Nyack Ridge Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Nyack Ridge Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 25, 2023

  Based on observation, interview, and record review conducted during the recertification survey, the facility failed to ensure that each resident received adequate supervision and assistance to prevent falls. for 2 of 6 residents (Resident #129 and #145) reviewed for accidents. Specifically, Resident #129 sustained injuries related to falls between 8/19/2023 and 8/22/2023 : one injury required staples to the back of the head and one injury resulted in left arm proximal (nearer to the trunk of the body) and left arm distal (further from the trunk of the body) wounds (injuries that break the skin or other body tissue). Subsequently, Resident #145 had 5 falls between 7/4/2023 and 9/21/2023; one of which resulted in a right hip fracture on 8/13/2023. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based on observations, record review, and interviews, the facility did not ensure the resident environment remained as free from accident hazards as possible and did not ensure residents received adequate supervision to prevent accidents for 4 (Residents #1, #3, #5, and #6) of 6 residents reviewed for accidents. Specifically, 1. Resident #1, who had a history of behavioral symptoms including refusal of care and agitation during care, sustained a 4 centimeter by 1 centimeter laceration to the head when Certified Nurse Aide #6 shaved the resident's head while providing care. Resident #1 was transferred to the emergency room and required four staples. […]

• Actual harm, isolatedF689Nov 4, 2025

  Based on observation, record review, and interviews conducted during the Abbreviated Survey (#2583624), the facility did not ensure that the residents' environment remained as free of accident hazards as possible for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was transferred by Certified Nurse Aides #1 and #2 with a new mechanical lift they had not received training on. The lift tilted during the transfer, hitting Resident #1 on the head. Resident #1 sustained a laceration to the head and was transferred to the hospital for emergency care and received staples for the laceration. […]

• No harm, potential for more than minimal, patternF584Jan 14, 2025

  Based on observation, interview, and record review conducted during the Recertification and abbreviated (NY00343179) survey from 1/6/2025 to 1/14/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 of 2 resident floors (3rd Floor) during observation of the environment. Specifically, the 3rd Floor was observed with foul, pervasive, and strong odor of urine and feces on multiple occasions; shower rooms with hanging ceiling tiles, stained wall and floor tiles, and stained worn shower chairs; there were multiple resident rooms with soiled and stained bathrooms, broken light fixtures, and dirty, spackled walls with mismatched paint; and, there was a floor dayroom with soiled bins of dolls and stuffed animals,… […]

• No harm, potential for more than minimal, patternF661Jan 14, 2025

  Based on interviews and record review conducted during the Recertification and abbreviated surveys (NY00335588, NY00358884) from 1/6/2025 to 1/14/2025, the facility did not ensure the completion of discharge summaries for 3 out of 3 residents (Resident #124, #247 and #245) reviewed for discharge. Specifically, 1) Resident #124's electronic medical record did not contain a discharge summary. 2) Resident #247 was severely cognitively impaired and discharge did not include adequate communication with the resident's family regarding injectable medications. 3) Resident #245's discharge summary and instructions were incomplete and did not included a recapitulation of the residents' stay. […]