Sky View Rehabilitation & Health Care Center L L C
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the bed, the resident rolled off the bed.The hospital physician admission assessment, dated 05/30/2025, documented the resident had a scalp laceration near the shunt with bleeding and reported back pain. The X-rays showed acute fractures in the L1 and L2 transverse process. The review of systems was limited due to resident wincing if moved from side to side.During an interview on 10/09/2025 at 12:38 PM, Certified Nurse Aide #10 stated they were aware the resident required two (2) person assistance but had rolled them
in bed by themselves in the past. On 05/30/2025, they were with Resident #1 and changed their brief. When Resident #1 was positioned on their left side, they noticed the draw sheet had a stain on it. When they saw
the stain, they did not roll the resident to their back but left them on their left side and went to the bottom of
the bed where the clean draw sheet was. At that time, they saw the resident roll off the bed and to the floor.
The resident had blood on their head, and they called Licensed Practical Nurse #12.During an interview on 10/09/2025 at 2:48 PM, Registered Nurse Supervisor #9 stated they were called by Licensed Practical Nurse #12 regarding the fall. They were told Certified Nurse Aide #10 was about to change the draw sheet when the resident fell/rolled out of the bed. They did an assessment, suspected there were injuries, and the resident was sent out to the hospital. They stated Certified Nurse Aide #10 should have looked at the
record to see if the resident required staff assistance of one (1) or two (2) staff prior to starting cares.During
an interview on 10/10/2025 at 9:45 AM, Licensed Practical Nurse #12 stated they were not asked to help Certified Nurse Aide #10 with changing residents that night. It was expected the certified nurse aides would help each other and would organize themselves to be available. Certified Nurse Aide #10 came to them and stated the resident was on the floor. They went to the room and the resident was lying on their back and bleeding from their head. They called the supervisor, then called 911. They stated Certified Nurse Aide #10 told them they turned the resident, and the resident rolled out of bed. They stated they asked Certified Nurse Aide #10 if the resident required a two (2) person assist, and they said they thought so. They further asked Certified Nurse Aide #10 why they were turning the resident on their own and did not receive an answer.During an interview on 10/10/2025 at 10:06 AM, Physician #2 stated they were aware that Resident #1 fell out of bed, and it could have been avoided if there was assistance of two (2) certified nurse aides.During an interview on 10/10/2025 at 10:13 AM, Licensed Practical Nurse Unit Manager #3 stated
this incident could have been prevented and Certified Nurse Aide #10 was not thinking. Resident #1 was very stiff and needed two (2) people to turn them. It would be very hard to do with one (1) person. They stated they could not understand why or how it happened. During an interview on 10/09/2025 at 2:43 PM,
the Administrator stated Certified Nurse Aide #10 was at the facility for a short time and had just finished all
the training. The resident rolled off the bed, received immediate help and was transferred to the hospital.
Certified Nurse Aide #10 was terminated, and new interventions were put in place. Certified Nurse Aide #10 did not follow the care plan and get help for the two (2)person assist. 10NYCRR 415.12(h)(2)
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SKY VIEW REHABILITATION & HEALTH CARE CENTER L L C in CROTON ON HUDSON, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CROTON ON HUDSON, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SKY VIEW REHABILITATION & HEALTH CARE CENTER L L C or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.