Hudson Hill Center For Rehabilitation & Nursing

F 0656 Level of Harm - Minimal harm or potential for actual harm

confirmed they noticed the Elopement/Wander Guard was missing from Resident #3's care plans and that

they initiated the elopement care plan on 09/04/2025 and included the wander guard placement. [10 NYCRR 415.11(c)(1)]

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hudson Hill Center for Rehabilitation & Nursing

65 Ashburton Avenue Yonkers, NY 10701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on observations, record review, and interviews conducted during the Abbreviated Survey (649783),

the facility did not ensure that the comprehensive care plan was revised to include measurable interventions to address an identified elopement risk for 1 (Resident #2) of 3 residents reviewed.

Specifically, review of the facility's investigation summary dated 03/23/2025 documented that Resident #2 was to be placed on one-to-one supervision at night following an elopement incident. Review of Resident #2's care plan showed that one-to-one supervision intervention was not incorporated into the plan of care.

As a result, the resident's comprehensive care plan did not reflect all identified interventions necessary to address their assessed elopement risk. Subsequently on 04/14/2025, Resident #2 eloped again from the facility and was found by local police wandering on a nearby street. The Resident was brought to the emergency room for further evaluation.The findings are:The Facility policy titled Care Plan-Comprehensive revised 06/2025 documented that assessments of residents are ongoing, and care plans are revised as information about the residents' condition change. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.Resident #2 was admitted with diagnoses including but not limited to adjustment disorder, Dementia with mood disturbance and agitation, and Parkinson's disease.The 01/14/2025 admission Minimum Data Set documented that Resident #2 had severely impaired cognition and exhibited wandering behaviors occurring one to three days during the assessment period. The 03/23/2025 Accident/Incident Report documented that at approximately 5:45 PM, staff discovered Resident #2 was not in their bed. The resident's room was searched, and the resident could not be found. A Code Orange was activated and 911 was called. Police officers responded to the facility to gather information regarding the resident. Shortly thereafter, the facility received a call from the hospital emergency department that Resident #2 had been located and was brought there. Review of the facility's investigation summary dated 03/23/2025 documented that Resident #2 was to be monitored every 30 minutes for three days and placed on one-to-one supervision at night.

However, review of the resident's care plan revealed it was not revised to reflect these interventions, and documentation showed the interventions were not implemented, and on 04/14/2025, Resident #2 again eloped from the facility.During an interview on 09/05/2025 at 11:54 AM, Registered Nurse #1 stated that Resident #2's care plan should have been updated to reflect the new interventions indicated after the elopement. Registered Nurse #1 stated that the Care Plans are implemented and revised by the Registered Nurses and that the staff member responsible for the investigation should have updated the care plan to ensure the interventions were reflected.During an interview on 09/05/2025 at 2:52 PM, the Director of Nursing stated that when new care plan interventions are required, the nurse completing an incident/accident report or investigative summary is responsible for revising the care plan to reflect the new interventions. The Director of Nursing further stated that Resident #2's care plan should have been updated to certify and reflect the intervention of one-to-one supervision following the elopement. Registered Nurse #1 explained that revising the care plan to include new interventions is very important because Certified Nurse Aide tasks are generated directly from the care plan, and without revisions, staff would not receive updated directives to implement the required interventions.10 NYCRR 415.11(c)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hudson Hill Center for Rehabilitation & Nursing

65 Ashburton Avenue Yonkers, NY 10701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interviews conducted during the Abbreviated Survey (649752), the facility did not ensure that necessary care and services were provided to maintain the resident's highest practicable physical well-being for one (Resident #3) of three residents reviewed for respiratory infections. Specifically, for Resident #3, the facility did not ensure timely medical evaluation and initiation of appropriate treatment

after receiving positive laboratory results for Influenza A on 01/31/2025. The Physician was not immediately notified about the test results causing a delay in treatment. The facility treatment plan for the resident was initiated on 02/02/2025. The facility policy titled Influenza Protocol reviewed 04/2025 documented that Influenza antiviral treatment should be administered to residents and healthcare personnel according to current CDC guidelines. Antiviral treatment/prophylaxis should not be delayed while awaiting test results.

Resident #3 was admitted with diagnoses including but not limited to malignant neoplasm of cerebellum, diabetes mellitus, multiple sclerosis, and thrombocytopenia.The 02/27/2025 Quarterly Minimum Data Set (an assessment tool) documented that Resident #3 had severely impaired cognition.The laboratory report dated 01/31/2025 documented that Resident #3 had a Respiratory Panel plus COVID test completed on 01/30/2025, with results showing positive for Influenza A. There was no documented evidence that the laboratory results were reviewed or addressed by nursing staff on 01/31/2025 or 02/01/2025. There was also no documentation that the physician was notified. Treatment was not initiated until 02/02/2025, when Tamiflu was prescribed and started.Review of the physician's order documented that Tamiflu 75mg was ordered on 02/02/2025 for resident #3 for positive Influenza A results.During an interview on 09/18/2025 at 12:33 PM, the Medical Director stated they were unable to recall if they were notified of Resident #3's positive results but confirmed that Tamiflu was ordered on 02/02/2025 after they became aware of the Influenza A test results. The Medical Director stated that Tamiflu should be started within 48 hours of a positive result to be most effective and stated that there was a delay in treatment due to a lack of timely communication from nursing staff. The Medical Director also stated that nursing staff could have implemented droplet precautions before the physician was notified and that a physician's order is not required to begin droplet precautions when Influenza is suspected or confirmed.During an interview on 09/18/2025 at 01:27 PM, Registered Nurse Unit Manager #4 stated that the Respiratory Panel plus COVID test was ordered as a precautionary measure during an Influenza outbreak and stated that there was no documentation showing the physician was notified when the positive results were received. Registered Nurse Unit Manager #4 stated that they should have followed up with the physician to obtain timely treatment orders.During an interview on 09/19/2025 at 10:26 AM, the Director of Nursing stated that Tamiflu should be started at the onset of symptoms and no later than 48 hours after a positive Influenza result to ensure effectiveness. The Director of Nursing stated that nursing staff are responsible for promptly notifying

the physician of critical results and obtaining treatment orders. The Director of Nursing stated that droplet precautions could have been implemented sooner while awaiting physician notification, and that the delay

in starting Tamiflu for Resident #3 represented a delay in treatment and response to the positive Influenza diagnosis.10NYCRR 415.12(a)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hudson Hill Center for Rehabilitation & Nursing

65 Ashburton Avenue Yonkers, NY 10701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

guard integration so that if a resident with a wander guard attempted to use the elevator, the elevator would not leave the unit. The Administrator stated that prior to the upgrades in March, a resident with a wander guard could access the elevators without triggering an alarm. The Administrator further stated that as of April 2025, all exit doors on the 5th floor are now equipped to delay egress meaning the doors only opens with a code or if pushed for 15 seconds. When pushed for 15 seconds, the alarm would sound, giving staff time to respond. The Administrator stated that they were out on leave on 03/13/2025, and while they were notified of the incident, they could not recall how the resident exited the building. They also confirmed that

the facility did not have exterior cameras at the time of the elopement.10NYCRR 415.12(h)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hudson Hill Center for Rehabilitation & Nursing

65 Ashburton Avenue Yonkers, NY 10701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

physician, the interaction and response must be documented in a nursing progress note. The Director of Nursing stated that when a resident tests positive for Influenza, respiratory precautions should be implemented immediately. The nursing supervisor is responsible for ensuring these protocols are followed.

The Director of Nursing stated that this situation represented a delay in treatment and a delay in implementing precautionary measures. The Director of Nursing stated that even if a resident presents with signs and symptoms of a respiratory illness such as sniffling or coughing, staff should wear personal protective equipment as a precautionary measure until test results are obtained.10 NYCRR 415.19

Event ID:

Facility ID:

If continuation sheet