interviewed regarding Recreation Department's role in room and unit decoration |
| Director of Building Services | Director of Building Services | Interviewed regarding building renovation and window insulation issues |
| Director of Nursing | Director of Nursing | Interviewed regarding injury reporting and protocols for resident with dislocated hip |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided investigative summary and statements regarding abuse investigation and care plan adherence |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 14, 2023
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements and investigate specific incidents and care concerns at Sutton Park Center for Nursing and Rehabilitation.
Findings
The facility failed to immediately notify the physician of a resident's refusal to take prescribed medications, did not conduct a thorough investigation of a shower chair incident, and did not develop or implement comprehensive person-centered care plans for several residents, including issues with medication self-administration, fall risk interventions, and addressing refusal to wear clothes.
Deficiencies (3)
F 0580: The facility did not immediately inform the physician or nurse practitioner of Resident #67's refusal to take prescribed medications, including Latanoprost and artificial tears, despite multiple consecutive refusals.
F 0610: The facility did not ensure a thorough and complete investigation was conducted after Resident #95 reported a shower chair broke during transfer on 5/8/2023, with no documented evidence of investigation or assessment of injury.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for Residents #120, #10, and #46, including lack of care plan for medication self-administration, failure to implement fall risk interventions, and failure to address refusal to wear clothes.
Report Facts
Residents reviewed for accidents: 6
Residents reviewed for hospitalization: 3
Residents reviewed for dignity: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in relation to shower chair incident and investigation |
| CNA #4 | Certified Nurse Aide | Named in relation to shower chair incident and resident care |
| NP #1 | Nurse Practitioner | Interviewed regarding medication refusal notification |
| Pharmacist | Interviewed regarding medication administration records and reporting | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication self-administration and resident supervision |
| CNA #6 | Certified Nurse Aide | Observed resident behavior and supervision related to fall risk |
| CNA #14 | Certified Nurse Aide | Interviewed regarding Resident #46's refusal to wear clothes |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding Resident #46's refusal to wear clothes and care plan |
| Assistant Director of Nursing | ADON | Interviewed regarding medication self-administration policy and shower chair incident |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Nov 14, 2023
Visit Reason
Complaint Survey with 8 health and 5 life safety code deficiencies, all Level 2 and corrected by early 2024.
Findings
Complaint Survey with 8 health and 5 life safety code deficiencies, all Level 2 and corrected by early 2024.
Deficiencies (13)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Investigate/prevent/correct alleged violation
Notice requirements before transfer/discharge
Notify of changes (injury/decline/room, etc.)
Nurse aide peform review-12 hr/yr in-service
Quality of care
Resident rights/exercise of rights
Electrical systems - essential electric syste
Local, state, tribal collaboration process
Maintenance, inspection & testing - doors
Sprinkler system - installation
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 14, 2023
Visit Reason
The survey was conducted as a Recertification Survey from 11/7/2023 through 11/14/2023 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, notification of transfers/discharges, development and implementation of care plans, medication administration, staff performance evaluations, and food storage practices. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (6)
10NYCRR 415.3: The facility did not ensure residents were treated with dignity; staff were not seated when feeding Resident #71 and staff entered Resident #119's room without knocking.
10NYCRR 415.3(I)(3)(i)(a): The facility failed to provide timely written notification to Resident #109, their representative, and the Ombudsman regarding hospital transfers/discharges.
10NYCRR 415.11(c)(1): The facility did not develop or implement comprehensive person-centered care plans for Residents #120, #10, and #46, including medication self-administration, fall prevention, and refusal to wear clothes.
10NYCRR 415.12: The facility did not ensure appropriate administration of long-acting insulin for Residents #119 and #116 as per physician orders and lacked clear parameters for holding insulin doses.
10NYCRR 415.26: The facility did not complete performance reviews for certified nurse aides #8, 9, 10, 11, and 12 at least once every 12 months and lacked a policy for staff evaluations.
10NYCRR 415.14: The facility did not ensure perishable foods in kitchen freezers #1 and #2 were properly labeled with use-by or received/prepared dates.
Report Facts
Hospitalizations: 3
Residents reviewed for dignity: 4
Residents reviewed for hospitalization notification: 5
Residents reviewed for care plans: 6
Residents reviewed for insulin administration: 2
Certified Nurse Aides reviewed for performance evaluations: 5
Unlabeled food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Observed standing while feeding Resident #71 and admitted knowing they should have been seated. |
| Activity Aide #1 | Activity Aide | Entered Resident #119's room without knocking and stated it slipped their mind. |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of notification for Resident #109's hospital transfers and insulin administration issues. |
| Director of Social Work | Director of Social Work | Admitted not providing transfer/discharge notices or notifying Ombudsman for Resident #109. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #120 self-administering medication and Resident #10 safety concerns. |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated policy that nurses administer all medications and not leave medications at bedside. |
| CNA #6 | Certified Nurse Aide | Observed Resident #10 alone with door closed and call bell out of reach; acknowledged safety concerns. |
| CNA #14 | Certified Nurse Aide | Reported Resident #46 was supposed to wear clothes but always took them off. |
| CNA #4 | Certified Nurse Aide | Stated Resident #46 refused to wear clothes and gown and refused blanket. |
| LPN #6 | Licensed Practical Nurse | Believed Resident #46 had right to refuse clothing and no care plan meetings were held. |
| Charge Nurse #1 | Charge Nurse | Interviewed about insulin administration inconsistencies and lack of audits. |
| Pharmacy Consultant | Pharmacy Consultant | Reviewed medications and stated no parameters for holding long-acting insulin; recommended MD involvement. |
| Dietary Supervisor | Dietary Supervisor | Acknowledged unlabeled food items and responsibility for labeling. |
| Dietary Director | Dietary Director | Stated food without manufacturer use-by date should be used within 3 months and labeled accordingly. |
| Dietary Aide #1 | Dietary Aide | Responsible for labeling food items and stated procedure for unlabeled foods. |
| Administrator | Administrator | Confirmed no staff performance evaluations were provided. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 23, 2023
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: May 5, 2023
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with regulatory requirements related to resident care, discharge planning, treatment, accident prevention, and food safety at Sutton Park Center for Nursing and Rehabilitation.
Findings
The facility failed to ensure accurate resident assessments, timely updates to care plans, effective discharge planning, appropriate treatment post-fall, adequate supervision to prevent accidents, and proper food safety practices. Resident #1's care was notably deficient in assessment accuracy, care plan updates, fall management, and discharge planning. Dietary staff were observed not wearing required beard restraints.
Deficiencies (6)
F 0641: The facility did not ensure Resident #1's assessment accurately reflected transfer and toileting status, with inconsistent documentation and failure to update care plans per physician orders.
F 0657: The facility failed to review and revise Resident #1's Comprehensive Care Plan timely, missing updates after a change in transfer status and a fall.
F 0660: The facility did not develop or implement an effective discharge planning process for Resident #1, lacking documented discussions and updates to discharge goals.
F 0684: Resident #1 was not provided treatment according to professional standards post-fall; neurological checks and timely assessments were not documented, and hospital transfer was refused without adequate documentation.
F 0689: The facility failed to provide adequate supervision to prevent Resident #1's fall in the bathroom despite requiring extensive assistance, and care plans were not updated post-fall.
F 0812: Dietary Aides were observed without required hair and beard restraints, violating food safety policies and risking contamination.
Report Facts
Residents reviewed: 8
Date of survey completion: May 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Mentioned in relation to care plan update responsibilities and findings |
| LPN #3 | Licensed Practical Nurse | Signed Physical Therapy recommendation and failed to update care plan |
| Assistant Director of Nursing | ADON | Provided interviews about care plan updates and fall supervision |
| Director of Nursing | DON | Interviewed regarding facility process and care plan updates |
| Social Worker #1 | Social Worker | Responsible for updating discharge care plan for Resident #1 |
| Social Worker #2 | Social Worker | Interviewed about discharge planning efforts and documentation |
| Nurse Practitioner | NP | Provided care and orders post-fall, interviewed about treatment and documentation |
| Primary Care Physician | PCP | Interviewed regarding Resident #1's fall and treatment recommendations |
| Medical Director | MD | Interviewed about Resident #1's care and documentation |
| Dietary Aide #1 | Dietary Aide | Observed without beard restraint during kitchen observation |
| Dietary Aide #2 | Dietary Aide | Observed without beard restraint during kitchen observation |
| Dietary Director | Dietary Director | Interviewed about dietary staff hair and beard restraint policy |
| CNA #1 | Certified Nursing Assistant | Interviewed about fall incident and supervision |
| CNA #2 | Certified Nursing Assistant | Interviewed about fall incident and supervision |
| CNA #5 | Certified Nursing Assistant | Interviewed about toileting supervision practices |
| CNA #6 | Certified Nursing Assistant | Interviewed about toileting supervision practices |
| Occupational Therapy Assistant | OTA | Interviewed about Resident #1's toileting assistance needs |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: May 5, 2023
Visit Reason
Complaint Survey with multiple Level 2 health deficiencies related to assessments, care planning, discharge planning, food sanitation, accident hazards, and quality of care; all corrected by June 30, 2023.
Findings
Complaint Survey with multiple Level 2 health deficiencies related to assessments, care planning, discharge planning, food sanitation, accident hazards, and quality of care; all corrected by June 30, 2023.
Deficiencies (6)
Accuracy of assessments
Care plan timing and revision
Discharge planning process
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 24, 2022
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 16, 2022
Visit Reason
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Findings
Covid-19 Survey with one Level 2 health deficiency related to reporting to the national health safety network; deficiency not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 25, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in conducting a Significant Change Minimum Data Set (MDS) for a resident with a decline in condition, providing an adequate ongoing activity program for a cognitively impaired resident, and ensuring certified nursing assistants received required annual in-service training including abuse prevention.
Deficiencies (3)
F 0637: The facility did not ensure a Significant Change Minimum Data Set (MDS) was conducted for 1 of 5 residents reviewed after a significant decline in condition post hospitalization.
F 0679: The facility did not provide an ongoing program of activities to meet the psychosocial needs of 1 of 2 residents reviewed, who was kept in bed without adequate sensory stimulation or social interaction during the day.
F 0730: Two of five certified nursing assistants did not receive the required 12 hours of annual in-service training, including abuse prevention, as evidenced by incomplete training records.
Report Facts
Residents reviewed for MDS: 5
Residents reviewed for activities: 2
Certified Nursing Assistants reviewed: 5
In-service hours documented for CNA #1 in 2018: 3
In-service hours documented for CNA #2 in 2018: 3.5
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 18, 2017
Visit Reason
The inspection was a recertification survey to assess compliance with care plan development and urinary incontinence management for residents.
Findings
The facility failed to review and revise comprehensive care plans with measurable objectives and appropriate interventions for residents with urinary incontinence. There was a lack of documentation and monitoring of changes in residents' continence status and inadequate implementation of toileting programs.
Deficiencies (2)
F 0657: The facility did not develop or revise the comprehensive care plan with measurable objectives, time frames, and appropriate interventions for a resident with urinary incontinence to address decline and potentially restore continence.
F 0690: The facility failed to provide appropriate care to maintain continence or restore continence for residents who were continent or incontinent of bowel and bladder, including lack of bladder retraining and inadequate assessment of incontinence causes.
Report Facts
Residents reviewed for urinary incontinence: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse | Interviewed regarding resident continence status and care plan completion | |
| Unit Nurse Manager | Interviewed about resident urinary incontinence episodes and care plan interventions | |
| Certified Nurse Aide | Interviewed about resident continence and toileting assistance | |
| Medical Doctor | Interviewed regarding resident diagnoses and incontinence status | |
| Registered Nurse | Interviewed about resident incontinence development and retraining candidacy |
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