Inspection Reports for Epic Rehabilitation and Nursing at White Plains
120 Church Street, NY, 10601
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 22, 2025
Visit Reason
The abbreviated survey was conducted to review compliance with professional standards of practice related to treatment and care according to orders, resident preferences, and goals, specifically focusing on consultation processes and physician review of care for residents.
Findings
The facility failed to ensure that one resident (Resident #1) received treatment and care according to consultation recommendations, specifically a medication order for Linzess was not implemented despite a gastroenterology consult recommending it. Additionally, the physician did not review and approve the resident's total program of care, including medications and treatments, at each required visit. Consultation documentation was missing or not properly filed in the resident's record.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically not ordering Linzess as recommended by gastroenterology consult.
Failure to ensure the resident's doctor reviewed the resident's care, wrote, signed, and dated progress notes and orders at each required visit.
Report Facts
Residents reviewed for consultations: 3
Residents affected: 1
Medication dosage: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in relation to failure to document consultation recommendations and medication orders | |
| Director of Nursing | Named in relation to inability to locate consultation documentation and process explanation | |
| Nurse Practitioner #2 | Named in relation to reviewing consultation services and lack of documented medication order | |
| Assistant Director of Nursing | Named in relation to consultation documentation review process |
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Oct 11, 2024
Visit Reason
The inspection was conducted as part of Recertification and Abbreviated Surveys from 10/03/24 to 10/11/24 to assess compliance with medication administration, storage, and labeling regulations.
Findings
The facility was found to have significant medication errors involving two residents, unlocked medication and treatment carts accessible to residents and visitors, and improper storage of drugs and biologicals. Additionally, residents were found to have medications at bedside without proper physician orders for self-administration.
Deficiencies (5)
Resident #202 was administered Lasix and Losartan without a physician's order, resulting in blood pressure monitoring and intravenous fluids.
Resident #96 was almost given a 4 mg dose of Tizanidine instead of the ordered 2 mg dose during medication observation.
Medication and Treatment carts on the 5th floor were observed unlocked and unattended, accessible to residents, visitors, and non-licensed staff.
Resident #12 had physician-ordered medications on bedside table without monitoring and no care plan for self-administration.
Resident #96 had multiple inhalers and medications at bedside without assessment or care plan for self-administration, and medications were taken from them causing distress.
Report Facts
Residents reviewed for Medication Administration: 9
Residents reviewed for Medication Administration: 8
Medication monitoring frequency: 30
Intravenous fluid rate: 75
Duration of intravenous fluids: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Administered wrong medication to Resident #202 and almost gave wrong dose to Resident #96 | |
| Registered Nurse #6 | Responsible for 5th Floor Medication Cart which was found unlocked | |
| Licensed Practical Nurse #20 | Observed unlocked 5th Floor Treatment Cart | |
| Assistant Director of Nursing | Documented hypotension episode for Resident #202 and performed medication administration competencies with Licensed Practical Nurse #2 | |
| Medical Director | Provided clinical explanation of medication effects and discussed self-administration policies | |
| Licensed Practical Nurse #1 | Stated that medication should not be left at bedside without physician's order for self-administration | |
| Director of Nursing | Stated that residents must have physician orders and evaluation to self-administer medications |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Oct 11, 2024
Visit Reason
The inspection was a recertification survey conducted from 10/3/2024 to 10/11/2024 to assess compliance with regulatory requirements for Epic Rehabilitation and Nursing at White Plains.
Findings
The facility was found deficient in multiple areas including failure to ensure staff wore identification badges, lack of resident rights review during Resident Council meetings, incomplete care plans for self-administration of medications, insufficient nursing staff competencies and performance evaluations, inadequate behavioral health care and dementia services, medication errors, improper medication storage, food safety violations, improper garbage disposal, and lapses in infection control practices.
Deficiencies (12)
Several nursing staff on the Dementia unit were observed without identification badges.
Facility did not ensure residents were informed of their rights during monthly Resident Council meetings.
Facility did not develop a care plan for Resident #96 carrying and self-administering their albuterol sulfate aerosol inhaler.
Facility did not ensure sufficient nursing staff competencies and skills for nursing and related services.
Facility did not ensure performance reviews and in-service education for nurse aides at least once every 12 months.
Facility did not ensure necessary behavioral health care and services for Resident #107, including lack of non-pharmacological interventions for behaviors.
Facility did not ensure appropriate treatment and services for Resident #24 diagnosed with dementia, including lack of meaningful activities and engagement.
Facility did not ensure residents were free from significant medication errors, including wrong medication administration and incorrect dosing.
Facility did not ensure drugs and biologicals were labeled and stored in locked compartments; medication and treatment carts were left unlocked and open.
Facility did not ensure food was stored in accordance with professional standards; food items were unlabeled and undated; improper glove use by food service workers.
Facility did not ensure proper disposal of garbage and refuse; dumpsters were uncovered and missing lids; evidence of pest activity.
Facility did not ensure infection control practices during medication administration; lapses in hand hygiene, equipment sanitization, and hair containment observed.
Report Facts
Residents affected: 15
Certified Nursing Assistants with no competency evidence: 6
Licensed nursing personnel with no competency evidence: 4
Medication errors: 2
Food items unlabeled: 18
Inservice hours required: 6
Inservice hours provided: 9.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #13 | Observed without identification badge on 10/03/2024 | |
| Certified Nursing Assistant #15 | Observed without identification badge on 10/03/2024 | |
| Certified Nursing Assistant #16 | Observed without identification badge on 10/11/2024 | |
| Human Resources Director | Interviewed about badge machine and staff education on 10/11/2024 | |
| Director of Nursing | Interviewed about staff compliance and competency evaluations on 10/11/2024 | |
| Administrator | Interviewed about staff compliance and competency evaluations on 10/11/2024 | |
| Assistant Director of Nursing | Interviewed about competency evaluations and inservices on 10/11/2024 | |
| Certified Nursing Assistant #14 | Interviewed about Resident #107 behaviors on 10/11/2024 | |
| Certified Nursing Assistant #19 | Interviewed about assignment and resident behaviors on 10/11/2024 | |
| Director of Recreation | Interviewed about activity scheduling conflicts and dementia unit activities on 10/11/2024 | |
| Licensed Practical Nurse #2 | Interviewed about medication error on 11/30/23 and medication administration observation on 10/11/2024 | |
| Registered Nurse #3 | Interviewed about infection control lapses and medication administration observation on 10/09/2024 | |
| Licensed Practical Nurse #1 | Observed with poor infection control practice during medication preparation on 10/08/2024 | |
| Licensed Practical Nurse #4 | Interviewed about infection control lapses on 10/08/2024 | |
| Staff #22 | Interviewed about dental appointment scheduling for Resident #56 | |
| Dentist | Interviewed about dental referral and scheduling for Resident #56 | |
| Food Service Director | Interviewed about food safety and glove use on 10/07/2024 | |
| Dietitian | Interviewed about job description and food handling education on 10/07/2024 | |
| Food Service Worker #8 | Observed improper glove use on 10/07/2024 | |
| Food Service Worker #9 | Observed improper glove use on 10/07/2024 | |
| Food Service Worker #10 | Observed improper glove use on 10/07/2024 |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Aug 9, 2023
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse and neglect involving Resident #1, including a complaint that a Certified Nurse Assistant (CNA #2) stuck their tongue out at the resident and concerns about timely reporting of suspected abuse and proper care plan implementation.
Complaint Details
The visit was complaint-related based on allegations that CNA #2 abused Resident #1 by sticking their tongue out and rough handling. The investigation concluded abuse and neglect could not be substantiated due to no physical or mental harm, but the behavior was unprofessional. The complaint was reported 16 hours late by CNA #1, delaying investigation and reporting to the New York State Department of Health.
Findings
The investigation found that the allegation of abuse could not be substantiated due to lack of physical or mental harm, but CNA #2's behavior of sticking their tongue out was deemed unprofessional and a form of abuse. The facility delayed reporting the suspected abuse to the state by 16 hours. Additionally, the resident's care plan was conflicting and not consistently followed, particularly regarding assistance levels for bed mobility and toileting.
Deficiencies (3)
Failure to protect resident from abuse including mental abuse by a CNA who stuck their tongue out at the resident.
Failure to timely report suspected abuse to supervisor and state authorities, delaying investigation initiation.
Failure to develop and implement a comprehensive person-centered care plan that was consistent and followed, specifically regarding assistance levels for bed mobility and toileting.
Report Facts
Residents reviewed: 4
Residents affected: 1
Incident report submission time delay: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA #2) | Involved in alleged abuse incident by sticking tongue out at Resident #1 | |
| Certified Nurse Assistant (CNA #1) | Witnessed alleged abuse and delayed reporting by 16 hours | |
| Director of Nursing (DON) | Oversaw investigation, suspended CNA #2, and mandated re-education | |
| Licensed Practical Nurse (LPN) Unit Manager | Provided information on resident's assist levels | |
| Physical Therapist (PT) | Provided information on resident's assist levels | |
| Certified Nurse Assistant (CNA #4) | Provided information on resident's assist levels |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as a standard annual survey of Epic Rehabilitation and Nursing at White Plains to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met required health standards.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 14, 2020
Visit Reason
The inspection was conducted as an annual survey of Epic Rehabilitation and Nursing at White Plains to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Capacity: 60
Deficiencies: 0
Date: Inspection Report
Visit Reason
Inspection history and citations summary for Epic Rehabilitation and Nursing at White Plains
Findings
No citations or deficiencies were found in any inspections from October 1, 2021 through September 30, 2025. No enforcement actions have been taken during the reporting period.
Report Facts
Total inspections: 0
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