Adira At Riverside: Resident Fall Causes Head Injury - NY
The fall came to light during a complaint inspection completed October 17, 2025. Inspectors cited the facility under F0689, the federal tag covering protection from accidents and preventable injury. The level of harm was recorded as actual harm, not a technical paperwork violation or a near-miss. A resident was hurt.
The sequence, as described by facility leadership, began when a certified nurse aide was in the middle of changing the resident. At some point during that care, the resident fell. The Medical Director told inspectors the decision was made to send the resident to the hospital because of the hematoma on their head. The Director of Nursing, interviewed on October 14, 2025, confirmed the fall and its consequences directly: a hematoma, a laceration, left side of the forehead, hospital transfer.
That is the entirety of what the facility's two most senior clinical leaders offered inspectors. Not an explanation of how the fall happened. Not what the aide was doing when it occurred, or what position the resident was in, or whether any equipment was in use. The Director of Nursing said they remembered the fall. What they remembered, apparently, stopped at the injury itself.
Falls during personal care are among the most documented and studied risks in nursing home settings. A resident being changed is often repositioned, partially lifted, or moved in ways that require close physical support. Whether that support was adequate here, inspectors were not told, or did not record being told.
What the record shows is a resident who came to Adira At Riverside and left it by ambulance with a wound on their head.
The facility, a rehabilitation and nursing center on the Hudson River waterfront in Yonkers, serves residents who are often recovering from surgeries, strokes, or other acute events, populations that frequently carry elevated fall risk. The inspection that produced this citation was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators before inspectors arrived.
Federal inspectors classified this as affecting few residents. That designation does not mean the harm was minor. It means the number of people directly affected was small. For the resident who sustained a laceration and a hematoma and was loaded into a vehicle and sent to an emergency room, the number was one.
The Director of Nursing's account, given four days before the inspection closed, was brief. They remembered the fall. The physician was notified. The resident was transferred. There is no indication in the inspection record that anyone at the facility explained to inspectors what steps, if any, were taken after the transfer to understand how the fall occurred or to prevent a similar one.
The certified nurse aide who was present when the resident fell was identified in the inspection record only by number. What they saw, what they did immediately after, whether they called for help or were alone, none of that appears in the narrative inspectors made public.
A hematoma on the head, particularly in an elderly or medically fragile resident, is not a minor finding. It signals a blow with enough force to cause bleeding beneath the skin. Paired with a laceration, it suggests significant contact with a surface, a floor, a bedrail, a piece of equipment. The inspection record does not say which.
What it says is that a resident in the care of a certified nurse aide, during a routine task, ended up hurt badly enough to require hospital-level evaluation. The facility's leadership confirmed it. Inspectors cited it. The resident was gone before the inspection closed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Adira At Riverside Rehabilitation and Nursing from 2025-10-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
Adira At Riverside Rehabilitation and Nursing in Yonkers, NY was cited for violations during a health inspection on October 17, 2025.
The fall came to light during a complaint inspection completed October 17, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.